Prevention of Future Deaths reports · 2019

Tyereece Johnson

Regulation 28 report to prevent future deaths, reference 2019-0166, written 23 May 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report23 May 2019
Reference2019-0166
DeceasedTyereece Johnson
CoronerShirley Radcliffe
Coroner areaLondon Inner (West)
CategoryChild Death (from 2015) · Police related deaths · Emergency services related deaths (2019 onwards)
Sourcejudiciary.uk record · original PDF
Responses published1

The report

Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO

Cressida Dick,

Commissioner for the Metropolitan Police,
Metropolitan Police Service,

New Scotland Yard,

Victoria Embankment,

London.

SWI1A 2JL.

CORONER

| am Dr Shirley Radcliffe for the coroner area of Inner West London

CORONER’S LEGAL POWERS

| make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28
and 29 of the Coroners (Investigations) Regulations 2013.

INVESTIGATION

On 20" July I commenced an investigation into the death of Tyereece Johnson, aged 16 years. The
investigation concluded at the end of the inquest on 9'" May 2019. The conclusion was a narrative,
the medical cause of death was Head and Thoracic injury. (Narrative attached)

CIRCUMSTANCES OF THE DEATH

Tyereece died following a collision with a police vehicle (not the vehicle following the moped). He
was driving a moped with 2 passengers.

The moped had been identified as a suspect in attempted thefts earlier in the evening and was being
followed by the police helicopter and latterly by a police vehicle.

CORONER’S CONCERNS

The MATTERS OF CONCERN are as follows. —

During the course of the inquest evidence revealed a matter giving rise to concern.
In my opinion there is a risk that future deaths could occur unless action is taken.

The first CAD messages gave an approximate age of the riders of the moped (aged 15 to

16). However this was not passed on to the team in the Police Control Centre who were formulating
tactics to bring the moped to a stop. All witnesses from the police control room and police helicopter
agreed that the age of the riders was a relevant factor to take into account when formulating a risk
assessment in order to inform their tactical decision making.

(However I did not find that it caused or contributed to the death in this instance.)

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and | believe you [AND/OR your organisation]
have the power to take such action -

_]

In my opinion action should be taken to ensure such important information is made available to all
relevant staff who are formulating risk assessments in this type of scenario.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report, namely by 11" July
2019. |, the coroner, may extend the period.

Your response must contain details of action taken or proposed to be taken, setting out the timetable for
action. Otherwise you must explain why no action is proposed.

COPIES and PUBLICATION

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons :

lam also under a duty to send the Chief Coroner a copy of your response.

The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a
copy of this report to any person who he believes may find it useful or of interest. You may make
representations to me, the coroner, at the time of your response, about the release or the publication of your
response by the Chief Coroner.

23" May 2019

ans

Dr Shirley A Radcliffe

HM Assistant Coroner,

Inner West London,
Westminster Coroner’s Court,
65, Horseferry Road,

London.

SW1P 2ED.

|
|
i
j
i]
|

Responses

1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.

Response from Metropolitan Police (PDF)
METROPOLITAN

POLICE
Dr Shirley A Radcliffe Peter Holdcroft
HM Assistant Coroner OCU Commander
Inner West London Directorate of Professional Standards
Westminster Coroner's Court Empress State Building
65 Horseferry Road Lillie Road
London London
SW1P 2ED SW6 1TR

Telephone: 020 7161 6474
(i

WWW.MeT. police.u

Your ref:
Our ref: IX/79/17
Date: 10" July 2019

Dear Dr Radcliffe

| am writing on behalf of the Commissioner in response to your Regulation 28 Report to
Prevent Future Deaths dated 23 May 2019, following the conclusion of the inquest into the
death of Tyereece Johnson. In Deputy Assistant Commissioner Matthew Horne’s absence, |
will be responding in my role as OCU Commander for the Directorate of Professional
Standards.

In drafting our response we_have consulted with the relevant subject matter experts,

principally: Superintendent Service Delivery for Met Command and Control
(MetCC) ae ead of Support for MetCC and Chief Inspector Lisa Maslen, Met
Grip, MetCC.

Response to Matter of Concern:

The first CAD messages gave an approximate age of the riders of the moped (aged 15
to 16). However this was not passed on to the team in the Police Control Centre who
were formulating tactics to bring the moped to a stop. All witnesses from the police
control room and police helicopter agreed that the age of the riders was a relevant
factor to take into account when formulating a risk assessment in order to inform their
tactical decision making. (However | did not find that it caused or contributed to the
death in this instance). Action should be taken to ensure such important information
is made available to all relevant staff who are formulating risk assessments in this type
of scenario.

Since 2016 a number of changes have been made within Met Command and Control (MetCC).
There is a now a dedicated pod for police pursuits and follows as occurred here, which consists
of the following six roles;

1. Intop Channel Operator (Interoperability — a dedicated channel to allow neighbouring
forces to have a set of radio channels that could easily be used for cross-border
incidents, especially pursuits. Each police force has at least two interoperability
channels which each surrounding force has access to).

2. Channel 5 Operator (This is the support function for the Pan London radio channels.
In the event of a pursuit/follow on Intop, the Channel 5 operator can help the Intop
operator with typing whilst the operator speaks, assigning units to the incident).

1|Page

North Area and South Area Operator.
Pursuit Tactical Advisor.

Traffic Supervisor.

Pan London Supervisor.

DOr Go

Whilst each has a number of responsibilities, it is for the Pan London Supervisor to take overall
control of the pursuit/follow. Their role is to constantly risk assess the situation based on the
information and intelligence available using the National Decision Model.

Due to the dynamic nature of incidents it is for the Pan London Supervisor to determine who
is best placed at that time to carry out any additional intelligence checks and to continue to
assess and task as appropriate throughout the incident.

The MPS considers that the changes implemented since 2016 are sufficient, however as a
result of this Regulation 28 Report to Prevent Future Deaths, MetCC led by Superintendent
Gary Warby in charge of Service Delivery, will take the following action;

e Review the roles and responsibilities of the pod to ensure they are maximising
information/intelligence opportunities.

e Consider whether there should be a mandatory checklist of indices at the start of a
pursuit e.g. Police National Computer, Computer Aided Despatch (CAD) incidents
including linked CADS, and Integrated Information Platform.

e Ensure Pan London courses and refresher training includes an input on information
and intelligence gathering.

This review will be completed by 31%t October 2019.
In Conclusion

In the last couple of years MetCC has created a dedicated police pursuits pod. This contains
the necessary resources to support the Pan London Supervisor, who has overall control of
pursuits/follows, with the information and intelligence required to risk assess the incident using
the National Decision Model. MetCC believes this is sufficient to address the matter of concern
raised by the Coroner, however they seek to improve their practices further and will conduct
a review of the roles and responsibilities contained within the pod to ensure they maximise all
available information and intelligence opportunities. This review will be completed within the
next four months.

| trust this provides the reassurance that we have considered the point you have raised and
that we have made improvements and continuously seek to do so.

Yours sincerely,

Beotobleht

Peter Holdcroft
Detective Chief Superintendent

2|Page

Related reports

Other reports by Shirley Radcliffe

See all →

More reports categorised “Child Death (from 2015)”

See all →

Track Child Death (from 2015)

See every Prevention of Future Deaths report matching Child Death (from 2015), and how often a new one appears.

What would an alert for this have sent me? Search the full text

Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.

These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.