Edir DA Costa

Hak METROPOLITAN

20S! POLICE
DIRECTORATE OF PROFESSIONALISM

Miss N Persaud Matthew Horne
Senior Coroner | Deputy Assistant Commissioner
Waithamstow Coroner’s Court 6" Floor
Queens Road New Scotland Yard
Walthamstow Victoria Embankment
E17 8QP London

SW1A 2JL

Coroner’s Email: coroners@walthamforest.gov.uk

Tel: 020 8496 5000 Email:

Your ref: 6562
Our ref: 1X/69/17
Date: 22"4 August 2019

WDece Ms Pesos ,

| am the Deputy Assistant Commissioner for Professionalism in the Metropolitan Police
Service (MPS). | write in response to your Regulation 28 Report to the Commissioner dated
27th June 2019, following the conclusion of the Inquest into the death of Mr Edir Frederico
Araujo Da Costa.

In drafting this response we have consulted with the relevant subject matter oe ala
MPS, principally: Inspector iE Officer Safety Unit, Acting Chief Inspecto:
HE Met Control and Command MetCC), Jar Senior Advisor First Aid, Policy &
Assurance, Superintendent ia Chair of Officer Safety Board and

Medical Director.

Responses to Matters of Concern:

(1) The evidence at the Inquest revealed that not all police officers are up to date with
mandatory Emergency Life Support training. In addition, the current system in place
makes it difficult for supervisors to check whether members of their team have received
mandatory training. | request that the working group, driven by Met training, review the
attendance of officers at mandatory ELS training and review the systems in place for
supervisors to monitor attendance. | request that in doing so they consider the
concerns raised by Inspector BC in his evidence at the Inquest.

itil? group to address this challenge and | have been supported by Commander
r from ‘Front Line Policing’. Together we have significantly reduced the number
of officers who are in need of training. In addition, new issue personal protective equipment is
not being given to officers until they are suitably trained and in-date. Corporate
communications have been published and the matter discussed personally with the
Commissioner in her regular MPS-wide on-line questions and answer sessions. On 12th July
2019 a news item was published on the MPS intranet site confirming this instruction to all
officers.

1|Page

Recognising that the current electronic training system ‘PSOP’ has some limitations on the
data being provided to supervisors, a request for a change with our external partner is being
progressed to allow a monthly compliance package to be produced and circulated to senior
managers. In the interim, the MPS is re-introducing a paper “Form 250C’ training card to be
carried by all officers which will be stamped with the date of their last attendance at an
approved Officer Safety Training/Emergency Life Support training session. This will make the
information more accessible for officers and supervisors to check compliance. As a shorter
term measure | have also issued local data packs to enable police commanders to readily
understand which of their officers are in need of up-to-date training. Ultimately it is a matter
for supervisors to know and account for their own officers and this expectation has been made
clear.

In the longer term, the MPS is actively exploring opportunities for OST and ELS training to be
built into team rosters making it a rostered tour of duty (as opposed to the self-service system
currently in place). This work is expected to deliver improvements from April 2020.

(2) The evidence at the Inquest did not provide assurance that a safety officer had taken
control of the restraint or that one officer was taking the lead in communicating with Mr
Da Costa and/or monitoring his condition. In addition, the officers who gave evidence
considered that the role of the safety officer mainly applied to restraint in a controlled
custody setting. The MPS are requested to review the training provided to staff in
relation to the role of the safety officer in a street setting and to consider whether a
reminder of the importance of the safety officer role, in the street setting, should be
issued to staff (by way of bulletin or otherwise).

The current training for the role of the safety officer covers environments to include custody
and street settings. The practice of instructing officers to take the lead when they are
controlling the head of a subject works well. The safety officer has a better communication
and monitoring ability with the subject of the restraint and all other officers have the training to
“speak up, speak out’. This method ensures everyone present is responsible for the subject’s
safety. We will however include this reminder in the OST refresher training package from 1st
October 2019. This new package will incorporate a presentation delivered by MPS trainers
reminding officers of the importance of identifying themselves as the safety officer throughout
the incident. In addition, they must provide evidence as to what action they took throughout
the incident referencing when they were the safety officer.

(3) The Inquest heard that it is well documented that members of the public may swallow
plastic bags to evade arrest or conceal evidence. Placing plastic bags in the mouth
raises a very high risk of choking. Police officers should be aware of these risks. The
MPS are requested to review the training provided to police officers to ensure they are
fully informed about the specific risks around the use of plastic bags and the associated
risk of choking.

Future restraint lessons will reference the revised Module 12 of the National Personal Safety
Manual (NPSM) which was presented by Inspector Collett during the Inquest as the final draft.
The revised Module 12 states the following:

“If there is suspicion of concealment of drugs or articles within the mouth, officers
should encourage subjects to empty their mouths voluntarily without the need for force.
If they refuse, officers may consider using reasonable force to encourage them to expel
the foreign object(s) from their mouth. However, the retrieval of evidence is always
secondary to the person’s welfare.

Incidents of choking have occurred due to objects falling into the airway owing to the
position of the subject’s body. This can be avoided if the subject's head and airway are

2|Page

tilted forwards. For this reason, the application of force to help expel suspected articles
from the mouth should only take place when the subject’s head is tilted forwards and
not in the supine (face up position). At all times officers must consider and monitor the
subject's airway and breathing and follow the basic life support training, as required.”

Following the deaths of Mr Da Costa and Mr Rashan Charles in 2017, the MPS suspended
the use of mouth searches by force on 3 October 2017. This was initiated by Deputy Assistant
Commissioner Matt Twist who commissioned a review into the technique. This then led to
revision of Module 12 of the National Personal Safety Manual. It now refers to the
‘management of suspected articles in the mouth’. The completed Module 12 was made
available to all chief constables by 14 June 2019. The MPS led this work and had full
oversight on the content of the final review.

As a result of the Inquest and this Regulation 28 Prevention of Future Deaths’ report, from 1st
October 2019 the MPS will highlight this in their training. In addition, further training has been
scheduled from April 2020 to include the officer safety restraint lesson on ‘prone resistance’.
This will reflect the findings of the Inquest and guidance around Module 12 considerations.
This will remind officers not to restrain a person suspected of having an object(s) in their mouth
if resources at that time cannot deal with the restraint safely; a reminder to treat as a medical
emergency will be reinforced.

(4) The evidence given at the Inquest hearing revealed a concern that the use of CS
spray, when a person has something in their mouth, could increase the risk of a
complete airway obstruction. The MPS is requested to review the guidance and
procedures in place for officers, in relation to the use of CS spray where a person is
believed to be holding items in their mouth.

The MPS has considered the expert testimony off EE rovided at the Inquest during
which he said that “...it is theoretically possible that CS spray in those circumstances could
perhaps make airway obstruction worse” (page 201 of transcript dated 29th May 2019). To
emphasise that he was making a theoretical point only, he further added “I am not an expert
on CS spray, it is something | have looked up .... There is to my knowledge no firm evidence
for what I am saying, it is a rational opinion (pages 200-201 of the court transcript dated 29th
May 2019).

The MPS is seeking medical evidence on this subject EE has sought authority to
commission a survey of police officers identifying how they react after exposure to CS spray.
This will provide initial evidence to progress further research into this matter. It is anticipated
once authority is granted this work will begin immediately.

The OST refresher training programme will include lessons to reference consideration of
tactics when faced with a person intent on trying to swallow drugs, assessing all tactical
options and justification, accounting and recording of which options were considered as well
as used. This is in line with wider existing National Decision Model training. Module 4 of the
NPSM (entitled Medical Implications) is currently under review to reflect the irritant position
and will state there is no current conclusive study confirming irritant spray as a causative
factor, however care should be taken. Consultation with stakeholders will take place prior to
publication.

Inspector Bruce Collett’s provided the following evidence at the Inquest, “The use of irritants
is a lower level of force than the application of physical force or restraint and the avoidance of
use of irritants may lead officers on to other tactics, which might include physical restraint.
This could present a higher threat level to the officers and place subjects at higher risk of
choking during this physical interaction (page 10 of the court transcript dated 5'" June 2019).

3|Page

(5) The evidence at the Inquest revealed that agonal breaths were likely to have been
missed. The officer provided the description of the breaths as looking like “yawning.”
The independent expert stated that these were, beyond reasonable doubt, agonal
breaths. The MPS is requested to review the training to officers around the recognition
of agonal breaths. Within the training, the MPS may wish to incorporate the helpful
descriptions provided by the officer in this case.

On 4th July 2019 Sue Warner tasked the MPS Clinical Panel and the National Clinical Panel
to identify appropriate video clips which demonstrate agonal breathing which can be shown
during ELS (Emergency Life Support) training. The same request was made to the National
Police Chiefs Council's First Aid Forum on 18th July 2019. From 1st October 2019 these video
clips will be introduced into the new Emergency Life Support programme to support the
existing training.

(6) Evidence was heard at the Inquest that errors were made in communicating
information to the LAS. This was in part due to the noise levels within the
communications command centre for the London Borough of Newham. The MPS is
requested to carry out an immediate review into the noise levels within the
communications command centre and to take steps to reduce noise levels as far as
possible. The longer term plans that the MPS have put in place to review their
communications command centre is very much welcomed but it is considered that
interim, proportionate measures should be explored.

A physical review at Bow MetCC took place on 11th July 2019 and was followed up on 30th
July 2019 by Mike Chinchen from the Strategic Health and Safety Department. Sound testing
revealed that there were no current issues. All entry doors into Despatch and First Contact
floors were checked for opening and closure noise. There was negligible noise generated
upon opening or closing any of the doors. However an inspection has now been carried out
by a contracted maintenance provider to check hinges. They have been found to be in working
order and unable to be adjusted further to reduce noise. A separate order was raised on 3rd
August 2019 to replace all doors for silent or near silent opening or closure and are expected
to be delivered within three to four weeks.

As a result of the review, it was identified that printers on the despatch floor were contributing
to the noise levels and as such have been moved to an area furthest away from the Operators.
On 2nd August 2019 sound reducing screening was erected around printers to further mitigate
noise distraction to all staff on the operational floor.

Communication was circulated on 12th August 2019 to all team duty officers to remind
Despatch Controllers and First Contact Supervisors to manage non-operational discussions
on the operational floors. Although it is almost impossible to create a completely sterile noise
working environment, this intervention by team Duty Officers should help mitigate further noise
distraction.

On 19th August 2019 further communication was circulated to all team Duty Officers offering
double ear headsets to staff within the First Contact and Despatch environment, which assists
in reducing outside noise. The issuing of these headsets will be phased with priority in the first
instance being given to those supported by an Occupational Health referral and line
management.

A recommendation will be made to implement all the above actions at all MetCC sites and the
work will be overseen by MetCC Buildings Manager, Marissa Howard.

4|Page

(7) The controller who was communicating with the LAS received information that Mr.
Da Costa had stopped breathing. She did not use the correct procedure to update the
LAS in relation to this life threatening deterioration. The MPS are requested to review
the operation of the procedure for updating CADs and to take any necessary action to
ensure that staff are fully aware of the correct procedure to be adopted.

There is an existing policy in place between the MPS and LAS regarding this matter. Itis clear
from this policy that on any occasion when the condition of the individual being dealt with by
the police either directly or indirectly undertakes a significant change, then a separate CAD
should be created and passed to the LAS with the update. LAS will re-triage the nature of the
injury and re-assess the priority and their subsequent response. The Memorandum of
Understanding between the MPS and LAS dated November 2018, states on page 8;

“Any updates to the original message can be completed via an EXP/LAS/INFO
command. However any significant deterioration of a patient’s condition will require a
new CAD message with EXP/LAS submission. This message must include the
reference to the original CAD and clearly state that the new CAD is for a significant
deterioration of a patient's condition.”

The new CAD will have its own time of origin but will be linked to the original CAD.

To this effect, on 2nd August 2019 a reminder was circulated to all staff via a weekly MetCC
Operational Update bulletin. This policy is emphasised in MetCC initial call handler training
and included in the next Personal Development Days (training days) in October 2019. It must
be stated however that although on this occasion the policy was not correctly complied with,
it is the experience of Team Duty Officers and Met Grip Chief Inspectors that no previous
issues have been identified and that the policy has been adhered to.

In Conclusion

Much of the work needed to review our compliance for OST and ELS training was underway
or complete prior to the Inquest. Module 12 of the National Personal Safety Manual was fully
reviewed by the MPS Officer Safety Unit prior to the Inquest with key adaptations to enhance
the welfare of subjects being detained. The Strategic Group led by Commander Dave Musker
and the monthly strategic meetings held by myself, will continue to drive forward improvements
in compliance. The learning from the Inquest will feature in the new programme of OST/ELS
training from 1st October 2019. OST and ELS training is continuously adapting and the
strategic and working groups may direct further changes as practices evolve.

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

Please do hesitate to contact me should require further information or clarification.

Yours sincerely

Matthew Horne
Deputy Assistant Commissioner

5|Page