Douglas Oak

ASSOCIATION OF

AMBULANCE

CHIEF EXECUTIVES
Association of Ambulance Chief Executives
Metal Box Factory (GG322)
25 November 2019 30 Great Guildford Street
. : London
BY EMAIL: coroner.service@bcpcouncil.gov.uk SE1 OHS

Rachael Clare Griffin 7 :
H M Senior Coroner for Dorset ;

Dear Ms Griffin
REGULATION 28 REPORT — ACTION TO PREVENT FUTURE DEATHS: DOUGLAS PAUL OAK

We are writing in response to the Regulation 28 report to prevent future deaths following the inquest
into the death of Douglas Oak which you issued on 24th October 2019 to Martin Flaherty on behalf of

the National Ambulance Service Medical Directors (NASMeD) and Anthony Marsh i

Association of Ambulance Chief Executives (AACE). We would like to clarify is the
Managing Director of AACE and in relation to this report we have liaised wit ho is
the Chair of NASMeD.

AACE is a formally constituted private company wholly owned by the English Ambulance NHS Trusts
who are all full voting members. Its primary focus is the ongoing development of the English
ambulance services and the improvement of patient care. It is a company owned by NHS
organisations and it wholly owns the intellectual property rights of the JRCALC UK ambulance service
clinical practice guidelines. NASMeD is a subgroup of AACE.

You requested that the NASMeD and AACE consider matters of concern and suggested that action is
taken to prevent future deaths. We will address each of your concerns, insofar as we are able.

i) NASMeD, and the Association of Ambulance Chief Executives (AACE) as its parent body, have
no involvement in the development of the content of First Aid manuals and are therefore unable
to assist with this matter.

ii) Joint guidance between the statutory ambulance services and the Police Forces is in
development, overseen by a joint committee of AACE and the National Ambulance
Commissioning Network, and supported by the ambulance and mental health group in NHS
England. NASMeD has requested development of ambulance guidelines by the Joint Royal
Colleges Ambulance Liaison Committee (JRCALC) and these are due to be ratified shortly. The
guidelines have been developed following consultation with the Faculty of Forensic and Legal
Medicine (FFLM) and the Faculty of Pre-Hospital Care (FPHC).

The provision of chemical sedation by all paramedics is a matter of contention, and one which we
have previously discussed on more than one occasion with EEE including in
national conference with the Police in December 2018. Chemical sedation for any indication and,
perhaps more importantly, the skills to manage a chemically sedated patient falls outside the
scope of practice of frontline ambulance paramedics. In addition, the infrequency with which they
would need to practise these skills would lead to skill fade and poses a risk to patient safety.

Dr Mark does not agree with EEE position that “chemical sedation or
tranquillisation is often the best way to calm a person suffering with ABD”. A two-year audit by
London Ambulance Service NHS Trust, the results of which are known to Dr Yong, demonstrated

Chairman: Professor Anthony C Marsh QAM SBStJ DSci (Hon) MBA MSc MA FASI
Managing Director: Martin Flaherty OBE

ili)

iv)

vi)

vii)

that 62% of patients with suspected ABD, attended by Advanced Paramedics who were trained in
chemical sedation, were successfully managed using only verbal de-escalation techniques.

Work is ongoing, between Yorkshire Ambulance Service NHS Trust and the four Yorkshire and
Humber Police Forces on behalf of the national groups described above, to establish the most
appropriate response categorisation for patients with suspected ABD. The first component of this
study is due to conclude in March 2020 and will report shortly afterwards. The framework for the
study was devised following consultation with all English Police Forces.

The primary goal in the prehospital management of patients with suspected ABD is rapid transfer
to an Emergency Department for further assessment and intervention as indicated therefrom. It
may be that on an individual case by case basis, in consultation with Police and Ambulance
control rooms, the most appropriate management for a patient with ABD is transfer by the Police
to an Emergency Department. The study described above is exploring this and other options.

Following the publication of the JRCALC guideline on ABD there will be an expectation that all
statutory ambulance services will ensure that their frontline staff are aware of, and cognisant with,
its contents and ambulance control staff are also made aware of the new guidance.

Following the outcome of the study described above recommendations will be made to the NHS
England lead group which oversees emergency call prioritisation to incorporate specific response
categorisation for patients with suspected ABD.

Annual refresher training in ABD is disproportionate given the incidence of these cases and the
need to maintain and develop the broad range of competencies required of a frontline paramedic
in a statutory ambulance service. We believe each of the English ambulance services receives
two or three calls each week for patients with suspected ABD, amongst two to four thousand 999
calls per day. Whilst NASMeD or AACE is not in a position to mandate training requirements, we
would not support a recommendation for annual refresher training on this subject.

We do not believe that the absence of common terminology or the use of the term ‘on the hurry
up’ was the issue. The ambulance response to all incidents are prioritised on information based
on the patients presenting condition. Therefore it is essential to obtain appropriate information
about the patient’s condition, and that this is passed from police to ambulance services in order to
correctly prioritise the response and this will be our principal focus of ongoing work with the police
Once the new guidance on ABD has been ratified and issued and the trial in Yorkshire as
described in point ii above has been completed, we will continue to discuss this in our work with
the police to improve communications between ambulance and police control rooms.

On the subject of cross working with emergency services, whilst we understand the motivation
behind the evidence given, in practice, where ambulance trusts have placed clinicians in Police
control rooms, it has not proven to be an efficient operating model. Improving communications
and operating practices appears to be at the heart of this recommendation and we feel this would
be best addressed through the arrangements to improve the joint working between police and
ambulance services. As described in point v) above we would propose to develop this in close
partnership with the police.

The provision of training for control room staff in ambulance services will be considered following
recommendations that arise from the response categorisation study described in point ii above.

vill) We welcome the development of clinical governance partnerships between Emergency Services,

rather than Police Clinical Governance Boards that operate independently of the ambulance
service. The development of partnerships would assist in addressing the interoperability issues
you have highlighted in your report.

Chairman: Professor Anthony C Marsh QAM SBStJ DSci (Hon) MBA MSc MA FASI
Managing Director: Martin Flaherty OBE

ix) AACE agree with the evidence offered > EE that a direct call from the Police Officer on
scene to the ambulance control room (either through dialling 999 or use of Airwave radio) is likely
to result in more accurate triage of the patient’s condition and better assessment of the
appropriate response priority. AACE have previously shared this view with the National Police
Chiefs Council (NPCC) and with the multi-agency Emergency Services Demand Management
Group (ESDMG) chaired by the Home Office.

AACE understand the cultural and practical barriers raised by the NPCC and accept that direct
communication from the Police Officer on scene may not always be practicable. Ambulance
trusts have locally agreed arrangements for the passage of information between Police and
Ambulance control rooms. This is best determined at a local level due to differing technologies
and working practices.

For example, in London the Police and Ambulance Computer Aided Dispatch (CAD) technologies
are linked enabling direct passage of information with no voice contact by phone. In some
ambulance services, requests from Police control rooms are directed through the 999 system and
in others there is a dedicated phone number for contact between Police and Ambulance control
rooms.

Where an ambulance trust has agreed arrangements with the Police for a dedicated phone line
for the passage of emergency requests for ambulance attendance it would seem important to
ensure that the speed with which the phone is answered is in line with 999 call answering. AACE
will share this, and the other operational considerations outlined in this report, with the National
Directors of Operations Group (NDOG) for ambulance services.

X) Prior to your report, the subject of the recognition and management of ABD in the prehospital
environment had already received considerable attention and work has been progressing to
address this complex topic, as described above. South West Ambulance Service NHS
Foundation Trust have been appraised of this work through NASMeD. Our work nationally will
continue to progress in this important area as soon as practicable, as described in the other
points within this report.

xi) This report and our ongoing work will be discussed and shared at future meetings of NASMeD,
NDOG and with the Ambulance Chief Executives Group.

| hope that you will agree that we have responded to the concerns that you have raised and explained
our reasoning. We can assure you that we are absolutely committed to learning from all such adverse
events and doing everything within our power to prevent them happening again in the future.

If we may be of further assistance, please do not hesitate to contact us.

We would like to extend our sincere condolences to the family of Mr Oak.

Yours sincerely

Martin Flaherty OBE
Managing Director

Chairman: Professor Anthony C Marsh QAM SBStJ DSci (Hon) MBA MSc MA FASI
Managing Director: Martin Flaherty OBE

C O | le g e of College of Policing college. police.uk
Leamington Road
e ° Ryton-on-Dunsmore
Policin aa
e) CV8 3EN
T 02476 639639

F 02476 639172
contactus@college.pnn.police.uk

Rachael Clare Griffin
H M Senior Coroner for Dorset

Dear Ms Griffin
Re: Douglas Paul Oak (Deceased)

We write on behalf of the College of Policing (the College) and National Police Chiefs Council (NPCC) in
relation to paragraph 7, Schedule 5 of the Coroners and Justice Act 2009, and regulations 28 and 29 of the
Coroners (Investigations) Regulations 2013, prevention of future deaths reports to the College and to the
NPCC, both dated the 24'" October 2019. Whilst the College and the NPCC have separate and distinct
responsibilities, the two organisations frequently work together on national approaches to policing policy. As
such, this response is provided jointly in respect of both organisations’ separate prevention of future deaths
reports.

The notice sets out concern that arose from the information received during the inquest in to the death of Mr
Oak. We are very sorry to read of the circumstances of Doug’s death. Our sympathies are with his family
and friends and we share your commitment to addressing the issues that contributed to his untimely loss.

The notice sets out your principle concerns which were in respect of the recognition of ABD as a matter
requiring an immediate medical response and the communication and coordination between the police and
ambulance service who responded to Mr Oak. You specifically asked for a response in relation to a number
of areas for concern in which the College of Policing and NPCC would have involvement.

The College is the independent professional body supporting everyone working in policing to reduce crime
and keep people safe. The College has three complementary functions

e Sharing knowledge and good practice: creating and maintaining easy access to knowledge,
disseminating good practice, and facilitating the sharing of what works

¢ Setting standards: setting standards for key areas of policing which help forces and individuals provide
consistency and better service for the public

« Supporting professional development: setting requirements, accrediting, quality assuring and delivering
learning and professional development, promoting diversity and wellbeing, and helping to nurture and
select leaders at all levels.

The NPCC brings police forces in the UK together to help policing coordinate operations, reform, improve
and provide value for money. It does this in fulfilment of its six primary functions, those being:

e The co-ordination of national operations including defining, monitoring and testing force contributions to
the Strategic Policing Requirement, and working with the National Crime Agency where appropriate

e The command of counter terrorism operations and delivery of counter terrorist policing through the
national network as set out in the Counter Terrorism Collaboration Agreement

e The co-ordination of the national police response to national emergencies and the co-ordination of the
mobilisation of resources across force borders and internationally

olicing Limited 1s a cornpany ceqistered in England and Wales,

e The national operational implementation of standards and policy as set by the College of Policing and
Government

e To work with the College of Policing, to develop joint national approaches on criminal justice, value for
money, service transformation, information management, performance management and technology

e Where appropriate, to work with the College of Policing in order to develop joint national approaches to
staff and human resource issues, including misconduct and discipline, in line with the Chief Officers’
responsibilities as employers

The College works closely with the NPCC to ensure that the guidance and standards that it sets are likely to
be effective in supporting police officers and staff in their principle roles of keeping the public safe and
reducing crime. Where the work of the police overlaps with other agencies or bodies the College and NPCC
also seek to ensure that we work together to jointly address areas of risk and concern.

The College and NPCC are particularly concerned to learn lessons from circumstances such as those that
were involved in Mr Oak’s death. We have processes in place to formally consider Prevention of Future
Death (PFD) notices and the concerns they contain.

In this letter we have set out the responses of the College and the NPCC to each of the concerns that you
have raised in your letter.

i. There is a lack of awareness generally regarding ABD and | would request consideration is given to
the inclusion of the signs, symptoms and management of ABD within the First Aid Manual so that all those
trained in first aid are able to deal with a patient presenting with ABD.

The College First Aid Learning Programme (FALP) already includes a learning outcome for recognising
Acute Behavioural Disorder (ABD) as part of Module 3 (relating to first aid in a custody setting). In light of the
above cause for concern the College will work with police stakeholders through the NPCC First Aid Forum
and the national clinical governance panel to reflect this learning outcome in Module 2, the refresher training
module for front line staff. This will ensure that this training is given to all front line officers. This amendment
will be made as part of the wider scheduled review of the FALP following the release of updated guidance by
the UK Resuscitation Council in 2020.

Officers undergo personal safety training (PST) every year with the content varying in line with national
priorities and local need. The PST is informed by the content of the National Personal Safety Manual
(NPSM) which is developed jointly by the College and NPCC and published to policing by the College. ABD
training also sits within NPSM contained in Module 4: Medical Implications. This part of the Manual is
currently undergoing a full review by Dr Meng Aw-Yong. This is in response to a number of changes that
have been included over the past 12 months due to PFD notices. An interim update to the information has
been agreed with Dr Meng and will be instigated in the near future. Each change to Module 4 is
communicated to forces so that they and their PST trainers are aware.

The College and NPCC have developed a PowerPoint presentation on ABD which describes the
behavioural and physical signs of ABD and makes very clear the need for rapid clinical
assessmentintervention. The ABD PowerPoint was developed with the benefit of clinical input and was last
updated in July 2019.

The ABD PowerPoint covers the bullet points raised above by HM Coroner, containing the latest information
on recognising ABD, the management which includes containment, de-escalation, implementation of a MOU

with ambulance trusts to respond as a category 1 cali, sedation where necessary and transfer options for a
person suffering from ABD.

Each update is communicated to forces by the NPCC Self Defence and Restraint (SDAR) Lead, Deputy
Assistant Commissioner Matt Twist, NPCC Custody Portfolio Lead, Deputy Chief Constable Neville Kemp
and the College posts the changes on POLKA (a site that enables the college to share learning) and the
Managed Learning Environment (MLE) which hosts on line learning materials for the police service.

We welcome the feedback that officers involved in responding to Mr Oak were able to identify ABD as a
medical emergency shortly after attending.

Recognising that concern about awareness of ABD extends beyond the police and ambulance services the
College and NPCC will share the PowerPoint presentation on ABD with the Tripartite Committee who
publish the First Aid Manual. The College and NPCC hope that this collaboration will increase knowledge of
ABD amongst the first aid societies (St John Ambulance, The British Red Cross and St Andrews First Aid)
and ultimately the public.

The ABD PowerPoint has already been shared with NHS Trusts and Ambulance partners. The PowerPoint
is aimed at frontline police officers and the College and NPCC have made it clear that ambulance partners
are at liberty to utilise and amend the PowerPoint, as appropriate, to meet the needs of their staff

ii. There is no joint national guidance on the management of ABD by those who work for the Police and
Ambulance Services, both on the front-line and in the control rooms. They are the people most likely to
encounter those suffering with ABD and in most cases work together in the management of these patients.
Accordingly, | request consideration is given to providing joint national guidance on the management of ABD
patients by the Police and Ambulance Services to include:

. the provision of chemical sedation in pre-hospital care

. the training of all paramedics in administering chemical sedation
. the categorisation of Emergency Service calls relating to ABD

. the transfer of an ABD patient to hospital

The College has recently joined the NHS Clinical Commissioners National Mental Health forum at which the
ambulance service are represented. At the last meeting on 18 November 2019, this PFD notice was
discussed to help formulate a joint response to some of the concerns you raise that cover both emergency
services. The police and ambulance services are committed to raising awareness of ABD and have an
ongoing programme of work to achieve this. The ABD PowerPoint has been made available to ambulance
trusts as described above. As well as the content already mentioned, it also addresses the importance of
appropriate conveyance for these patients which would be in an ambulance unless a dynamic risk
assessment identified the need to use police transport.

The other matters within this area for concern (chemical sedation and categorisation of calls) are clinical
matters in which police officers would not be directly involved other than to ensure that the ambulance
service has access to the information that it needs. Police officers would defer to ambulance colleagues in
these matters. |

The College and NPCC are aware of the current good practice that exist in London where the London
Ambulance Service would respond to calis of suspected ABD by Metropolitan Police Service officers and
where appropriate paramedics would sedate cases of suspected ABD and that Surrey Police and
SECAMBE will have a similar process (MOU) in place. The ABD PowerPoint reinforces the necessity of
such an MOU between all police forces and ambulance trusts.

The College and NPCC are aware of a pilot across the Yorkshire forces where police and ambulance
services in this region are trialling new ways of prioritising and responding to cases of ABD. The pilot will
review patient care from start to finish and as part of this trial the Yorkshire Ambulance Service have agreed
to respond to all ABD calls as a category 1 response. The College is linked in with the local team in relation
to this and when this pilot concludes in early 2020 the outcomes will be assessed with a view to sharing this
knowledge across policing and health.

fii. | believe it is likely there are persons working within Ambulance Service Trusts and Police Forces,
whether it be on the front line or in the control room who are not aware of ABD and the serious risk to life it
presents. | therefore request that consideration is given to ensuring all those working on the front line, or in
control rooms in Ambulance Service Trusts and Police Forces in England and Wales are trained in ABD.

The College is in the process of refreshing the National Contact Management Learning Programme
(NCMLP). This is a detailed set of learning standards that forces use to develop their local training for all
contact management staff including those taking calls from the public and tasking and informing resources
who respond. In this refresh we will include the importance of call handlers and dispatches understanding
the medical emergency that is ABD. This will complement the ABD presentation referred to below.

The NPCC is working with and Subject Matter Experts in police and ambulance (SECAMBE
and LAS) Control Rooms to produce a PowerPoint on ABD specifically for police and ambulance control room
staff. This PowerPoint will form the basis of a template for both police force or ambulance trusts to train their
staff with the aim of teaching recognition of ABD and the risk to life, thereby standardising the language and
response to ABD (point 2.v). For the first time this PowerPoint is also endorsed by the Independent Ambulance
Association and Heath Practice Associates (Council) increasing the reach of the material. We will also share
this with the Association of Ambulance Chief Executives or the National Ambulance Service Medical Directors.

iv. | also have concerns in relation to the frequency of the delivery of the training referred to in (iii) and |
therefore request consideration be given to that training being delivered regularly, at least on an annual
basis and with a variety of training techniques, including simulation and role play scenarios.

The learning outcomes relating to ABD will in future be contained within Module 2 of the FALP.
Consequently this will feature as part of the structured refresher training, which is completed annually, on a
rolling three year cycle of content.

Those officers and staff who attend PST have refresher training on a yearly basis. This training varies
depending on national and force priorities.

The College and NPCC have a current programme of work to develop a national PST curriculum to improve
national consistency. The potential impact of restraint on a person with ABD is well recognised, highlighted
and communicated in both the NPSM and the PST through the use of the ABD PowerPoint. The
presentation has video content which illustrates ABD to assist officers in recognising the signs.

The College has produced Conflict Management Guidelines which contain information to assist in the
development of de-escalation training and skills for front line staff. The College and NPCC will shortly be
piloting conflict management/de-escalation training as part of its work to develop the national PST
curriculum. The approach involves the use of role play as well as presentations and didactic learning. The
College Guidelines recommend that role plays include resolution through de-escalation and of the medical
impacts of any physical intervention used by learners.

Through first aid and PST officers will receive training focusing on ABD at least every three years and
probably more frequently in practice. The first aid and PST training represent a minimum requirement,
balanced against the other significant training police officers require for their role. It would not be

proportionate to mandate more frequent training given the tens of thousands of staff involved and the
relative infrequency of incidents where ABD is suspected to be a factor. Chief Officers do retain the ability to
direct additional training in both PST and first aid provision where specific local needs are identified.

v. Given that the Police and Ambulance Services work very closely in treating and managing a patient
with ABD, and other patients who present with life threatening conditions, it is important that they understand
each other. It was clear from this Inquest that there is different terminology used by the different services,

the meaning of which is not understood by the other Emergency Services. An example of this was the use of
the phrase ‘on the hurry up’. Although the confusion regarding this terminology was not found to be
causative or contributory to Doug’s death, it could be in respect of a future death. | therefore request that
consideration is given to the joint national training packages for all Emergency Services, namely the Police
Service, Ambulance Service and the Fire Service on the workings within each control room and around the
language used in the control rooms.

The ABD PowerPoint and NPSM content make it clear that cases suspected to be ABD are to be treated as
a medical emergency and that immediate medical attention is sought. In addition the control room version of
the ABD PowerPoint will assist in standardising the terminology used with regard to ABD

We accept that clarity in language is important when communicating across emergency services. Contact
Management officers and staff are trained to enquire and probe for additional details when‘receiving calls
and our experience leads us to believe that there are seldom misunderstandings in relation to the
importance of response required. It is however recognised that the ambulance service triage each call based
on the description of the medical presentation of the patient not on the type of illness being stated.

The College and the NPCC will continue to work at a national level to secure greater consistency in the
recognition and prioritisation of ABD. It is also our position that forces should discuss communication issues
with their local emergency service providers.

vi. Extending this point further, evidence was given that there would be benefit in cross working within
the emergency services, so for example an Ambulance Clinician working within the Police control room to
provide advice. | would therefore request that consideration is given on a national level to cross working
within the emergency services.

The College is aware of a number of schemes involving police forces across England & Wales having direct
access to clinical advice that looks to support people in mental health crisis. We are working with
Nottinghamshire University to evaluate these schemes following a recommendation from HMICFRS to give
greater clarity on any system wide benefits from adopting such schemes. This is due to report in early 2020
and will be shared across policing and ambulance service commissioners/trusts.

The College and NPCC are aware that Surrey Police, in conjunction with SECAMBE ambulance trust, will be
working on a joint training exercise involving contro! room and officers responding to ABD

vil. In relation to the training package that has been provided by the College of Policing regarding ABD,
although EE bas recommended this could be rolled out to control room staff, the package is tailored
for front-line staff. | would therefore request consideration is given to a specific training package on ABD
being designed and rolled out to those working in the control room environment by the College of Policing
together with the Association of Ambulance Chief Executives or the National Ambulance Service Medical
Directors.

As stated above. The refreshed NCMLP will feature ABD to raise awareness among control room staff. In

the meantime the College will ask the NPCC national lead for Contact Management, ACC HEEE( Police
Service of Northern Ireland) to circulate the ABD PowerPoint presentation to force leads, with advice on how
this could be delivered locally to brief staff working in control rooms.

viii Evidence was given that Dorset Police have established a Clinical Governance Board which helps to
create an awareness of, and improvement in, medical care provided by those working in the Police Service.
This is not something adopted by all Police Forces in England and Wales and | therefore request that
consideration is given to setting up a Clinical Governance Board in every Police Force in England and
Wales. a

The need for forces to establish local clinical governance is already a condition of the use of the College of
Policing’s licence for the FALP. Additionally, the NPCC, through the National Clinical governance Group,
has issued guidance reiterating this requirement and articulating the specific requirements of good clinical
governance. Joint work through the College of Policing and the NPCC First Aid Forum has already
commenced to ensure that forces have developed suitable clinical governance structures.

With the support of the NPCC lead we have written to all force first aid and governance leads to remind of
this requirement.

It may assist HM Senior Coroner to know that there is also currently a Clinical Advice Panel in the Metropolitan
Police Service which operates on a similar (voluntary) basis as the Clinical Governance Board in Dorset.

The NPCC recognises the importance of Clinical Governance and multiagency working in developing safe
working systems. The NPCC together with the College will be developing a Medical and Police Advisory
Committee (MAPAC) with medical representation from each of the 9 police regions. These doctors will come
from Emergency Medicine where the bulk of medical/police interactions take place. The MAPAC will form local
liaisons with hospital and individual police forces and local ambulance trusts.

As HM Coroner may be aware many police forces have commissioned their healthcare provision to external
providers. NHS England has a group of advisors as part of the National Liaison & Diversion & Police
Healthcare team. This operates on a strategic level developing national policy and the national service
specification for commissioning of these providers. The next re-iteration of this service specification will
include awareness of medical conditions including ABD and its management.

ix. It was clear from the evidence that there appears to be confusion of when Dorset Police Officers
should call 999 directly and when they should request assistance through the Police control room. | would
request that there is consideration of the redrafting of the current “Police Requesting Ambulance Support”
policy within Dorset Police and specifically when Police Officers should dial 999. In addition, | would request
consideration of training be provided by Dorset Police to all Police Officers regarding the use of dialling 999
when contacting other Emergency Services. In doing this | would ask that consideration is given to liaising
with the other local emergency services regarding their expectations, especially SWAST.

The College and NPCC position is that forces should discuss communication issues with their local
emergency service providers.

x. Given the number of relatively recent deaths associated with ABD that have resulted in reports such
as this being issued by my fellow Coroners, and the fact that all of the above points | have raised still create
a risk of future deaths due to the lack of national guidance and policy, | would request that the concerns |
have raised in this report are given immediate attention. | further request urgency is taken in responding to
this report and taking any action deemed appropriate. This is a sentiment very much echoed by Doug’s

family, who are very keen to assist the authorities following their tragic loss to prevent any future deaths
occurring in similar circumstances to Doug’s death.

As already covered in this response the College and NPCC are working with forces and medical service
partners to address the concerns raised in this report. We are undertaking both immediate and longer term
steps to raise awareness and consistency in the recognition and response to ABD which we recognise
continues to present a very significant risk to those who experience it.

Xi. In addition, | would request that those in receipt of this report make the individual Police Forces and

Ambulance Services within England and Wales aware of the risks surrounding ABD as a matter of urgency

and consider forwarding this report to all Chief Constables and Chief Executives of the Ambulance Services
in England and Wales.

The Chair of the NPCC will be writing to all Chief Constables to bring the content of this PFD and the
proposed response to their attention.

The College and NPCC are committed to continuing their work with forces, the NPCC and other agencies to
raise standards of practice in the care of suspects who come to police attention. This includes their safe
restraint and care if they are subject to police detention. We would like to thank you for bringing the
circumstances of Mr Oak’s death to our attention so that we can ensure that our immediate and future work
is informed by the events that culminated in his death.

Yours sincerely,

reo fon tasecagiion

Martin Hewitt QPM Mike Cunningham
Chair, National Police Chiefs’ Council CEO, College of Policing

Department
of Health &
Social Care
Department of Health & Social Care
Quarry House
Quarry Hill
Leeds
LS2 7UA

Mrs Rachael Griffin

HM Senior Coroner, Dorset
The Coroner's Office

Town Hail

Bournemouth

BH2 6DY

Your Reference: RCG/01301-2017/LJ
Our Reference: PFD1195251

7 November 2019

Dear Mrs Griffin
Prevention of Future Deaths Report (Douglas Paul Oak)

| am writing to you in relation to a Prevention of Future Deaths Report issued to the
Department of Health and Social Care on 24 October 2019, following the inquest into the
death of Douglas Paul Oak.

As you will be aware, a General Election will take place on Thursday 12 December
2019. Dissolution of Parliament happened on 6 November and there will now be a five-
week pre-election period.

General Elections have a number of implications for the work of Government
departments. In line with Cabinet Office guidelines, it is customary for Ministers to
observe discretion in initiating any new action of a continuing character. The guidelines
further recommend that matters of policy on which a new Government might be
expected to want to take a view should be postponed until after the election, provided
that such postponement would not be detrimental to the national interest or wasteful of
public money.

ae

Department
of Health &
Social Care

My purpose in writing to you is to advise that it is unlikely the Department will be able to
respond to your report by the deadline of 19 December 2019.

The Department respectfully submits that an extension to your deadline to a time when a
new administration is in place, Ministerial appointments have been made and incoming
Ministers have an opportunity to consider your report, would enable a full response to be
made.

The Department will ensure that your office is contacted to discuss, and agree, a new,
appropriate deadline once a new administration is in place.

| appreciate that the Department's delay in responding will be disappointing. However,

we will work to ensure the concerns you have raised are considered carefully and that a
full response is provided as soon as possible.

Yours sincerely

so ale
a

Senior Policy Manager, Patient Safety

=

St John

Ambulance

Rachael Griffin

HM Senior Coroner for Dorset

The Coroner’s Office for the County of Dorset
Town Hall

Bournemouth

BH2 6DY

3 December 2019

Dear Ms Griffin,

Further to your letter dated 24" October 2019 regarding the Report to Prevent Future Deaths, | can
confirm that St John Ambulance are providing additional Continuous Professional Development
training around Acute Behavioural Disturbance.

As one of the co-authors of the First Aid Manual we have raised this at the Tripartite Committee

who oversee the publication. The latest version of the manual is being written and we will push to
get this topic covered.

Yours sincerely.

Dr'Lynn Thomas

MStJ, BSc, MBBS, MA, FRCP
Medical Director St John Ambulance
27 St John’s Lane

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