Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0017, written 21 Jan 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 Jan 2020 |
|---|---|
| Reference | 2020-0017 |
| Deceased | Jason Devoti |
| Coroner | David Reid |
| Coroner area | Worcestershire |
| Category | Alcohol, drug and medication related deaths · Emergency services related deaths (2019 onwards) · Mental Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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 THIS REPORT IS BEING SENT TO: 1. Dave THOMPSON, Chief Constable West Midlands Police CORONER lam David REID, H.M. Senior Coroner for the coroner area of Worcestershire. 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 and INQUEST [the details below are fictional] On 12 December 2018 | commenced an investigation into the death of Jason Paul DEVOTI, then aged 46. The investigation concluded at the end of the inquest on 10 January 2020. The conclusion of the inquest was misadventure, the medical cause of death being: 1a acute ethyl! alcohol poisoning. | CIRCUMSTANCES OF THE DEATH (1) Jason Devoti had a history of mental health issues and alcohol dependency. In the weeks leading up to his death he had had a number of hospital admissions having been heavily intoxicated and expressing suicidal thoughts. Mental health assessments found him not to be suffering from any enduring mental illness, but rather to be someone who, when under the influence of alcohol, was more likely to engage in risk-taking behaviour. (2) On 5 October 2018 Jason was admitted to the Alexandra Hospital, Redditch having told paramedics that he had taken an intentional overdose of diazepam and drunk half a bottle of vodka. On arrival at hospital he denied any overdose, and having been medically and mentally assessed, was discharged. At the time of his discharge, he was unable to return to his mother's address ( where he had been staying ) and therefore attended the offices of Redditch Borough Council, who arranged accommodation for him in Aston, Birmingham, through an agency called Select Homes. He was taken to Select Homes' offices by taxi, and from there to the accommodation at (3 Later that day, in the afternoon/early evening Jason spoke to his mother by phone and confirmed that he had arrived at the address. That was the last contact he had with any member of his family. (4) On 7 October 2018, there having been no further contact from Jason, his sister now phoned West Mercia Police expressing concerns about his safety. at time, the family were unable to provide the police with Jason's address. West Mercia Police carried out a number of enquiries and, having failed to locate him, classified him as a Medium risk Missing Person, i.e. the risk of harm to Jason was assessed as likely but not serious. (5) On the morning of 8 October 2018 West Mercia Police identified the address at which Jason was believed to be staying. As a result, they emailed West Midlands Police ( within whose area the address fell ) at 1235hrs asking them to carry out a check on Jason at the address. In that email, West Midlands Police were advised of the recent background history, the risk level ( Medium ) and the contact details of the landlord of the address. (6) West Midlands Police accepted the request, and created their own incident log requiring a P2 priority response. This required officers to attend the address within 60 minutes. The incident log was transferred to and accepted by a Dispatcher within the Bournville control room at 1331hrs. That log was not looked at by 3 consecutive Dispatchers, despite having become overdue after 6 hours at 1931hrs. When a Dispatcher did eventually look at the log at 0653hrs the following morning ( 9 October 2018 ) he entered "for allocation when resourcing allows" because there were no officers available to attend the address. (7 During the course of the morning of 9 October 2018, having heard nothing from West Midlands Police, West Mercia Police continued their enquiries, and eventually arranged for one of their officers to meet the landlord at the [I dress. They discovered Jason deceased in his room at the address at 1140hrs that morning. (8) By the time of Jason's discovery West Midlands Police had taken no action in respect of their incident log, despite having accepted the incident and opened a log more than 22 hours earlier, and despite the incident being graded as a P2 priority response by them. (9) At inquest, the pathologist who carried out the post-mortem examination on Jason confirmed in evidence that: (a) Jason died as the result of acute ethyl alcohol poisoning ( his blood alcohol level was 483mg/dL; his urine alcohol level was >500mg/dL ); (b) it was not possible to say when he died; (c) whenever he did die, it is probable that he was consuming alcoho! within the 12 hours before his death ( as opposed to within the 12 hours before he was found at 1140hrs on 9.10.18 ); (d) it is possible that he was alive at 1430hrs on 8 October 2018 (i.e. an hour after West Midlands Police accepted the incident ), but no more likely he was alive then than at any other specific time; (€) if he had been found unconscious at 1430hrs, it is possible that treatment may have saved his life ( but one can't say higher than that ). CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. — (1) Chief Inspector FY who investigated the incident on behalf of West Midlands Police, accepted in his evidence to the inquest that the West Midlands Police had failed not only to deal this particular incident log, but also many other P2 incident logs which were open at the time, as they should have; (2) The four police Dispatchers working in the Bournville control room gave evidence to the inquest that: (a) At the time of these events a very large number ( 150-200 ) of P2 incident logs would regularly be outstanding at the beginning of a shift; (b) That many of those logs would be "overdue" — which meant not only that they had passed the one hour deadline, but in fact that more than 6 hours had passed since the log was last looked at; (c) That those operating the terminals which would have to try to deal with these logs were overwhelmed by the number of logs they had to deal with; (d) That if there was an escalation process in force at the time, then: (i) Either dispatchers were not sufficiently aware of the process so as to be able to act in accordance with it; or (ii) They were being given the impression by supervisors that there was little point in escalating overdue logs to them, as there was little that could be done; (e) That the reason for the large number of logs being overdue was mainly because there were insufficient officers to deploy to incidents, but also because there were not enough staff in the control room to work through the logs; (f) That_measures taken to reduce the number of overdue logs ( known as ) would provide only temporary respite before the number of overdue logs built up again; (g) That at various times since these events, there had been little improvement in_the situation: in January 2019 the situation was "still overwhelming" in June 2019 there would always be a lot of overdue logs ( ); in October 2019 there were still too many P2 logs that were not being dealt with in time ( [MM] ); the current situation is "a little better" in that "more robust decisions are being taken by call takers", but there are still problems now, and "the crux is that we don't have enough police officers on the streets to deal with incidents" ( i. (3) | heard evidence from a a Senior Leader within the West Midlands Police's Force Contact Department about changes which have been put in place to try to deal with the problems identified above. | was told that: (a) Figures suggested that compared with a backlog of 189 P2 logs in the Bournville Control Room in October 2018, there were 54 P2 logs open on 8.10.19, and 27 open on 7.1.20; (b) Anew Command & Control system is due to be introduced shortly; (c) The triage terminal at Bournville would no longer hold onto open logs, but would only review new logs and pass them onto other terminals straightaway; (d) Dispatchers would be able to identify differing levels of risk within P2 incidents, and tag those with higher levels of risk for supervisors to be aware of; Whilst there were still the same numbers of logs coming through, control rooms were better able to manage how to deal with them, resulting in a decrease in the number of outstanding logs which required resourcing. (e (4 > In order to try to assist with understanding the figures involved, | was provided with a number of tables designed to give a "snapshot" of current logs and available police resources at particular times, viz. 8-9 October 2018, 8 October 2019 and 7 October 2020. In my view, this provided limited assistance as (a) the column giving the total of logs open appeared to be incorrect as it did not tally with the figures within other columns; and (b) it was not possible to see how many of the open logs were overdue, and in particular how many of the P2 logs had passed the critical one hour mark without a response. (5) | am concerned at how overwhelmed those working in the Bournville control room had been by the increased demand on resources, and how their views about any improvement in the situation in the months following Jason's death did not appear to match what | was told by J | was also concerned about the lack of awareness of and implementation of whatever escalation process may have been in place in the control room at the time of these events; this suggests a lack of appropriate training. Whilst | understand that the West Midlands force is undergoing a period of transition so far as their control rooms are concerned, | am not satisfied that measures have yet been put in place to ensure that all those working in control rooms have received sufficient and appropriate training to deal with situations of increased demand. _(6) | therefore remain concerned that in times of increased demand, and particularly unanticipated demand, there is a risk that West Midlands Police will be unable to | resource and attend a P2 incident within the 60 minute period that is their stated aim, and that that in turn will create a risk of death of the subject of such a P2 incident, if vulnerable and at some risk of harm as Jason Devoti undoubtedly was. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 13 March 2020. |, 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 | have sent a copy of my report to the Chief Coroner and to the following Interested Persons: (1) Deighton Pierce Glynn solicitors, who act for Jason Devoti's family; (2) West Mercia Police; (3) Independent Office for Police Conduct. | have also sent it to David Jamieson, West Midlands Police & Crime Commissioner who may find it useful or of interest. | am 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. 24 January 2020 Signed: rT wa
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.
Keeping our Communities Safe and Reassured Preventing crime, protecting the public and helping those in need STAFFORDSHIRE AND WEST MIDLANDS POLICE JOINT LEGAL SERVICES Director of Legal Services VIA EMAIL ONLY coroner@worcestershire.gov.uk Worcestershire Coroner’s Court The Civic, Martins Way Stourport on Severn Worcestershire DY13 8UN Dear Sir, Your Ref: GUW/TW/28229 Our Ref: L14002682/NB Email: jointlegalservices@west-midlands.pnn.police.uk Date: 30 April, 2020 Inquest touching the death of Jason Devoti Regulation 29 response to a report on action to prevent other deaths Please find attached to the end of this letter, the Chief Constable’s response to the PFD report from the Coroner. Firstly I must apologise for the delay in this being sent to you but I am sure you can appreciate with the critical issues that have arisen from COVID-19 it has been difficult to get this finalised. I hope this response provides some reassurance to the Coroner and the family in this matter that the Chief Constable and West Midlands Police Force have and will continue to take all necessary steps to ensure our procedures and practices are reviewed and are fit for purpose to meet the challenges when dealing with calls in Force Contact. Also that the necessary steps to train and support staff are in place and will be reviewed on a regular basis. If I can assist further please do not hesitate to contact me. Please reply to: Birmingham Office: Joint Legal Services West Midlands Police Lloyd House, Colmore Circus Birmingham, B4 6NQ Tel: 0121 626 8317 Fax: 0121 626 8272 Staffordshire Office Joint Legal Services Staffordshire Police Headquarters PO Box 3167 Stafford, ST16 9JZ Tel: 01785 232259 Please be aware that all information provided to Staffordshire and West Midlands Police Joint Legal Services will be held and treated in confidence in accordance with the Data Protection Act 2018. It may be shared with other Force departments or third party organisations including, but not limited to, external solicitors, Counsel and, in relation to claims handling, Insurers. Personal information may also be used for statistical purposes, for fraud and crime prevention and may be checked with/disclosed to regulatory bodies. The information provided may be held electronically and/or in paper form and will be kept secure at all times. Please be aware that your personal data will be processed for the performance of tasks carried out in the public interest or in the exercise of the Police’s official authority, and to comply with legal obligations. *Calls may be monitored and/or recorded for security, quality control or training purposes. Regulated by the Solicitors Regulatory Authority WE DO NOT ACCEPT SERVICE OF DOCUMENTS BY EMAIL OR FAX L14002682/SA / 00281346 Yours faithfully Principal Lawyer Staffordshire and West Midlands Police Joint Legal Services Attached Below: Response to PFD report 2 Jason DEVOTI- Response to PFD issued by HM Senior Coroner DDW Reid 1. Pursuant to Regulation 29 of the Coroners (Investigation) Regulations 2013, this is the response of the Chief Constable for West Midlands Police to the coroner’s Regulation 28 report to prevent future deaths dated 21st January 2020. The coroner’s report and this response arises from the inquest into the death of Mr. Jason Devoti which was concluded on 10th January 2020. 2. The coroner raises in principle two key matters for consideration. Firstly the actions taken to reduce the demand pressures placed on control room staff, recognised at the time of Mr. Devoti’s death. Secondly the training and support provided to staff to alleviate these demand pressures ensuring that incidents are dealt with effectively. 3. 4. 5. Chief Inspector gave evidence at the inquest of Mr Devoti and accepted that at the time of this incident, there were a number of other P2 incidents outstanding. There were in excess of 500 P2 incidents open across West Midlands Police Force and this was reflected on the date of the incident regarding the death of Mr Devoti on 9th October 2018. West Midlands Police supports the evidence presented at the inquest and was explained by a Senior Manager within Force Contact. This demonstrated that a year on, in October 2019, the number of outstanding P2 incidents was reduced to an average to 200 open P2 incidents; and at the time of the inquest in January 2020, this was further reduced to approximately 100 open incidents. This position has been maintained since. These reductions have been achieved through changes in systems and processes across the force to better understand and manage demand: a. Escalation process – Whilst this was in place at the time of the death of Mr Devoti, this has been refreshed with all staff and is now subject of regular audits and feedback. The ‘rank’ involved in this decision making has been reduced to make the decision process quicker and has been explained to the wider organisation. b. Changes to control room model – The model that is used within dispatch is continually reviewed to ensure that it delivers the most effective approach. Changes were implemented in the summer of 2019 in order to manage incoming demand and the risk contained within existing logs. This includes the introduction of a dedicated triage terminal. This terminal does not hold legacy demand, therefore is able to review every new incident log sent to 3 dispatch, ensuring the risk is understood, primary actions and checks have been completed and the incident is ready to dispatch officers. c. Incident logs are now reviewed at various touch points during the day with increasing supervisory levels and at three review touch points during Threat Risk Meetings (TRM) by managers. d. The new dispatch model reviews unresolved incidents at 24 hours to assess whether the risk still exists or the incident can be managed in a different way, reducing the front end incident management and resourcing pressures. At this point it will be moved out of the dispatch group for resolution. This means that there is a greater ability for dispatchers to concentrate on the risk contained within the incidents still in the dispatch group. e. This has been combined with a focus within Contact handling, around the policing purpose for incidents. Historically there were incidents being created as a P2 that were lower risk and should have been graded as a P3, or where there was no policing response required. This has further reduced unnecessary demand on control rooms. f. In June 2019 a new shift pattern was implemented for control rooms, this was in part due to there being no dedicated training days in the previous pattern and to align with Contact handling colleagues to improve understanding and opportunities for joint training. 6. 7. 8. There is acceptance that there is still work more to do, including the introduction of a new Command and Control System and a performance analysis tool which provides incident and resource demand data at 15 minutes periods in order that this can be easily identified and responded to. This has continued to improve the position demonstrated by the snapshots presented as evidence and described at Point 4 above. In relation to the Birmingham West (BW) dispatch group specifically, the dispatch group covering the incident involving Mr. DEVOTI, at the time there would be in excess of 150 P2 incidents to be resourced. During the inquest, evidence was presented to show that at the time of the inquest, this had reduced and was currently at 12 outstanding P2 incidents. This reduction had been achieved through the changes described above and continues to be our focus. It was presented during the inquest that the reason for the number of outstanding incident logs was due to resourcing challenges because of austerity and the availability of officers to deploy. This has been addressed in a number of ways since the incident involving Mr DEVOTI: a. Support of the Force Support Unit to manage legacy demand. b. Use of the closest available resource to support with front end log demand. 4 c. Support from Neighbourhood Policing Unit senior leaders to allocate logs unresolved at 96 hours to the most appropriate resource to own until finalised. d. Load sharing across control rooms to match demand with resource. Logs are now transferred to another control room to ensure that demand is equally managed across all staff. 9. Even Keel has proven to be a successful tactic that can be used to manage a sudden increase in demand (i.e. following a critical incident where resources have been committed elsewhere). The tactic can be used to surge resources into demand to bring it back under control. 10. In relation to point 4 of HM Coroners areas of concern, it is accepted that there were some issues with how the ‘snapshot’ was completed. This has been addressed and as seen during the inquest, this snapshot has been changed to simplify what is being presented and an online dashboard is now in place to support the understanding of resources. 11. Staff across the control rooms continue to be supported in the use of the escalation process. There are a number of processes being implemented to ensure that this is the case: a. THRIVE, which is a tool used to gather information to assess risk incorporated with the National Decision Model (NDM), supporting decision making on how an incident should be managed. This is now an agreed policy and the process change training is being developed ready for delivery to teams. b. THRIVE is now embedded into the new Command and Control system and was delivered to all Force Contact staff as part of the training for the system ‘go live’. c. Introduction of the new Command and Control system – This is now implemented, having gone live on 2nd March 2020. The functionality of the system allows for the improved management of incidents and risk identification and also improves the management of demand across our control rooms. 12. The role by its very nature is one of managing competing demands, assessing risk and identifying appropriate resources to deploy against this assessment. The initial training is over a six month period involving initial training, mentoring and the completion of a portfolio for competence and capability in being able to operate in this high pressured role. To support staff in delivering against these demands, all of these systems and processes are now in place to support staff appropriately. 5 13. In relation to the lack of resources to deal with incidents, the introduction of the escalation process allows for the use of any resource to respond to an incident where the risk dictates. It has taken time to embed this process and we are now seeing this supporting delivery. This has become more focussed during Force TRM, held three times a day, where decisions are made to move additional resources according to demand. 14. It is right to reflect the positive news of an uplift to police resources over the next three years, recently announced by the Government and these are welcomed. It is necessary to acknowledge the impacts of austerity through the funding formula over the last five years particularly on West Midlands Police and the challenge this has created in managing increasing demand levels. 15. Within the limits of the resources available, it is the aim of West Midlands Police to allocate funds in the most efficient and appropriate way to deal with the demand for a huge range of policing activities. West Midlands Police recognises that response to emergency calls from the public within an appropriate time is of vital importance and seeks to prioritise this as far as possible. 16. Before and since the events leading up to Mr Devoti’s death, West Midlands Police has taken steps to ensure that the Response resources it has available are allocated as swiftly and efficiently as possible to all emergency calls. In addition to those measures set out above the following steps have also been taken: a. Instituting a process of involving the Force Incident Manager (FIM) when response shifts become particularly busy so resources from outside the area b. can be redeployed to Response or a different policing area. Instituting a “Log Closure Doctrine” to encourage bolder decision-making from dispatchers dealing with emergency calls to ensure resources are focussed on those calls requiring greatest need. c. Reducing the number of logs held by each dispatcher. Logs more than 24 hours old are now dealt with by a different team so that dispatchers can concentrate on the most critical calls without the distraction of managing older logs. 17. West Midlands Police takes its response to emergency calls extremely seriously. We constantly review and strive to implement new processes, systems and technology, maximising the efficiency of the control room. This allows redeployment of available resources to respond at particularly busy times. An 6 example is the ongoing completion of a record of all missing person logs managed and overseen by supervisors in control rooms until resolved. This maintains the constant awareness including in the handover between teams. 18. West Midlands Police will endeavour to ensure that they manage and maximise those available resources it has designated to them to improve our ability to provide the most efficient and effective service possible to our communities. Signed Dated: 29th April 2020 7
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