Marc Cole

Mr Geraint Williams 
Assistant Coroner for Cornwall and the Isles of Scilly  

1 April 2020 

Your Ref: GUW/LJB 

Dear Mr Williams,  

Re: Marc Antony Cole (deceased) 

I am writing on behalf of the College of Policing (the College) in response to the concerns raised in the Reg 
28 Prevention of Future Deaths notice that you issued in respect of the death of Mr Marc Anthony Cole. 

I was very sorry to read of the circumstances of Marc’s death.  My sympathies are with his family and friends 
and I share your commitment to addressing issues that contributed to his untimely loss.  I understand the 
jury found the medical causes of death to be: “Use of cocaine, episode of altered behaviour including self-
harm, exertion, excitement, the use of x26 Taser Device and restraint.” 

The Reg 28 Notice sets out concerns that arose from the information received during the inquest. In my 
detailed response, appended below, I will explain the role of the College and address each of the issues 
raised in relation to the College in turn.   

In summary, my detailed response explains that current College guidance and learning material address the 
risks associated with the number and duration of Taser activations. Our materials have been developed in 
close consultation with the independent body (SACMILL)* that advises the Home Office on the medical 
issues associated with conducted energy devices and are in line with their advice. The Home Office and 
SACMILL would be better placed to comment on the associated evidence base.  

The Reg 28 Notice suggest there were gaps in the information available to the inquest in respect of the 
medical evidence about the use of Taser, and the advice the College gives on multiple activations, medical 
implications and first aid. Had SACMILL, AXON and the College been called to give evidence at the 
Coroners court, information could have been provided that would have been highly likely to be useful to you 
and the jury in your considerations.  

In any future inquests, where the College’s training material and guidance are to be examined, we would be 
glad to attend to provide information and clarity where needed.  I believe this would be in the interests of the 
family, jury and wider public and would help ensure that lessons are learned in the most appropriate areas. 

We would like to thank you for bringing the circumstances of Mr Cole’s death to our attention and we will 
ensure that our immediate and future work is informed by the events that culminated in Marc’s tragic death. 
We keep Taser training under regular review and we will carefully examine the findings of Mr Cole’s inquest 
to ensure learning continues to be reflected. The College will also continue to work with SACMILL to ensure 
that our guidance and training are always informed by the most up-to-date independent scientific evidence 
available to us.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Yours sincerely 

Mike Cunningham 
Chief Executive Officer 
Mobile: 

Email address: 

*SACMILL: Scientific Advisory Committee for the Medical Implication for Less Lethal Weapons (an 
independent scientific body funded by the Ministry of Defence). 

 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 APPENDIX  

Section 1. The role of the College of Policing 

The College of Policing is the professional body for policing and provides everyone working in policing with 
the skills and knowledge necessary to prevent crime, protect the public and secure public trust. 

The College has three complementary functions:  

  Knowledge: developing the research and infrastructure for improving evidence of ‘what works’. Over 

time, this ensures policing practice and standards are based on knowledge, not custom and 
convention.  

  Education: supporting the development of individual members of the profession. We set educational 
requirements to assure the public of the quality and consistency of policing skills, and facilitate 
academic accreditation and recognition of our members’ expertise.  

  Standards: drawing on the best available evidence of ‘what works’ to set standards in policing for 
forces and individuals, for example, through authorised professional practice and peer review.  

The College works closely with the National Police Chiefs’ Council (NPCC) to ensure that the guidance and 
standards that it sets are likely to be effective in supporting police officers and staff in their principal 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 seeks to ensure that we work together to jointly address areas of risk 
and concern.  

In relation to Taser, the College of Policing works closely with the NPCC Lead for Less Lethal Weapons, 

 and the Home Office. The guidance and training on the police use of Taser are informed 

by the work of the Scientific Advisory Committee for the Medical Implication for Less Lethal Weapons 
(SACMILL) an independent scientific body funded by the Ministry of Defence.  SACMILL also monitor the 
police use of Taser. 

Section 2. Response to issues raised in Reg 28 Notice 

2.1: No training provided as to the maximum number of activations nor of their duration which is appropriate 
or safe. The evidence was that the training given to police officers in this aspect is as set down by the 
College of Policing and that it is silent as to the potential incremental risk of multiple and or sustained 
activations (the so called ‘detention under power’). 

College learning materials and guidance do address the risks associated with the number and duration of 
Taser activations.  Section 3 and 4 below set out the relevant materials the College has provided to police 
forces.  They are in line with the medical implications and advice provided by SACMILL. 

2.2: Although I found as a fact that the training given to the police officers was appropriate I did so ONLY 
upon the basis that it was given based upon the limited knowledge presently available. I am concerned, 
based upon the evidence that was led before the jury, that there is insufficient independent data as to the 
lethality of Taser use and that, therefore the advice and training provided to police officers may be deficient 
or incomplete. 

SACMILL is the independent body that advises the Home Office on the medical issues associated with 
conducted energy devices. They are entirely independent of the manufacturer and the police service. The 
College consults SACMILL on the training material it produces to ensure it properly reflects their advice. 

2.3: Perhaps by a wholesale review of the effects of multiple Taser activations and the effects of sustained 
activations (whether in isolation or in combination) so that fuller and more comprehensive advice, guidance 
and training can be given to those officers who are authorised to carry Tasers.  

 
  
  
 
 
 
 
 
 
 
 
  
 In performing its role SACMILL has taken account of a body of evidence relating to the use of Taser.  The 
College is not able to comment on the detail of the evidence that has been reviewed.  The Home Office and 
SACMILL would be better placed to comment on the detail and as to whether any further research is 
required. 

The causes for concern set out suggest there were gaps in the information available to the inquest in 
respect of the medical evidence about the use of Taser, and the advice the College gives on multiple 
activations, medical implications and first aid. Had SACMILL, AXON and the College been called to give 
evidence at the Coroners court], information could have been provided that would have been highly likely to 
be useful to the coroner and jury considerations.   

Section 3. College Guidance 

College guidance is contained in Authorised Professional Practice (APP). Please see 
https://www.app.college.police.uk/app-content/armed-policing/conducted-energy-devices-taser/#risk-factors  

The second of the risk factors listed within the APP is: 

 

repeated and/or prolonged application of discharge 

In addition, the warnings provided by AXON, the manufacturers of Taser devices, are sent out to all police 
forces together with College learning materials for Taser. 

Section 4. Learning materials 

College learning materials for Taser are set out below: 

Module J2 (Taser use and safe handling) mentions relevant issues in two places: 

  Slide 8 which highlights the SACMILL medical statement. One of the key points is ‘SACMILL 

recommends keeping duration to a minimum’. 

  Slide 9 continues the theme of the SACMILL medical statement, stating ‘SACMILL is aware of 

fatalities and serious injuries in the UK where the use of a CED has been seen as a causal factor.’ 
The trainer notes expand on the point providing more detail of the cases to date. 

Module J4 (Operational and tactical skills) discusses the issue in three places (Module J4 PowerPoint). 

  Slides 20 and 21 provides advice on the use of ‘detention/control under power’.  It helps officers to 

understand that the use of Taser to incapacitate a person by extending the cycle to maintain control 
can, where proportionate, be more effective than alternative ways of achieving detention or control 
and can reduce the overall force used.  
The module also states that “Where a CED has been discharged three or more times, and it has 
failed to incapacitate the subject, officers should consider other use of force options and 
contingencies. However, earlier use of an extended cycle, and control under power may prove more 
effective than multiple shorter cycles, and potentially reducing the overall use of force.” 

  Slide 25 reiterates the risk factors in the manufacturer’s guidance, APP and SACMILL medical 

statement. It includes risk factors: 

o 
o 
o 
o 

‘repeated and/or prolonged application of discharge’ 
‘subjects already restrained’ 
‘acute behavioural disturbance/excited delirium’ 
‘vulnerable people’ – a term that includes subjects under the influence of drink or drugs. 

  Slide 32 discusses the SACMILL advice around heart rhythm disturbance. It makes the point that the 

shorter the discharge the less likely it is to affect the subject. It also highlights increased risk to 
‘persons who are intoxicated with drugs/alcohol’. 

 
 
 
 
 
 
 
 
 
 
 
 
 Module J3 (Vulnerable people) also reinforces the training officers receive around acute behavioural 
disturbance (ABD). It lists the signs and symptoms: 

Specific groups – Severe Medical Conditions 

  apparently inexplicable and/or aggressive behaviour  
  apparently confused thinking  
  disorientation  
  hallucinations  
  acute feelings of paranoia  
  panic  
  shouting  
  violence towards others  
  unexpected physical strength  
  apparent ineffectiveness of irritant sprays  
  significantly diminished sense of pain  
  sweating, fever, heat intolerance  
  sudden tranquillity after frenzied activity. 

Also of relevance are the enhanced risk factors discussed in Module J5 (Aftercare) which states: 

If there are any signs or combinations of: 

  Adverse or unusual medical reactions 
  Relevant pre-existing medical condition 
  Drug / alcohol misuse  
  Mental illness  
  Extreme violence (acute behavioural disturbance) 
  Positional asphyxia 
  Extended or multiple Taser applications 
  Child, pregnant or elderly persons 

Medical assistance should be provided immediately. If necessary this must be given precedence 
over conveyance to the place of detention. 

The point should be made that it is not possible to give officers definitive guidance on the number and 
duration of discharges, as the factors that would influence this decision are many and varied. We take the 
position that every discharge must be lawful, necessary and proportionate to the threat posed and be 
informed by the risk factors identified, where possible. However, some risk factors may not be immediately 
apparent to the officer, meaning that it is not possible to account for them. We reiterate the SACMILL 
position that Taser activations should be minimised to reduce risk, however it is not possible to eliminate all 
risk.

Kit Malthouse MP 
Minister of State for Crime and Policing  
2 Marsham Street 
London SW1P 4DF 

www.gov.uk/home-office 

Mr Geraint Williams 
Assistant Coroner 
Cornwall and the Isles of Scilly 

BY EMAIL ONLY  

Dear Geraint,  

2nd April 2020 

Thank you for your Regulation 28 report, dated 6 February 2020, following the 
inquest into the death of Mr Marc Cole.  I am the Minister of State for Crime, 
Policing  and  the  Fire  Service  and  have  oversight  of  the  policy  on  the  police 
use  of  force.    I  am  grateful  to  you  for  sharing  your  findings  with  the  Home 
Office  and  for  the  opportunity  to  reflect  on  the  evaluation  of  the  medical 
implications  of  Conducted  Energy  Devices  (commonly  known  as  Tasers), 
along with the guidance and training for police officers who use Tasers in the 
UK.  

I will begin by outlining the overall UK policy on the police use of force and on 
Tasers in particular, before setting out our response to your recommendation 
of a wholesale review of the effects of multiple Taser activations and the 
effects of sustained activations in order to provide fuller and more 
comprehensive advice, guidance and training on Taser to the police. 

Due to the special nature of the role that police officers perform in serving the 
public, there are occasions when it is essential for them to use physical force 
to protect the public and/or themselves from harm.  

The British model of ‘policing by consent’ is based on the principle that the 
power of the police comes from the common consent of the public, as 
opposed to the power of the state.  Public consent is obtained by balancing 
the need to ensure public security whilst protecting civil liberties.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The policy in this country has long been that the police should not generally 
be armed. This is vital in promoting good relations with the public and the 
community they serve. It gives character to our policing that we should not 
readily give up.  All police use of force must be proportionate and necessary.   
Less lethal weapons provide the police with more options to meet that 
requirement.  They are defined as: weapon systems designed to be used by 
law enforcement directly against an individual or group of individuals to 
achieve a physical effect to mitigate a threat, without substantial risk to the 
subject of permanent or serious injury or death.  While the actual outcome 
may, on occasion, be lethal, this outcome is less likely than when 
conventional firearms are used. 

Approval of Less Lethal Weapons 

Only less lethal weaponry that has been approved by the Home Secretary 
may be used by the UK police service.  The evaluation and assessment 
processes before less lethal weapons are submitted to the Home Secretary 
for approval include, where appropriate: 

•  a needs analysis 
•  determination of operational requirement 

technical evaluation 
• 
•  medical assessment 
•  operational performance trials. 

In addition, when Home Office officials provide advice to the Home Secretary 
on new devices they also take into account relevant strategic, ethical, 
operational and societal issues, including an assessment of environmental 
factors.  Of course, once a device is approved, relevant guidance and training 
are provided to the police and there is continued oversight of how Taser is 
being used.  I have focused below on the medical assessment, guidance and 
training, and government oversight. 

The Government believes that our approach to the use of less lethal weapons 
is in line with Articles 2 and 3 of the UN Basic Principles on the Use of Force 
and Firearms which state:  

•  Article 2: “Governments and law enforcement agencies should develop 
a range of means as broad as possible and equip law enforcement 
officials with various types of weapons and ammunition that would 
allow for a differentiated use of force and firearm…”  

Article 3: “The development and deployment of non-lethal incapacitative 
weapons should be carefully evaluated in order to reduce the risk of 
endangering uninvolved persons, and the use of such weapons should be 
carefully controlled.” 

 
 
 
 
 
 
 
 
 Medical Assessment 

Medical evaluation is an important aspect of the approval process of less 
lethal weapons. The Scientific Advisory Committee on the Medical 
Implications of Less-Lethal Weapons (SACMILL) provides independent advice 
to UK government departments and organisations on the biophysical, 
biomechanical, pathological and clinical aspects of less-lethal weapon 
systems.  

SACMILL’s membership includes an independent chairman and other 
independent members, who are mainly medical and academic experts from 
the public and private sectors, providing an appropriate balance of 
independent lay and medical expertise on the committee.  SACMILL 
succeeded the Defence Scientific Advisory Council Sub-Committee on the 
medical implications of less-lethal weapons (DOMILL) in 2012. 

SACMILL is responsible for:  

• 

issuing independent statements on the medical implications of the use 
of specific less-lethal weapon systems, when used in accordance with 
published operational guidance provided to users; 

•  giving advice on the risk of injury from specific less-lethal weapon 

systems striking specific areas of the body, in a format that will assist 
both those responsible for developing policy and for operational users 
to help make tactical decisions. 

SACMILL’s medical evaluations of Taser use are published on Gov.UK1. You 
may be interested to note that in their 2012 medical statement on the X26 
Taser device (which would have been used by Devon and Cornwall police in 
May 2017), SACMILL refer to the risks of prolonged duration in paragraph 
752: 

“For the majority of known Taser injury mechanisms (para. 12), reducing the 
physiological burden imposed by the discharge would likely reduce the risk of 
adverse outcome. DOMILL, therefore, considers that the duration of 
application of Taser discharge should be limited to that necessary to achieve 
the desired operational effect. Multiple discharges should be avoided where 
tactically feasible.  These recommendations further reinforce advice given to 
users in the ACPO Guidance on Operational Use of Taser.” 

As SACMILL recommendations are published they are incorporated into the 
College of Policing’s National Taser training curriculum. 

The Code of Practice for Armed Policing and Police Use of Less Lethal 
Weapons 

1 https://www.gov.uk/government/publications/medical-implications-of-the-taser-x2 
2https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/443
842/DOMILL14_20120127_TASER06.2.pdf  

 
 
 
 
 
 
 
 
 
                                                
 On the 14 January 2020 the Home Secretary approved a new Code of 
Practice for Armed Policing and Police Use of Less Lethal Weapons3.  The 
Code makes clear that all new less lethal weapon systems, certain specialist 
munitions and significant changes to pre-approved less lethal weapons 
systems require approval by the Home Office before they can be used by 
police forces in England and Wales. 

Although the Home Secretary approves specific devices, their actual 
deployment is an operational matter for chief officers and based on each 
force’s assessment of the threats and risks in their areas.  The code has a 
statutory basis in law, meaning all chief constables have a duty to have regard 
to it.  

It describes their roles and responsibilities and sets out the basic principles of 
the selection, evaluation, approval, authorisation, acquisition and deployment 
of these weapons by the police.  

The revised Code of Practice is used in conjunction with the College of 
Policing Authorised Professional Practice (APP) for Armed Policing.  We 
believe that the Code and APP ensure that our police service maintains the 
high, nationally recognised standards for the police use of firearms, specialist 
munitions and less lethal weapons. 

Manufacturer’s Guidance for Law Enforcement 

AXON, the manufacturer of Taser devices, issues guidance to law 
enforcement on the operational use of Taser.  This guidance is issued to 
police forces along with the training package and with the devices themselves.  
The following was included in their latest warning/guidance to law 
enforcement in 20184: 

“Cumulative Effects. CEW exposure causes certain effects, including 
physiologic and metabolic changes, stress, and pain. In some individuals, the 
risk of death or serious injury may increase with cumulative CEW exposure. 
Repeated, prolonged or continuous CEW applications may contribute to 
cumulative exhaustion, stress, cardiac, physiologic, metabolic, respiratory and 
associated medical risks which could increase the risk of death or serious 
injury.  Minimize repeated, continuous or simultaneous exposures when 
practicable”.   

3 The Code was published on The College of Policing website and on GOV.UK at 
https://www.gov.uk/government/publications/armed-policing-and-police-use-of-less-lethal-weapons-
code-of-practice and can be accessed via https://www.gov.uk/official-documents  
4 https://axon.cdn.prismic.io/axon%2F3cd3d65a-7500-4667-a9a8-0549fc3226c7_law-enforcement-
warnings%2B8-5x11.pdf 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
                                                
 Training 

All officers who are selected to use Tasers have to pass a comprehensive 
training process and need to have an appreciation of the physical and 
psychological effects of these devices.  This includes training officers to factor 
in the potential vulnerability of a person and factors such as mental health, 
age and stature when assessing each situation.  

As set out in the College of Policing guidance (APP)5, all Tasers trained 
officers have to undergo annual refresher training in line with the most up-to-
date training curriculum. 
When confronted with a violent situation an officer uses this training and 
experience in conjunction with the National Decision Making Model (NDM)6 to 
decide the most appropriate use of force in the circumstances.  

On your specific concern about the understanding of the risks of multiple 
Taser activations, the College of Policing Guidance, the APP sets out that: 

“The duration of the initial discharge and any subsequent discharge 
must be proportionate, lawful, accountable and absolutely necessary. 
Any medical risk may be increased the longer or more often the device 
is discharged.” 

Repeated or prolonged application of discharge is also listed as one of the risk 
factors associated with Taser use which has been identified from operational 
experience, medical evaluation, and the manufacturer’s guidance.  The 
National Taser Training Curriculum includes scenario-based training designed 
to emphasise precautions and considerations relevant to all risk factors.  

I understand that the College of Policing will submit a separate response to 
the Prevention of Future Deaths Report.  

Monitoring and evaluation 

I have set out some of the ways we ensure that only devices that are safe to 
use are put in the hands of officers who are well-trained and understand the 
risks they carry.  As you would expect, however, given the importance of 
maintaining our existing model of policing by consent we also monitor the 
police use of force, including Taser. 

In 2017, we introduced new transparency measures, which mean that all 
officers have to record the location and outcome of all police use of force, 
along with the ethnicity and age of those involved.  Use of force incidents, are 
recorded by all 43 Home Office police forces in England and Wales and 
reported to the Home Office annually.  This data is published annually, the 
most recent publication was 19 December 20197. 

5 https://www.app.college.police.uk/app-content/armed-policing/conducted-energy-devices-taser/ 
6 https://www.app.college.police.uk/app-content/national-decision-model/the-national-
decision-model/ 

7 https://www.gov.uk/government/collections/police-use-of-force-statistics 

 
 
 
 
 
 
 
 
 
 
                                                
 
 The publication of this data brings unprecedented transparency and 
accountability and delivers a commitment to respond to public interest in 
relation to this complex area of policing. 

In the longer term, as data quality improves, it will also provide an evidence 
base to support the development of tactics, training and equipment to 
enhance safety for all. 

In addition, any new CED device being introduced into service by forces is 
subject to very close monitoring through bespoke reporting by both the police 
and Government.   

There is a robust legal framework in place which sets out the process which 
must be followed for investigations conducted by the local force or the 
Independent Office of Police Conduct, established in the Police Reform Act 
2002 and Police (Conduct) Regulations 2012. Any death or serious injury 
(DSI) that happens in police custody or as a result of, or immediately 
following, police contact must by law be referred to the IOPC.  

The IOPC have stated that the police use of Taser is an area of considerable 
public interest and concern and that they will continue to monitor and maintain 
oversight of its use, and share learning arising from any cases that they are 
involved with. 

Her Majesty’s Inspectorate of Constabulary and Fire & Rescue Services 
(HMICFRS) is the independent inspectorate which works to promote 
“improvements in policing and fire & rescue services to make everyone safer”.  
HMICFRS is independent of government, the police and fire & rescue 
authorities. 

HMICFRS is charged in statute with inspecting the legitimacy, efficiency and 
effectiveness of the police service in England and Wales, and fire and rescue 
services in England.  The purpose of the Inspectorate is to ensure standards 
are achieved, good practice is spread, performance is improved, and the 
public are engaged and assured. HMICFRS inspections include assessment 
of whether police forces use force in a fair and appropriate way. 

We will continue to work with the College of Policing and National Police 
Chief’s Council to reduce the risks associated with the use of less lethal 
weapons such as Taser. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Conclusion 

I am grateful to you for highlighting your concerns about the use of Taser.  As 
you would expect, we take seriously your comments concerning the 
circumstances of Mr. Cole’s death.  We have we carefully reviewed the 
processes and safeguards in place for the police use of Taser, including the 
independent evaluations of the medical implications of Tasers carried out by 
SACMILL, the guidance available, the high standards of training, and the 
ongoing scrutiny of the Taser use.  I am satisfied that they are adequate and 
help ensure that any use of force by the police is proportionate, necessary 
and as safe as possible.  

Nonetheless, I accept that every death in police custody is a tragedy and our 
sympathies are with Marc Cole’s family and loved ones. 

Kit Malthouse MP 
Minister of State for Crime and Policing