Prevention of Future Deaths reports · 2021

Cheralyn Clulow

Regulation 28 report to prevent future deaths, reference 2021-0009, written 12 Jan 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report12 Jan 2021
Reference2021-0009
DeceasedCheralyn Clulow
CoronerRichard Middleton
Coroner areaDorset
CategoryAlcohol, drug and medication related deaths · Police related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS

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

The Chief Constable of Dorset Police, Police Headquarters,
Winfrith, Dorset DT2 8DZ

1 CORONER

I am Mr Richard T Middleton, Assistant Coroner for the coroner area of
Dorset

2 CORONER’S LEGAL POWERS

I 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.

http://www. legislation.gov.uk/ukpga/200925/schedule/5/paragraph/Z

http://www. legistlation.gov.uk/uksi/2013/1629/part/7/made

3 INVESTIGATION AND INQUEST

On 4 September 2019 I commenced an investigation into the death of
Cheralyn CLULOW. The investigation
The conclusion of the inquest was: Drug related death

la Multi-organ failure

1b Stroke

1c Infective Endocarditis (Staph. Aureus & Steptococcus)
II Intravenous Drug use

4 CIRCUMSTANCES OF DEATH

Ms Clulow lived alone in local authority accommodation at [I
HE Bournemouth. She was offered support from the Specialist Drug
and Alcohol Service but in the 4 months preceding her death she did not
attend 5 out of 5 key working appointments. On 28/8/19 neighbours had
concerns for her welfare and notified the Council who in turn contacted
Dorset Police. Officers attended late on 28/8/19 and could not gain access
to the property beyond the communal door. Officers attended on 29/8/19
and forced entry and discovered Ms Clulow semi conscious. Paramedics
were called and she was taken to hospital. Scans revealed she had suffered
extensive and multiple strokes. Her health continued to deteriorate and she
died in hospital on 30/8/19.

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 could 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) The Police Officers who were tasked with the initial attendance could
not gain access beyond the communal doors.

(2) The Police Officers did not believe it was proportionate (based on
the information which they had) to force entry through the
communal doors which required specialist input. They were aware
that a colleague had purchased for himself a fire drop kcy (to be
used in emergency situations which could be used to override the
communal lock door. There was a delay in gaining access to the
address of the deceased.

(3) The Police Officers had no formal information as to where they could
source a fire drop key. There was no knowledge of formal steps to
be taken to access to a fire drop key particularly as access to
communal properties is that more difficult to gain.

(4) There appears to be no general distribution of such keys or key fobs
to Dorset Police Officers in order to gain access to shared
accommodation by officers in an emergency situation 24 hours a
day, 365 days per year.

(5) There appears to be no training or dissemination of information as
to how such keys can be obtained.

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and I believe
you the Chief Constable of Dorset 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 9 March 2021. I, 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. The Interested persons as follows:

1
0 0lC Investigator Complaints and Misconduct Unit

Dorset Police
| 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.

13 ag
/

Mr Richard T Middleton
Dated: 12 January 202 H M Assistant Coroner for Dorset

Responses

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

Response from Dorset Police (PDF)
Chief Constable 

www.dorset.police.uk 

Mr Richard T Middleton 
Assistant Coroner for Dorset 
Coroner’s Office for Dorset 
Town Hall 
Bournemouth BH2 6DY 

Email: 

Dorset Police  
Force Headquarters 
Winfrith 
DORCHESTER 
DT2 8DZ 

Phone: 

ext. 

10 March 2021 

Dear Mr Middleton 

INQUEST  INTO  THE  DEATH  OF  CHERALYN  CLULOW:  REPORT  UNDER 
REGULATION 28 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 2013 

I am writing in relation to the above inquest, and in the particular the above-mentioned 
report  of  12  January  2021  (“the  Regulation  28  report”)  that  I  have  received  from 
yourself.    I  apologise  sincerely  for  the  delay  in  responding  and  for  missing  the 
proposed deadline of 9 March 2021. 

Firstly,  I  want  to  take this opportunity  to express my  condolences  to  the family  and 
friends of Cheralyn, as well to anyone else who may be affected by her loss. 

Secondly, I thank you for forwarding me a copy of the Regulation 28 report that was 
made in the inquest into Cheralyn’s death. I always welcome opportunities to consider 
whether there is potential for Dorset Police to improve the service that they provide to 
the public. 

I have now had the opportunity to consider the issues that you have raised within the 
Regulation  28  report.  Please  therefore  treat  this  correspondence  as  my  formal 
response to the same. 

In the Regulation 28 report, you make reference to fire drop keys and key fobs. On the 
basis of the enquiries that have taken place on my behalf in response to the report, it 
is  my  understanding  that  there  is  no  significant  distinction  between  the  two  in  the 
context of your concerns, in that both have the same effect of allowing access through 
this 
communal  entry  points 
correspondence, for brevity I will use the phrase ‘key and fobs’ on the basis that the 
phrase is intended to represent fire drop keys, key fobs, and any other such items that 
have the effect of facilitating access to buildings via communal entry points. 

in  shared  accommodation.  Therefore,  within 

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Having reflected on the Regulation 28 report, it is my view that allowing Dorset Police 
officers to have greater access to keys and fobs would mitigate against the issues and 
risks that you have raised to a significant degree. At my request, the position in respect 
of the provision and use of keys and fobs has been researched, and it appears to be 
the case that equipping frontline police officers with such items is a realistic option in 
that they can be readily obtained and they require little training.  

Accordingly, the decision has been made that all frontline Dorset Police officers will 
now carry keys and fobs when on duty. It is my view that this will serve to avoid delays 
in sourcing such items and allow for quick access to relevant properties in emergency 
situations. The process of procuring these items is already underway and I understand 
that they can be issued to frontline officers quickly (and, I believe, within a month). 

I  want  to  be  clear that  this  process  will primarily  only  be  implemented  in  relation  to 
communal buildings under the local authority’s control. This is because these buildings 
generally have a universal and standardised approach to the use of keys and fobs, so 
between  this  and  our  existing  working  relationships  with  the  local  authorities,  it  is 
straightforward for us to obtain and provide access to the relevant keys and fobs for 
our frontline officers. 

Our enquiries  have  led  us  to  conclude  that the  sheer variety  of  such  items  used  in 
privately-owned  properties  would  mean  that  it  is  difficult  (to  the  point  of  being 
unrealistic) to source every such item. In simple terms, I understand that there is no 
such  item  as  a  ‘skeleton  key’  in  this  context.  In  this  respect,  it  is  of  note  that,  as  I 
understand it, the fire service do not carry or have access to such items on a similar 
basis, and will instead force entry to such addresses when required. 

To  compensate  for  this,  we  are  in  the  process  of  identifying  specific  vulnerable 
individuals who live in similar but privately-owned communal premises, with a view to 
obtaining the relevant keys and fobs to facilitate access to those specific properties 
where required. Due to the volume of such items, where privately-owned premises are 
concerned  we  will  store  the  relevant  keys  and  fobs  in  a  police  station  local  to  the 
address in question, and link instructions for obtaining the relevant item to the record 
that  we  hold  for  the  vulnerable  individual  in  question  on  our  police  incident 
management system. 

It may reassure you if I point out that none of the above precludes use of enforcement 
equipment by frontline officers to enter premises where appropriate and lawful to do 
so. 

It is my understanding that the keys and fobs are extremely simple to use; essentially, 
they  function  as  a  key.  Accordingly,  no  training  should  be  required.  I  can  however 
confirm  that  a  reminder  on  police  powers  of  entry  will  be  circulated  to  all  frontline 
officers in due course, including on the organisation’s intranet. This will be used as an 
opportunity to remind frontline police officers of powers available to the police in terms 
of forcing entry to properties in situations such as that encountered by the colleagues 
who attended Cheralyn’s address prior to her death. 

In summary, Dorset Police officers are soon to be issued with keys and fobs to allow 
for  quick  or  emergency  access  to  communal  properties,  with  a  system  to  be  put  in 

 
 
 
 
 
 
 
 
 
 place to compensate for properties where this is not realistically achievable. This will 
be used as an opportunity to refresh the officers in question in respect of their powers 
of entry.  

I hope that this demonstrates that we have taken your concerns seriously. I am again 
grateful for you bringing these issues to our attention, particularly as it has provided 
us  with  an  opportunity  to  reflect  on  and  identify  an  opportunity  for Dorset  Police  to 
further enhance the service that we provide to the public. 

Yours sincerely 

Chief Constable

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