Prevention of Future Deaths reports · 2021
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 report | 12 Jan 2021 |
|---|---|
| Reference | 2021-0009 |
| Deceased | Cheralyn Clulow |
| Coroner | Richard Middleton |
| Coroner area | Dorset |
| Category | Alcohol, drug and medication related deaths · Police 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 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
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.
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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