Kevin Clarke

London Ambulance Service NHS

NHS Trust
220 Waterloo Road
London
SE1 8SD
Mr Andrew Harris Tel:
HM Senior Coroner for London Inner South Fax: 0207 783 2009
Southwark Coroner's Court www.londonambulance.nhs.uk
1 Tennis Street
London
SE11YD
14" April 2021
Dear Sir,
Regulation 28; Prevention of Future Deaths Report (PFD) arising from the inquest into the death of Kevin
CLARKE

Thank you for your Regulation 28 Report dated 18th February 2021 setting out your concerns to be addressed.

| would like to begin by expressing my deepest condolences to the family of Mr Clarke and to reaffirm the
sincere apology that was expressed on behalf of the London Ambulance Service NHS Trust (the LAS) at the
inquest for the failures in our care for Mr Clarke, for these | am truly sorry.

Prior to the inquest a detailed review was undertaken to investigate the circumstances surrounding the LAS
attendance to Mr Clarke on 9th March 2018. It was recognised and accepted by the Trust in evidence heard at
the inquest that the care provided to Mr Clarke by the attending ambulance clinicians fell significantly below
our expected standard. The Trust fully accepts the findings and conclusion of the Jury in setting out the failures
which were determined to have contributed to Mr Clarke’s tragic death.

The concerns set out in the PFD report, as directed to the LAS were in respect of the clear lack of leadership,
risk assessment or challenge on health and safety of Mr Clarke by the paramedic, for whom it appeared to you
to have insufficient seniority.

In addition, your concerns detail inadequate communication with police on scene about the critical conveyance
decision as well as inadequacy of supervision and the ‘collective leadership’ approach where decision making
seemed to emerge without discussion.

| will set out the LAS response to these as follows:

Leadership training and Acute Behavioural Disturbance (ABD) refresher training

The Royal College of Emergency Medicine sets out that Acute Behavioural Disturbance (ABD) is the accepted
terminology adopted by the UK Police Forces, the Ambulance Services and the Faculty of Forensic and Legal
Medicine. It describes the sudden onset of aggressive and violent behaviour and autonomic dysfunction,
typically in the setting of acute on chronic drug abuse or serious mental illness.

Page 1 of 4

The LAS fully recognises the need to ensure that all our front line staff are trained to recognise and manage
appropriately patients who are displaying signs of ABD and that whilst when attending Mr Clarke, our first on
scene ambulance clinicians were appropriately clinically trained to manage such a medical emergency, it is
accepted that there was clearly a lack of provision of adequate clinical leadership. The Trust fully appreciates
that clinical skills alone are not enough when faced with these circumstances and additional clinical leadership
training that supports the clinical skill set is equally essential.

Our expectation is that front line clinicians need to immediately recognise and manage their role on scene as
having clinical primacy for the patient and be confident in managing a multi-disciplinary scene, always
advocating for their patient and utilising the skills of others on scene to ensure their safety whilst putting the
clinical need to the patient at the forefront. The ability to communicate effectively with our emergency service
colleagues to ensure the best interests of the patient are being constantly reviewed and risk assessed.

We provided evidence at the inquest to explain how our front line staff are trained and kept up to date via our
Core Skills Refresher (CSR) training, which is a mandatory annual programme providing front line staff with
three, eight hour training sessions per year. Since 2010 our crews have been trained in ABD and in recognition
of how important ABD training is for ambulance clinicians, we have introduced ABD training as part of the
syllabus for all clinicians joining the LAS and this wilt be incorporated for every new entrant who joins from
April 2021.

As we set out in evidence, we are committed to regularly increasing the knowledge and awareness of our front
line staff on ABD and it will be included in our next CSR training which is due to be delivered in 2021/2022,
subject to Covid-19 restrictions.

The ABD (CSR) training will cover the spectrum across which a patient with ABD can present and will be
focussed towards scenarios and practical application of the assessment and management of ABD, including
communicating with other agencies on scene.

Our intention is to make sure regular refreshers are not only available through mandatory training but that we
engage staff in additional methods to keep the subject at the forefront of clinical updates and as such we have
created an ABD podcast which will be available to all staff with the next clinical update bulletin. This will be
complete before the end of the August 2021.

A clinical update article on ABD is currently being finalised and will be disseminated to all front line staff via our
intranet ‘The Pulse’ as well as received by email sent directly to staff.

Communicating with our emergency service colleagues

The vital need to advocate for the safe and effective management of the patient is core to this and the Trust
expects that all our ambulance clinicians are trained for and confident in knowing the importance of their role
on scene. The CSR training will include communication strategies to further empower ambulance clinicians to
communicate with the police in such situations.

Resourcing the scene and providing senior leadership

Recognising the challenge which you have highlighted around the “insufficient seniority or experience” of the
ambulance clinicians who attended Mr Clarke, there has been a program of national change in respect of how
paramedics transition into fully independent clinical practice, when they initially qualify. This program has

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introduced the formal role of Newly Qualified Paramedic (NQP) where there is a two-year preceptorship
program, where the graduate paramedic has a formal period of direct supervision on qualification, this then
transitions through to a period of further supported development during their first two years in clinical
practice. This process has formal ‘gateways’ which the paramedic must meet in order progress and the entire
process is supported by a development portfolio. This development program is linked to the paramedic’s
remuneration and in order to achieve the uplift in salary, this program must be completed. This program now
aims to provide a structured development program for paramedics entering the profession and improve the
experience and seniority of the national paramedic workforce.

The LAS recognises the importance of getting resources to scene to treat patients with ABD in the fastest
possible time and recognises that the complexity of the scene can call for enhanced clinical leadership presence
to support the care of the patient and the management of the scene. This can be especially important in a
dynamic scene such as in the circumstances of Mr Clarke, where multi agency working is necessary.

We provided evidence at the inquest to detail our commitment to continue to monitor and review the use of
‘Category 1’ triage for potential ABD patients, which goes above the national position and demonstrates the
importance the LAS place on ensuring the timeliest of response to this cohort of patients. The LAS will continue
to work with the police to ensure this is used correctly to maximise benefit and will continue to highlight the
need for accurate and concise sharing of information where ABD is suspected. The LAS will continue to ensure
that the process for this upgrade of calls is shared within our Emergency Operations Centres.

You also heard evidence that where pharmacological tranquilisation of an ABD patient is indicated, our
Advanced Paramedic Practitioners (critical care) are trained to undertake rapid pharmacological tranquilisation
and where possible we will continue to provide this treatment option when it is indicated. We are one of the
few UK ambulance services where this intervention is delivered by the ambulance services’ own paramedic
workforce, and we actively target this cohort of staff to this group of patients.

In order to further enhance the clinical leadership and experience on scene we are working through a process
of change in order to pro-actively send either a Clinical Team Manager (or an Incident Response Manager) to
calls where the Metropolitan Police Service or other Potice service, report a case of suspected ABD. This must
not distract from the timely response of the nearest available clinical resource, but will provide additional
leadership on scene to support our frontline clinicians and enhance patient care.

In order to optimise this response, ABD training will be to be included in the package of education for our
Clinical Team Managers (CTM) to further develop their core knowledge. There are two, two hour online
learning sessions taking place before the end of April 2021. Staff attendance will be recorded and each CTM
will have to report to confirm that they have completed the sessions.

National clinical guidance updates
The Joint Royal Colleges Ambulance Liaison Committee (JRCALC) and the National Ambulance Services Medical

Directors Group (NASMED) have published an ABD clinical guideline, specifically for ambulance staff, within the
Clinical Practice Guidelines. This is the first national guidance on ABD for ambulance staff in the UK. The LAS
have worked in partnership with a national team in developing this guideline welcomes this significant

improvement in patient care.

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The LAS has established processes for sharing updated clinical guidelines digitally with our clinicians through
the use of personally issued tablet devices to staff which alert staff to updated clinical guidelines. Further to
this my Chief Medical Officer, who chairs the National Medical Directors Group is keen to ensure the regular
update of these guidelines to reflect learning. our Clinical Practice Development Manager for
Critical Care, who you heard from at the inquest, has joined the group which is developing and reviewing these
guidelines and the learning from Mr Clarke’s death has been presented to the chair of the JRCALC guidelines
group.

| very much hope this response helps in setting out the ongoing work that the LAS are engaged with to ensure
staff are fully up date and trained in the importance of ABD as the priority and the ongoing work to further
develop and monitor Trust wide learning and communicate this to our staff.

ABD training and will remain at the forefront of our agenda and our expectations of our staff in demonstrating
not only high standard of clinical treatment but also leadership and the absolute requirement to advocate for
their patient, always putting their best interests at the forefront of clinical decision making.

The LAS will continue to further this work with our staff to ensure they are well trained and on a national basis
in respect of the development of clinical learning in an ongoing commitment to learn from Mr Clarke’s tragic
death, with the overarching aim to do all we can to mitigate the risks of another death in these circumstances.

Yours sincerely >

Chief Executive, London Ambulance Service NHS Trust

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PROFESSIONALISM HQ 

Mr Andrew Harris 
Senior Coroner 
London Inner South                                                       
Southwark Coroners Court                                                 Victoria Embankment 
1 Tennis Street                                                                      London 
London 
SE1 1YD                                                                                

SW1A 2JL 

Deputy Assistant Commissioner 
New Scotland Yard 

                                                                                            Tel: 

Email: 

Our Ref: 

                                                                                             Date: 15 April 2021 

Dear Mr Harris 

I am the Deputy Assistant Commissioner for Professionalism in the Metropolitan Police Service 
(MPS) and I am responding on behalf of the Commissioner of Police of the Metropolis to your 
Regulation 28 Report to Prevent Future Deaths, dated 18th February 2021. Your report was 
sent following the conclusion of the inquest into the death of Mr Kevin Clarke who died on 9th 
March 2018.  

The MPS has acknowledged and reviewed the four matters of concern raised by the Coroner 
and our response to the matters of concern are as follows:  

Evidence  was  adduced  that  the  police  officer  training  programmes  are  run  by  a 
specialist in officer safety, the core being Officer Safety Training, and another module 
being Emergency Life Support (ELS) and a bolt on of ABD Training. The focus of ELS is 
upon action in the event of a cardiac arrest, so that there is little attention given to health 
and  safety  of  the  detainee  in  non-emergency  situations  and  an  inadequate  input  by 
health professionals. It is illustrated by the officer who said that he had not been taught 
how  to  measure  vital  signs  as  part  of  monitoring  a  detainee.  The  expert  consultant 
physician who viewed the video of restraint observed a highly abnormal fast breathing 
rate, but none of the officers had noticed this at the time.  

Since the inquest into the death of Mr Clarke, the MPS has made a number of changes to the 
delivery  of  first  aid  training.    Although  the  training  has  always  consisted  of  monitoring  the 
casualty,  including  the  pulse  and  breathing  rate,  the  practice  of  this  in  the  classroom  was 
limited  and  mainly  carried  out  during  the  unresponsive  breathing  casualty  scenarios.  This 
training is now included in all scenarios and especially when monitoring responsive casualties 
in relation to signs of deterioration. The training now includes the ‘goalposts of life’ which state 
that the breathing rate should be between 10 and 30 breaths per minute and anything outside 
of this is a medical emergency. During classroom training the monitoring of the casualty is now 
fully practised and assessed as a learning outcome. 

We are currently in the process of producing an aide memoir which provides the relevant vital 
information.  It is anticipated that this will be published in May 2021 and will be available to 
anyone who undertakes emergency life support training.  I have attached a copy of the draft 
(Appendix A). 

 
 
 
 
 
                             
                                                     
 
 
 
 
 
                                                        
 
  
 
 
 
    
 
 
                                                                                                   
 
 
 
 
 
 Officers  and  staff  are  instructed  that  once  a  healthcare  professional  is  at  the  scene  of  the 
incident, the healthcare professional takes primary care of the casualty.  The officer or member 
of staff should provide a handover to the healthcare professional using the pneumonic ATMIST 
(Age,  Sex,  Name,  Time,  Mechanism  of  injury,  Injuries  or  Illness  identified,  Signs  and 
Symptoms and Treatment given) which provides a framework for the information required by 
the healthcare professional.  Officers and staff are instructed to call an ambulance because 
the casualty requires medical assistance beyond the first aid the officer or member of staff can 
provide.  They are instructed that the paramedic may ask them to assist them when they arrive, 
and that they should follow their instructions.  This is made clear in officer and staff training 
that they will be following the direction of the healthcare professional.  If specific instructions 
are not provided, there will be the assumption that they are taking the correct action for the 
casualty.   

It should be noted that in this specific case, the paramedics made no comment nor challenged 
any of the officer safety tactics used and therefore the officers acted in accordance with their 
training.  

Despite  organisation  protocols  and  the  MoU  there  was  a  conspicuous  lack  of 
leadership,  risk  assessment  or  challenge  on health  and  safety  of the detainee  by  the 
paramedic, who appeared to have insufficient seniority or experience to know what to 
do in a detention situation. Equally there was a lack or expectation or request by police 
for  her  input  and  advice.  My  expert  physician  opined  that  if  the  detainee  was  to  be 
moved,  he  wouldn’t  recommend  standing  him  and  walking  him,  which  would  make 
things worse. Yet the paramedic recalls no professional dialogue between police and 
paramedics about the critical conveyance decision, says she left it to them to decide, 
although preferring a safer method and then later changes her evidence. 

As previously stated, officers and staff are instructed that once a healthcare professional is at 
the scene of the incident, the healthcare professional takes primary care of the casualty and 
that they should therefore take instruction from them.  

The MPS is conducting a review of both policy  on restraint removal (or otherwise) during a 
medical  emergency  as  well  as  carriage  methods  of  individuals. Work  has  already  begun  in 
terms  of  identification  and initial  testing of  carriage  equipment,  namely  the  Megamover  ®  (a 
compact,  portable  unit  used  to  transport  or  transfer  patients  from  areas  inaccessible  to 
stretchers).  Following  a recent  event  this  year  in  the Thames  Valley  Police area,  as  part  of 
their investigation the IOPC are looking into the use of FLACS (Flexible Life and Carry System) 
used by officers to assist with carrying the detainee.  This is under scrutiny with direction being 
given from the National Police Chiefs Council (NPCC) that its use is suspended pending further 
investigation. The MPS is assisting with this investigation and will be in an informed position 
to  provide  an  appropriate  evidence  base  to  support  any  future  trial  or  implementation  of 
carriage  mechanisms  along  with  fully  considered  medical  implications  assisted  by  the 
Independent Medical Advisory panel (IMSAP). 

The protocols of the MPS require a Safety Officer to monitor the detainee’s health and 
safety in restraint situations. Evidence heard suggested that this was either not carried 
out or was ineffective. No officer challenged the decision to cuff the detainee when he 
started to get up and the Safety officer at the time agrees he did not consider whether 
his illness made the decision unreasonable, as laid out in ACPO guidance.  An officer 
agreed that the risks of restraint to the detainee were not balanced against the risks to 
everyone from not restraining. The Safety Officer at the head changed several times, 
making any monitoring of trend difficult and for critical period the most inexperienced 
officer was the Safety Officer, who was unaware of the benefits of looking at gums or 
nails. At the time he was escorted, the Safety Officer agreed that the face could not be  

 
 
 
 
 
 
 observed  as  it  was  hidden  by  a  hood.  The  risks  are  further  augmented  by  the  MPS 
submission that it is not always possible to identify a safety officer in all incidents.  

MPS officer safety training now contains a reminder to all officers and staff, through classroom 
training delivery and practical sessions, that all use of force needs to be justified and needs to 
take into account all factors including the balance of risk of restraint to the subject, officers and 
the wider public. This training includes an additional requirement for the Safety Officer at the 
scene to identify themselves using terminology equal to: 

“I am the Safety Officer. Everyone listen to me. If you have any concerns, speak up and speak 
out”.  

The role of the Safety Officer is self-appointed with the default position being that the person 
at the head of the subject will be responsible for monitoring the health, welfare and safety of 
the subject.   

The  training  schedule  for  April  to  September  2021  includes  a  specific  lesson  on  Acute 
Behavioural Disorder (ABD) as well as a mandate for all officers to complete the National ABD 
2021  package  created  by  the  MPS,  endorsed  by  IMSAP  and  published  by  the  College  of 
Policing.  The  College  of  Paramedics  and  Association  of  Ambulance  Chief  Executives  have 
been consulted during the creation of this package.  

Of further note, the MPS is committed to increasing the contact time denoted to officer safety 
training and indeed how this is delivered. The proposal is that from October 2021, officers will 
receive two days’ officer safety training and a separate emergency life support day, which is 
an  increase  of  one  day  per  year  from  the  current  position.  This  proposal  is  in  line  with  the 
national work being led by Deputy Assistant Commissioner Matt Twist as NPCC Lead for Self 
Defence,  Arrest  and  Restraint  which  will  try  to  achieve  consistency  across  police  forces  in 
terms  of  time  dedicated to training  as  well  as  content  delivery.  Moving  to  a  scenario  based 
framework will allow for a greater transition of tactics from the training setting to the operational 
environment. Furthermore, the concepts  ‘quality of encounters’ (providing an explanation of 
what is happening, obtaining an agreement or understanding and thus co-operation, providing 
an acknowledgement of the encounter and a positive departure) and ‘trauma informed policing’ 
(recognising that the subject’s perceived disproportionate response to police requests may be 
predicated on a previous negative experience), are also introduced to officer safety refresher 
training as well as the increase in the number of days afforded to foundation training.  

In  January  2021,  initial  recruit  officer  safety  training  increased  from  five  days  to  eight  days 
which is a significant increase in contact time and material delivered. This increase includes 
the addition of concepts such as performance under pressure through scenario assessment, 
the effects of stress and de-escalation and safety in mind.  

In autumn 2021, the MPS Police Power and Encounters Unit (PPEU) will be formed and will 
see Subject Matter Experts (SMEs) from across business groups come together to holistically 
deal with issues such as those identified in your report. This new unit will consist of SMEs from 
the  Officer  Safety  Unit,  Specialist  Firearms  Command,  Continuous  Policing  Improvement 
Command for Stop and Search and the Directorate of Professional Standards.  This team will 
have the capacity to reactively and proactively engage with supervisors and support them in 
scrutinising their officers’ use of force.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 The  unit  will  work  symbiotically  to  support  each  other  and  lead  on;  officer  safety  policy, 
curriculum  design,  use  of  force  reviews,  Taser  Policy,  Stop  and  Search  Policy/review  and 
represent  the  MPS  at  national  level  to  identify  and  address  use  of  force  and  officer  safety 
concerns.    It  will  translate  its  work  into  organisational  learning,  which  will  be  embedded  in 
training  and  policy  and  work  reciprocally  with  the  MPS  Learning  and  Development  Officer 
Safety  Training  Delivery  Unit  and  the  MPS  Learning  and  Development  Quality  Assurance 
Team to add value to officer safety training provision and ensure training is evidence-based. 

The unit will act as an initial point of contact for all MPS units that want to develop learning 
around individual incidents or wider trends.  It will also be responsible for identifying potential 
risks  and  emerging  opportunities  and  issues  regarding  officer  safety;  Taser  and  stop  and 
search  across  the  MPS,  nationally  and  internationally,  and  proactively  and  pre-emptively 
addressing these in the MPS.  
Scenario based training is being introduced into officer safety training from April to September 
2021  with  the  intention  of  incorporating  a  largely  scenario  based,  uplifted  package  from 
October 2021.  The training will also include supplementary material to solidify key learning 
outcomes, including: 

  Recording encounters accurately 
  When to use force 
  When to use restraint 
  De-escalation before, during and after an encounter 
  Situational awareness 
  Tactical communication 
  Procedural justice 
  Recognising the impact of stress on behaviour 
  Reflecting on your actions 

There  was  serious  inadequacy  of  supervision.  The  initial  scene  was  managed  by 
“collective leadership”, where decision making seemed to emerge without discussion. 
An  experienced  sergeant  who  arrived  after  the  initial  restraint,  alleged  she  had 
conducted  a  risk  assessment,  without  getting  an  adequate  briefing  on  the 
circumstances of his restraint. She was unable in questioning to identify any situation 
in which restraints should be released due to the length of restraint, unless directed by 
a  paramedic  or  emerged  from  mania.  She  asserted  that  she  knew  that  whatever  her 
officers had done prior to her arrival, she could trust that they made the right decision.  

It is the responsibility of the Safety Officer to look after the health, welfare and safety of the 
subject prior to the arrival of the supervisor. In the delivery of officer safety training from April 
to September 2021, supervisors will be informed of the requirement that upon arrival at the 
scene of an incident, they need to clearly identify themselves, their role and to liaise with the 
Safety Officer to be briefed on the circumstances of the incident including the welfare of the 
subject.   

The requirement will include the need for the Supervisor to verbalise the following: 

“I am the Supervisor at scene. I am reviewing the incident.  Who is the Safety officer? Can I 
have a briefing?” 

The use of body worn video will also allow for these instructions to be recorded. 

 
 
 
 
 
 
 
 
 
 
 I wish to express my sincere condolences to the family of Mr Clarke. I trust this provides the 
reassurance that  the  MPS  has  considered the matters  of  concern you have raised  and are 
addressing these in officer safety and emergency life support training for all police officers and 
staff who attend these courses.   

Please do not hesitate in contacting me should you have any queries. 

Yours sincerely 

Deputy Assistant Commissioner 

Enc.