Joseph Agnew

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eee POLICE
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Assistant Commissioner

FAO: HM Senior Coroner Andrew Harris

12 April 2021

Dear Senior Coroner,

| write on behalf of the Commissioner of Police for the City of London in order to respond to your
report made pursuant to paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and
regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 in relation to the tragic
death of Mr Joseph Agnew.

It is the first two of the four concerns, that relate to City of London Police officers, among others.

In relation to Concern (1); as you heard from 0 officer in charge of the City of

London Police Learning and Organisational Development Unit), who testified remotely before you:
since Mr. Agnew’s passing, and as a result of the lessons learned from his death, City of London
Police officers now receive further training on how to assess whether apparently intoxicated persons
meet the definition of being drunk and incapable or otherwise require medical attention.

Your concern is stated to be that there appears to be no clarity for officers from their training as to
when to refer an intoxicated person for medical attention. 0c I cxpiained to you the training
that officers are given.

This is as per the training and definition provided by the College of Policing in both the Initial Police
Learning and Development Programme (IPLDP) and in the Authorised Professional Practice (APP)
for Detention and Custody, which clearly sets out that a drunk & incapable person is someone who
has consumed alcohol to the point that any of the following applies:-

(a) they cannot walk or stand unaided

(b) they are unaware of their own actions or

(c) they are unable to fully understand what is said to them.

Officers in the City of London Police are trained that if someone appears to be drunk and showing
any aspect of incapability which is perceived to be as a result of that drunkenness, officers should

treat that person as drunk and incapable. They are trained that a drunk and incapable person in
need of medical assistance in hospital that they should call an ambulance immediately.

City of London Police HQ
Address 4" Floor, Guildhall Yard East, London EC2V 5AE

We believe that your point in relation to there appearing to be a lack of clarity, was that one of the
City of London Police officers (PC commented during his evidence that being
“unable to fully understand what is said to them” — if the word “fully” is to be taken literally ~ would
include many people who have had a lot to drunk but who are plainly not in need of being conveyed
to hospital by an ambulance. The officer explained that he would use his common sense in relation
to this and we would respectfully submit that that is the correct approach to take in order to avoid
ambulance services to be overwhelmed by calls to attend those who are not in need of emergency
treatment.

Concern (2) relates to the failure to appreciate the significance of snoring in a person with a reduced
level of consciousness. We believe that this concern was primarily one that related to the
Metropolitan Police officers who attended upon Mr. Agnew after the City of London Police officers
had left. It is they who explained to the jury that they had been reassured by hearing Mr. Agnew
snoring. He was not, of course, snoring when being dealt with by the City of London Police officers
shortly beforehand.

Furthermore, the reference to “good or bad snoring” originally came in questions from our counsel,
FY to the Metropolitan Police officers. He put to them that there is no such thing as
‘good’ snoring in a person who requires an emergency ambulance because of their reduced level of
consciousness and it should not have been reassuring to them.

| would, however, confirm that my instructions are that the first aid training of City of London Police
officers will henceforth fall in line with that given to Metropolitan Police officers, who you heard are
now trained specifically to recognise that snoring in a person with a reduced level of consciousness
is a sign of airway obstruction which must be rectified and are taught to perform the “jaw thrust” that
was described to you by EE the Metropolitan Police Service’s Senior Adviser, First Aid,
Policy, Assurance and Training, in her evidence before you. DCI ae 2: confirmed that this
will be thoroughly covered in the first aid training provided to City of London Police officers. Officers
will be taught how to monitor breathing and will be taught not to seek to rely on being able to see the
casualty’s chest rise and fall.

Yours Sincerely,

Assistant Commissioner

City of London Police HQ
Address 4" Floor, Guildhall Yard East, London EC2V 5AE

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College of Policing
Leamington Road
Ryton-on-Dunsmore
Coventry, CV8 3EN

Dr Andrew Harris, contactus‘@college.pnn.police.uk
. college.police.uk
Senior Coroner, London Inner South

19 April 2021

Dear Dr Harris
Re: Joseph Agnew (Deceased)

| write on behalf of the College of Policing (the College) in relation to paragraph 7, Schedule 5 of
the Coroners and Justice Act 2009, and regulations 28 and 29 of the Coroners (Investigations)
Regulations 2013, prevention of future death report to the College dated the 26" February
2021.

The report sets out concern that arose from the information received during the inquest in to the
death of Mr Joseph Agnew. | was very sorry to read of the circumstances of Joseph’s death.
My sympathies are with his family and friends and | share your commitment to addressing the
issues that contributed to his untimely loss.

The report sets out your principle concerns in respect of the training that is available for officers.
Your concerns were; firstly in respect of the ability of officers to assess a person as being “drunk
and incapable” and when to refer an intoxicated person for medical attention, and secondly in
respect of whether officers had learnt how to effectively monitor breathing and other symptoms
that might be linked to the need for medical assessment or attention. More specifically your
letter provides the following information.

1. For the attention of CoLP and College of Policing:

CoLP officers were not taught how to assess people to meet the agreed criteria for finding
someone “drunk and incapable”. A senior officer was not content that the officers involved had
given a satisfactory level of questioning nor welfare checks. The risk to life continues since
there appears to be no clarity for officers from their training as to when to refer an intoxicated
person for medical attention.

2. For the attention of CoLP, MPS and College of Policing:

No police officers who gave evidence understood the significance of snoring in a person with a
reduced level of consciousness, nor how to monitor breathing. My independent expert in A&E
gave evidence that snoring indicates partial airway obstruction. He dismissed perceptions of
officers that there was such a thing as good or bad snoring. He opined that in a person with
reduced consciousness officers should assume that snoring needs medical attention. The
person needs assessment to exclude when it is not a concern. Whilst he acknowledged the
difficulty of assessing breathing, he stressed its importance as an indication of medical
emergency, gave little weight to the value of chest movements which officers used, and
highlighted the danger signs of very slow or very fast breathing. He also stressed that concern
for medical attention should be triggered by unrousability. The evidence suggested that officers
were unaware of all these matters and had not learnt how to effectively monitor breathing.

The College is the independent professional body supporting everyone working in policing to
reduce crime and keep people safe. The College has three complimentary functions

. Sharing knowledge and good practice: creating and maintaining easy access to
knowledge, disseminating good practice, and facilitating the sharing of what works

. Setting standards: setting standards for key areas of policing which help forces and
individuals provide consistency and better service for the public

. Supporting professional development: setting requirements, accrediting, quality assuring
and delivering learning and professional development, promoting diversity and wellbeing, and
helping to nurture and select leaders at all levels.

The College licences the First Aid Learning Programme (FALP) used by Home Office Forces,
including the Metropolitan Police Service and the City of London Police. The programme is
endorsed by the National Police Chiefs Council (NPCC) and the Health and Safety Executive
(HSE). The College is responsible for ensuring appropriate quality assurance processes are in
place to guide forces in the implementation of the HSE guidelines relating to the provision of
first aid.

The FALP has five modules and the national recommendation is that police officers receive a
minimum of Module 2 training (the equivalent to the qualification of a HSE Emergency First
Aider). While Module 2 does not seek to provide detailed coverage of all specific medical
conditions it does allow officers and staff to make an assessment of the casualty, including the
known factors that may present a risk to their health.

Officers and staff are called on to provide first aid in a wide range of incidents during their work.
The range of incidents officers attend means it is not possible or viable for all officers to be
trained for all types of medical emergencies, or for the FALP to explicitly outline the appropriate
medical response in every context.

It is recognised that some areas of policing, such as working in custody environments, firearms
operations or public order teams, require additional skills and knowledge. The relevant staff
have additional FALP training modules available to ensure they are prepared for situations they
are likely to encounter in their specialist roles. Additionaly, where local force risk assessments
identify a critical need, Chief Officers are able to add additional medical training provisions
under the advice of iocal clinical governance.

The FALP modules are monitored via the College’s own governance and a national NPCC
coordination committee. The NPCC portfolio includes the HSE representation, and is supported
by a dedicated subject matter expert group of force first aid leads, and a national clinical
governance structure, which includes a broad range of independent clinical expertise. The
NPCC governance structure considers all relevant recommendations as a standing agenda
item.

In addition, a wider review of the high level learning outcomes for the FALP has already been
initiated to ensure that they remain fit for purpose. We will ensure that your causes for concern
will form part of this review. It is anticipated that this work will be completed towards the end of
2021 following the publication of updates expected from the UK Resuscitation Council this year.

The College also sets the education and training requirements for all new recruits. Historically,
all officers have been trained in accordance with the requirements of the Initial Policing
Development Programme (IPLDP) but increasingly forces are putting their recruits through the
Police Constable Degree Apprenticeship (PCDA). The IPLDP had content in respect of; the
‘signs and symptoms of drunkenness’, the potential for symptoms of drunkenness to be caused

by medical conditions, and where there is any doubt, that it should be assumed the person has
an illness or injury and medical assistance should be requested.

The PCDA places a high ievel of emphasis on the potential vulnerability of a person who,
because of their situation or circumstances, is unable to take care or protect them self from
harm or exploitation. This includes the importance of considering the possibility of hidden
medical conditions or non-visible signs that may lead to a person being vulnerable. The College
has developed a vulnerability learning programme which supports the PCDA programme and
can also be used for officers who have not been trained through the PCDA to ensure
consistency in learning.

in summary, through initial training, the vulnerability programme and the FALP the focus is on
providing officers with the skills and information to look for signs and symptoms that indicate the
need for medical intervention and to request it when found. For the FALP in particular, we will
use these causes for concern to inform the review of the learning outcomes that will be taking
place this year.

The College is committed to continuing our work with forces, the NPCC and other agencies to
raise standards of practice in the care of people who come to police attention. We would like to
thank you for bringing the circumstances of Mr Agnew’s death to our attention so that we can
ensure that our immediate and future work is informed by the events that culminated in his
death.

Yours sincerely,

Faculty Lead for Uniform Policing

29 April 2021 

Senior Coroner Andrew Harris 
London Inner South Coroner’s Court 
1 Tennis Street  
London  
SE1 1YD 

By email only -

Dear Sir 

Inquest arising from the death of Joseph Agnew 

I write on behalf of the Mayor of London (the Mayor) with regard to the Senior Coroner’s 
Regulation 28 Report to Prevent Future Deaths (PFD) dated 26 February 2020 following 
the inquest arising from the death of Joseph Agnew.  

Mr Agnew’s inquest and the Prevention of Future Deaths (PFD) report 

The Senior Coroner’s PFD report raises the following matter of concern for the attention 
of the Mayor: 

‘Evidence was heard that whilst the police can refer chronic rough sleepers to charities, 
there is no facility to which police can refer acutely intoxicated homeless people found on 
buses. It was reported that such facilities do exist elsewhere and that they create a place 
of  safe  refuge  where  monitoring  can  be  effectively  conducted.  The  potential of  such  a 
facility to save lives is drawn to the attention of the Mayor’. 

Mr Agnew died on 15 December 2016 and the inquest into his death concluded on 17 
November 2020. The Mayor was not an Interested Person in the inquest and was first 
made aware of this inquest upon receipt of the Senior Coroner’s PFD report. The Senior 
Coroner has kindly provided a copy of the IOPC’s report into the investigation into police 
contact with Mr Agnew prior to his death and the following extracts of evidence from the 
City of London Police officers at the inquest: 

PC 
bus shelters or at a station. He never received any guidance or instruction otherwise’. 

 – ‘It was a common practice in 2016 to have to leave intoxicated people in 

 – ‘To avoid instances of vulnerable people being left on the street, we need a 
PC 
way to deal with folk on buses – outreach services tend not to count these people. No 
solution  has  been  found  yet.  They  don’t  attend  –  they  may  fall  outside  their  LA.  What 
would be helpful is a place to take drunk people. There is an SOS bus in the City. The 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 time slot is critical – there is a narrow window. Such a facility needs to be more widely 
available. He has been involved in trying to secure facility for Christmas period’.  

I am the Executive Director for Housing and Land at the Greater London Authority (GLA) 
and  one  of  the  teams  within  my  department  is  the  rough  sleeping  team,  so  I  am 
responding to the Senior Coroner’s report on the Mayor’s behalf.  

I  would  like  to  take  this  opportunity  to  offer our  sincere  condolences  to  the  family  and 
friends of Mr Agnew and outlined below is a response to the area of concern raised by 
the Senior Coroner.  

The Mayor’s responsibilities for rough sleeping 

The Mayor’s Life Off the Streets programme provides a range of services and initiatives 
to  help  people  sleeping  rough  to  leave  the  streets  and  rebuild  their  lives.  These 
complement those provided by London’s boroughs.  

The Mayor does not have a statutory duty to provide these services but works alongside 
London’s  boroughs  who  also  provide  services  to  those  who  sleep  rough.  The  Mayor 
commissions  services  that  are  pan-London  or  multi-borough  in  their  remit.  Local 
Authorities  have  a  duty  under  the  Housing  Act  1996  to  secure  accommodation  for 
unintentionally homeless households who fall into a ‘priority need’ category. There is no 
duty to secure accommodation for all homeless people.  

Services available for rough sleeping 

The  Mayor  provides  a  range  of  services  to  assist  people  to  rebuild  their  lives.  These 
include  street  outreach  which  involves  teams  of  outreach  workers  locating  people 
sleeping  rough  and  supporting  them  to  leave  the  streets.  There  are  also  services  to 
provide immediate options for someone to leave the streets or prevent them from sleeping 
rough. This includes emergency accommodation services and assessment centres which 
provide safe shelter and support for people to find longer term accommodation. 

Services also include longer term accommodation solutions and access to appropriate 
support including mental and physical health, training and employment to enable people 
to move on with their lives.  

The priorities underpinning all the Life Off the Streets rough sleeping services, projects 
and  initiatives  funded  by  the  Mayor  are  set  out  in  the  pan-London  Rough  Sleeping 
Commissioning Framework. 

The overarching priorities of the Commissioning Framework are to work with boroughs 
and partners to: (i) minimise the flow of new rough sleepers onto the streets, (ii)  ensure 
that no-one new to the streets sleeps rough for a second night, (iii) ensure that no-one 
lives on the streets of London; and (iv) ensure that no-one returns to sleep on the streets 
of London.  

 
 
 
 
 
 
 
 
 
 
 
 There are also various cross-cutting priorities that are critical to tackling rough sleeping 
and  will  underpin  the  nature  and  shape  of  the  GLA’s  commissioned  services  over  the 
coming  period.  This  includes  working  with  boroughs  and  partners  to:  (v)  tackle  rough 
sleeping by non-UK nationals, (vi) improve partnership working around enforcement, (vii) 
tackle hidden or mobile rough sleeping, (viii) meet the physical and mental health needs 
of  rough  sleepers,  (ix)  help  ensure  the  availability  of  appropriate  accommodation, 
including  emergency  accommodation,  (x)  enhance  the  service  offer  from  smaller 
organisations,  including  faith  and  community  based  organisations,  (xi)  maintain  and 
improve  the  collection  and  use  of  data  about  sleeping  rough;  and  (xii)  promote 
employment, training and volunteering among rough sleepers.  

All  services  for  rough  sleepers  commissioned  by  the  GLA  are  tested  against  the  four 
overarching priorities and the relevant cross-cutting aims to ensure that they are making 
an appropriate and demonstrable contribution to tackling rough sleeping in the capital.  

More  information  on  all  of  these  services,  including  funding  and  the  provider 
organisations, can be found in the Mayor's Life Off the Streets rough sleeping services 
briefing. I enclose a copy with this letter.  

Policies on rough sleepers sleeping on buses 

In August 2017, the Mayor announced the creation of a new team dedicated to helping 
the  rising  number  of  homeless  people  who  use  Night  Buses  and  Tubes  as  a  place  to 
sleep. I enclose a copy of the Mayoral Decision (MD2166) which approved this policy.  

As set out in MD2166, the Mayor wanted to ensure there was an offer for every rough 
sleeper in London and that services were in place to help them access available support. 
One gap in provision was the coverage of outreach on London’s night buses and the tube 
network.  The  ongoing  extensions  of  the  night  tube,  in  particular,  created  additional 
‘spaces’ where people who were homeless may sleep to stay warm and safe. 

It  was  therefore  proposed  that  the  GLA-commissioned  London  Street  Rescue  (LSR) 
service be enhanced to provide a new ‘night transport outreach team’ to run for 18 months 
(starting in October 2017) to work on the night bus and tube network in London. The team 
would work closely with Transport for London (‘TfL’), with whom LSR already had good 
links.  This  would  enable  intelligence-led  shifts  based  on  TfL  staff  reports  which  would 
feed into shift delivery patterns. The service would also develop the skills of TfL staff to 
improve the quality of referrals.  

The team help find accommodation, provide access to support services and reconnect 
people with family and friends to prevent them from ending up sleeping on the streets.  

This announcement followed data from TfL which revealed that the number of homeless 
people sleeping on night buses in winter 2015/16 was 121% greater than the same period 

 
 
 
 
 
 
 
 
 
 
 
 in 2012/13. This reflected a trend of rising homelessness seen more widely across the 
capital in recent years. The Mayor’s aim for the night outreach team was to help prevent 
people using transport as a bed for the night and to ensure they receive immediate help 
to access he accommodation and range of services they need.  

The  night-time  transport team  focuses  on  transport routes  which homeless  people  are 
known to frequent or that bus and Tube drivers have referred the team to. The emergency 
services and members of the public can alert the outreach team to anyone needing their 
help by using the online Streetlink London service (www.streetlink.london).  

Prior to the establishment of the team, support for individuals rough sleeping on buses 
was, in the main, the responsibility of borough commissioned outreach teams. With the 
introduction of this team, bus drivers, tube workers and the emergency services were able 
to refer individuals to the service regardless of borough boundaries so that support can 
be given. The Mayor has recently agreed funding for this service to continue within the 
London  Street  Rescue  service  for  2021/22.  I  enclose  a  copy  of  the  relevant  Mayoral 
Decision (MD2789).  

However, this team is not a blue light service and whilst it will aim to respond to all referrals 
in a timely manner, this service aims to get help those who regularly rough sleep on buses 
in order to help the most vulnerable.  

Therefore,  since  Mr  Agnew’s  tragic  death  in  December  2016,  a  dedicated  outreach 
service to assist individuals who are rough sleeping on buses has been established by 
the Mayor. 

Facilities for intoxicated persons 

There  are  several  alcohol  intoxication  management  services  (AIMS)  that  have  been 
commissioned  by  local  borough  public  health  teams,  the  London  Ambulance  Service 
(LAS) and the NHS, such as the SOS bus in the City of London and Alcohol Recovery 
Centres that run in several London boroughs. These services are not run by the Mayor. 
These services are designed to receive, treat and monitor intoxicated patients who would 
normally attend Emergency Departments and to lessen the burden that  alcohol-misuse 
places on A&E services. These mainly operate at Christmas and other busy times of the 
year when demand for the London Ambulance and A&E services is high.  

These services are not generally designed to assist and support rough sleepers, as they 
are generally set up to help people sober up and reduce the strain on A&E departments 
rather than provide interventions and ongoing support for vulnerable clients.  

Conclusion 

As detailed above, the main development since Mr Agnew’s death in December 2016 has 
been  the  establishment  of  the  night  transport  outreach  team  to  assist  anyone  rough 
sleeping on the transport network at night, enabling drivers and others to refer those of 

 
 
 
 
 
 
 
 
 
 
 concern to this service. Since the creation of this service, the team has helped over 1,020 
clients.  

The  National  Institute  for  Health  Research  has  recently  published  an  evaluation  into 
alcohol intoxication management services and made several recommendations around 
future work on the management of alcohol intoxication in night-time environments which 
I  hope  will  be  taken  forward  at  national  and  borough  level  to  provide  a  more 
comprehensive safety net for those intoxicated and vulnerable.  

I trust this response is helpful. Please contact us if we can be of any further assistance.   

Yours faithfully 

Executive Director, Housing and Land