Paul Reynolds

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

THIS REPORT IS BEING SENT TO: 

(1) 

(2) 

, Director, Brittania Jinky Jersey Limited, Ainsdale 

House, Shore Road, Southport PR8 2PZ 

, Operational Director, Brittania Hotels Group Limited, 

Halecroft, 253 Hale Road, Hale, Cheshire WA15 8RE 

1 

CORONER 

I am Jacqueline Devonish, area coroner, for the coroner area of Suffolk 

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. 

3 

INVESTIGATION and INQUEST 

On 19 April 2021 I commenced an investigation into the death of Paul Steven Reynolds, 
aged 38. The investigation concluded at the end of the inquest on 10 May 2021 . The 
conclusion of the inquest was that Mr Reynolds died following an unlawful restraint by 
the neck and further in prone position at Pontins Pakefield in Lowestoft, Suffolk on 14 
February 2017.  

The inquest concluded that Pontins security had unlawfully restrained Mr Reynolds by 
the neck and then placed him in an unlawful prone restraint without conducting effective 
monitoring of his breathing. 

The medical cause of death was concluded to be ‘Complications Arising from Restraint 
of an Intoxicated Obese Individual in a Prone Position, with Compression of the Neck 
and Potential Obstruction of the Upper Airways’. 

4 

CIRCUMSTANCES OF THE DEATH 

On 11 February 2017 Paul Reynolds attended the Pontins holiday leisure park in 
Lowestoft.  During the evening of the 14th there was an incident between guests in the 
communal area of the leisure park.  As a result of this incident Mr Reynolds was 
restrained by security and other staff until police arrived.  He was grabbed from behind 
in a bear hug, taken to his knees in a neck hold and placed on the ground in a prone 
restraint. 

During the 11 minute prone restraint, captured on CCTV, Mr Reynolds did not appear to 
make any movement, although the Pontins staff involved in the restraint gave evidence 
that he had be wriggling, resisting the restraint, talking and later murmuring. He had also 
apologised and asked to be let up. This information had not been shared with the police. 

The police arrived just after Mr Reynolds was heard snoring, and presumed to be 
asleep.  The effectiveness of the monitoring by Pontins staff was deemed to be 
unsatisfactory as Mr Reynolds was in fact unconscious and no member of staff had 
recognised this.  

 A guest had identified to Pontins restraint staff that Mr Reynolds was at risk of breathing 
difficulties, but this was ignored. The police arrived and arrested Mr Reynolds by 
applying handcuffs and eventually placing him in the police van. On route to the Police 
Investigation Centre the police stopped the vehicle when they noticed Mr Reynolds 

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 appearing unwell.  They took Mr Reynolds out of the van and performed CPR until the 
paramedics arrived. Mr Reynolds was conveyed to James Paget University Hospital 
where he died with hypoxic brain injury due to a lack of oxygen to the brain, on 16 
February 2017.  

Experts attending the inquest gave evidence that Mr Reynolds may have fallen 
unconscious within seconds of the neck hold.  This was exacerbated by moving him into 
a prone restraint with his legs tucked up to his buttocks and failing to relax the constraint 
and get him back to his feet or into recovery position. 

5 

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 Physical Intervention Policy August 2016 places the onus on staff to seek 
additional training. 
(2) Pontins does not undertake any internal training or employ external trainers for 
security staff. 
(3) Unbadged staff are allowed to participate in restraint 
(4) Ground restraint remains in the PI policy as an appropriate method to contain an 
incident even though this is not taught in SIA accredited courses. 
(5) At no point during the prone restraint was Mr Reynolds placed in the recovery 
position.  Neither did any member of staff appear to seriously consider the potential for 
positional asphyxia by closely or effectively monitoring Mr Reynolds breathing. 
(6) There appeared to be no clarity in the Policy about who should take charge of an 
incident or what the responsibilities are for security staff and Managers.  
(7) There appeared to be a lack accurate information and clarity around what information 
should be shared with the police about the incident. 
(8) There was no documented evidence of the induction or any other training for staff. 

6 

ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I believe you and your 
organisation have the power to take such action.  

7 

YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date of this report, 
namely by 9 July 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. 

8 

COPIES and PUBLICATION 

I have sent a copy of my report to the Chief Coroner and to the following Interested 
Persons: 
SIA who may find it useful or of interest. 

. I have also sent it to 

, and 

, 

I am also under a duty to send a copy of your response to the Chief Coroner and all 
interested persons who in my opinion should receive it.   

I may also send a copy of your response to any other person who I believe may find it 
useful or of interest.  

2 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 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. 

9 

11 May 2021                                                                      Jacqueline Devonish 

3

BRITANNIA JJNKY JERSEY LIMITED 
Contact address: Ainsdale House Shore Road Ainsdale Southport PR8 2PZ 

0 ?  AUG  2021 

28th  July 2021 

Dear Sirs: 

Re:  Regulation 28 Report 

As you will be aware there was a delay in  the report being received by me. 

Having considered your report, I respond on behalfof Britannia Jinky Jersey Ltd as follows: 

The Company's policy regarding SIA badged training at the time of the incident was that 
those being recruited were required to produce their current SIA licence confirming that 
they had complied with the requirements of the SIA. We take on board your observations 
regarding external service providers and we are looking into the prospect of engaging 
external training providers to deliver annual refresher training to all security badged staff. 

The ground restraint references in the Physical Intervention Policy will be  removed. As per 
the documentation which was provided to prior to and during the inquest the Company 
emphasise in their training that employees should avoid confrontations and to defuse 
situations. The  incident involving Mr Gladwell was unprecedented as I believe you heard in 
evidence during the Inquest. 

Your concern regarding the information given by staff to the police is  unclear as  I believe you 
heard in  evidence that the employees in question responded to all questions asked of the 
Police and described the circumstances leading to his restraint and police attendance. 

I would like to make it clear that it is  not the case that non badged staff are allowed to 
participate in restraint. As part of our revisions to the Physical Intervention Po licywe will 
however re-emphasise this instruction. 

Registered  Office: 15 Esplanade, St Heller,  Jersey.  JEl lRB 
Company No.107325 

 BRITANNIA JINKY JERSEY LIMITED 
Contact address:  Ainsdale House Shore Road Ainsdale Southport PR8 2PZ 

Regarding staff inductions, all  staff receive inductions and I understand that prior to or 
during in the course of the Inquest copies for each of the employees were provided to you 
via the Company's Barrister. 

eeJones 
Director of Operations 
Britannia Jinky Jersey Ltd 

Registered  Office:  15 Esplanade, St Heller,  Jersey.  JEl lRB 
Company No.107325

Dear Judge Devonish,  

Inquest into the death of Mr Paul Reynolds – ** May 2021 Regulation 28 Report to 
Prevent Future Deaths  

I  am  writing  in  response  to  the  matters  of  concern  raised  in  your  Regulation  28  Report  to 
Prevent Future Deaths report following the Inquest in to the death of Mr Paul Reynolds. Your 
report and the Constabulary’s response have been carefully considered by the Constabulary 
and I have shared this response via the Suffolk Police and Crime Commissioner  to ensure 
openness and onward accountability.  

With respect to the matters of concern, the Constabulary has reviewed the circumstances of 
its involvement and responds as follows:  

1.  Officers appeared to be under the impression that pain/pressure testing to 

determine whether a person was unconscious or simply asleep was an assault 
rather than being justifiable in certain circumstances.  

The Constabulary’s involvement with Mr Reynolds stemmed from a reported incident 
of assault by Pontins Security Officers. Upon finding Mr Reynolds being restrained, 
the  Constabulary  training  would  have  directed  officers  to  assess  the  person  being 
detained and review the evidence being presented.   It was clear from the Inquest that 
the officers involved did not fulfil this assessment robustly and we acknowledge that 
their evidence identified confusion surrounding their police powers.  The Constabulary 
has enhanced its training delivery and supporting guidance to clarify the importance 
of the  initial  assessment  and the  differences  between proportionate  and necessary 
checks  of  health  and  the  application  of  force.  It  will  reinforce  this  learning  through 
practical  based  assessed  scenarios,  as  part  of  the  nationally  revised  curriculum 
design (see paragraph 3), that will specifically test officer’s ability to assess a person 
being  detained  and  determine  whether  the  circumstances  warrant  a  medical 
intervention or the reinforcement of restraint.  

2.  The time allowed for training had been reduced from 12 to 4.25 hours. 

Positional asphyxia training had been ringfenced, but there were questions 
about the impact of the reduction upon officers. 

Suffolk Constabulary’s delivery of Emergency First Aid at Work Training and Personal 
Safety  Training  are  compliant  with  the  requirements  of  the  College  of  Policing 
specification.   This has been reinforced by external and independent inspections as 
part of national and local governance arrangements.  

However,  we recognise  that  nationally  there  have  been  changes  to  the  programme 
that may have created a perception of a reduction in the time assigned to positional 
asphyxia. The time allocated to individual areas of the curriculum are subject to change 
and  nationally  the  focus  of  positional  asphyxia  has  shifted  towards  the  signals  and 
signs of acute behaviour disorder.  This is a precursor behaviour but is part of the same 
continuum.    Material  surrounding  both  acute  behaviour  disorder  and  positional 
asphyxia is delivered in accordance with national guidance and time allocations, but 
the Constabulary will do more to embed this learning within the wider  aspects of its 
Personal Safety Training through supplementary videos and guidance on its Learning 
Management System.  

3.  The College of Policing and NPCC Officer and Staff safety Review made two 

recommendations to include revising the curriculum to ensure greater 
consistency, and to implement guidelines to ensure officers are sufficiently 
skilled in non-physical aspects of conflict management. The time scales for 
implementation were not stated. 

 The  College  of  Policing  is  leading  the  redesign  of  the  personal  safety  training 
programme and we will support the College through this period and implement the new 
programme upon its adoption.  We understand that this new programme will come into 
fruition during 2022 and will be more scenario orientated.  From our understanding of 
the programme design there will be opportunity for us to re-enact scenarios of concern 
and,  as  identified  in  paragraph  1,  we  will  adopt  scenario-based  assessments  that 
recreates  the  events  of  this  incident.    This  will  allow  Trainers  to  assess  officer 
understanding of their medical responsibilities and use of force powers.  

4.  Officers did not control the scene by clearing the ballroom and switching off 
the music which would have improved their ability to assess Mr Reynolds’ 
condition. 

We  accept  the  concerns  raised  surrounding  the  control  of  the  scene.    We  also 
recognise that while the first officer attending may have had difficulty in coordinating 
the various aspects presented, the arrival of other officers gave sufficient opportunity 
for scene to be controlled.   As stated in paragraph 3, we will take this learning into the 
design of a scenario that will replicate and therefore enable the Constabulary to assess 
officer’s scene management approaches. 

Additional Learning   

As  reflected  within  our  evidence,  the  Learning  and  Development  department  did 
undertake  a  comprehensive  review  of  its  practices  and  procedures  following  this 
incident.  We acknowledge our responsibilities as a professional organisation to learn 
lessons and our review identified weaknesses within our records management.  This 
resulted in the lapses surrounding the frequency of refresher training for some of the 
officers involved, as shared during the inquest.   

Our  review  also  identified  that  training  material  constantly  evolves  around  new 
information  and best  practice  but  that  it  was equally  important to be  able  to identify 
officers learning to each iteration of a training package.  These two factors, would have 
enabled  the  Constabulary  to  present  greater  confidence  in  the  completeness  of  the 
officer refresher programmes as well as the rationale surrounding any changes to the 
time allocations, including when these were introduced.     

In response to this learning, we have invested in a new skills management system that 
will make it easier for our learning and development department to track and identify 
officer training records as well as link these records to the training the officer received.  

We trust that this combination shows the seriousness in which we have reflected upon 
the  circumstances  of  this  incident  and  the  changes  in  our  practices  that  we  will 
implement to prevent its reoccurrence.  

Yours Sincerely 

Chief Constable