Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0177, written 25 May 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 25 May 2021 |
|---|---|
| Reference | 2021-0177 |
| Deceased | Matthew Mackell |
| Coroner | Alan Blunsdon |
| Coroner area | North West Kent |
| Category | Police related deaths · Suicide (from 2015) · Child Death (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
North West Kent Coroners Cantium House County Hall Sandling Road Maidstone Kent ME14 1XD Date: 25 May 2021 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Chief Constable Kent Police; IOPC; CORONER I am His Honour Alan J Blunsdon for Kent County Council 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. 1 2 http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/m INVESTIGATION and INQUEST On 15 May 2020 I commenced an investigation into the death of Matthew MACKELL. The investigation concluded at the end of the inquest . The conclusion of the inquest was 3 Suicide with additional narrative: Matthew Mackell was found dead on the 7th May 2020 in Dunorlan Park, Tunbridge Wells, Kent. He had suspended himself from a tree using a ligature with the intention of taking his life. At 22:18 on the 6th May 2020 he had telephoned Kent Police to inform them of his intention but did not provide his identity or location. Kent Police did not deploy their available enhanced mapping system which would have provided an accurate location for Matthew Mackell. This was a missed opportunity, Kent Police did not maintain the correct "immediate" grading of the call. Kent Police did not despatch a patrol to the location of the deceased in response to the call. It was not possible to establish on the balance of probability whether the deployment of the enhanced mapping system would have resulted in a patrol finding Matthew Mackell before he was deceased. 1a Suspension 1b 1c II CIRCUMSTANCES OF THE DEATH 4 Police were initially called on the morning of the 7th May 2020 by a runner in Dunorlan park. He stated that he and his wife had been running in the park and had seen a male hanging from a tree. Police then attended and located the deceased. The body was initially found hanging from a tree in Dunorlan Park. A bedsheet had been used as a ligature. The tree was located around 50 metres in to the park from the Pembury Road entrance and was clearly visible from the footpath. The deceased was then cut down and CPR performed. It appears that the deceased has had ongoing suicidal thoughts that have been aggravated by relationship troubles.On the evening before his death the deceased had an argument with his brother. At 2218 hours on Wednesday 6th May 2020 the deceased made a call to Kent Police Force Control Room in which he stated that he was going to kill himself. No name or description was left and so the call could not be further explored. 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 will 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) In December 2019 a software update had been installed to a system in the Kent Force Control room which, if used, produced a much greater accuracy in detecting the location of mobile phone calls. There had been inadequate or no training on the use of the update which resulted in the system not being deployed to locate the deceased. The call from the deceased at 22.18 was therefore incorrectly downgraded as the area to search was regarded as too wide to be effective. The downgrade was incorrect because (a) the use of the software would have provided an accurate location and (b) the call should have been treated as a suicide call and not an abandoned 999 call. It is accepted that as a direct result of this incident the software system is now the default setting to detect locations. However, the evidence of those witnesses who were required to use the system raised a more general enquiry which identified gaps in or absence of effective training and the cascading of information. 5 (2) The totality of the evidence from several experienced operatives in the Force Control Room revealed gaps in their knowledge as to operating procedure in respect of the suicide policy, appropriate downgrading of calls, checking available patrols. Whilst it is accepted that following an IOPC report steps have been taken to review and improve procedures, it was apparent that there was an absence of an effective system to identify those that required training/updating and of the keeping a record of the specific training/updating received by individual operatives and the date it was undertaken. There did not appear to be a structured system in place to produce a regular training rotation which monitored and recorded individual satisfactory progress. Such a system would clearly identify what training/updating had been received thus identifying those who might otherwise be missed and when training/updating was scheduled to take place. (3) ACTION SHOULD BE TAKEN 6 In my opinion action should be taken to prevent future deaths and I believe you Kent Police 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 21st July 2021 I, the coroner, may extend the period. 7 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 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: IOPC, and to the LOCAL SAFEGUARDING BOARD (where the deceased was under 18)]. 8 I 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. 25 May 2021 9 Signature His Honour Alan Blunsdon Assistant Coroner for North West Kent
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.
Protecting and serving the people of Kent T/Assistant Chief Constable Central Operations 4th July 2021 Dear Sirs, Regulation 28 Report to Prevent Future Deaths – Matthew Mackell I write in response to the Regulation 28 Report to Prevent Future Deaths issued by the Coroner, HH Alan Blunsdon on 25th May 2021, following the Inquest into the death of Matthew Mackell. I would ask that this response is considered alongside the evidence of improvements made by Kent Police following Matthew’s death set out in (i) the IOPC report; (ii) the ; and (iii) Kent Police’s witness statement dated 4 May 2021 of Superintendent PFD submissions dated 19 May 2021. The following response from Kent Police is made. 1. Every Thursday, a mandatory learning and development day is undertaken. On these learning and development days, specific Continuous Professional Development Training packages are delivered on a 5-week rotation to cover all FCR teams. Each package covers a specific theme such as suicide or firearms. 2. A database is held to record which members of staff have attended the training and those that have not, with a view to capturing non-attenders through subsequent sessions within the 5-week rotation period. The Command duties teams schedule the training and identify those who miss their allotted sessions. 3. Those who are unable to attend a session across the whole 5-week rotation period (which is minimal in number) are identified by the Command duties team via the database. These members of staff are required to self-serve the training package they missed through online learning (comprised of the slides, trainer notes and any other training materials used in the training package when it was delivered). Kent Police Headquarters Thames Way, Northfleet, Gravesend, Kent DA11 8BD www.kent.police.uk Protecting and serving the people of Kent These members of staff have their understanding of the training they have self- served quality assured on a one-to-one basis by the Learning and Development team. 4. With reference to the terms of the regulation 28 report, I trust that this is sufficient to reassure the Coroner that Kent Police has in place (i) an effective system to identify those that require training/updating and of the keeping a record of the specific training/updating received by individual operatives and the date it was undertaken; (ii) a structured system to produce a regular training rotation which monitored and recorded individual satisfactory progress; and (iii) a system which clearly identifies what training/updating had been received thus identifying those who might otherwise be missed and when training/updating was scheduled to take place. 5. For completeness, I deal with two further points. Northgate XC mapping system 6. Kent Police has configured the default settings on the Northgate XC mapping system to ensure that the latest functionality is utilised by staff. This means that the accuracy of abandoned 999 calls as identified through the BT EISEC Eastings and Northings data is an improved status than that of 6th May 2020. 7. A range of briefings were delivered highlighting the enhanced functionality following the death of Matthew Mackell. A briefing was sent to all members of staff with a clear direction for supervisors to ensure the learning was captured by staff through monthly 1-2-1 meetings with the staff they supervise. 8. Quality Assurance officers within the Learning & Development team continue to ensure that this learning has been disseminated through thematically reviewing CADs of a similar nature. This is reported through to the Command Superintendent at the Daily Management Meeting. Suicide training 9. From reviewing the database referred to above, I have identified that 39 out of 229 members of FCR staff did not complete the suicide training package that ran between 16th July to 13th August 2020. This package had been developed following Matthew’s death, and focussed on how to respond in a similar scenario. Kent Police Headquarters Thames Way, Northfleet, Gravesend, Kent DA11 8BD www.kent.police.uk Protecting and serving the people of Kent 10. The 2020 suicide training package has been refreshed and expanded to include additional learning that arose from the evidence and conclusion at the Inquest into Matthew’s death, to which Kent Police paid very careful attention. This new suicide training package will be delivered to all FCR teams by 2nd September 2021. If Kent Police can be of any further assistance in this matter, please do not hesitate to contact me. Yours faithfully, Kent Police Headquarters Thames Way, Northfleet, Gravesend, Kent DA11 8BD www.kent.police.uk
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