Prevention of Future Deaths reports · 2021

David Ormesher

Regulation 28 report to prevent future deaths, reference 2021-0192, written 4 Jun 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report4 Jun 2021
Reference2021-0192
DeceasedDavid Ormesher
CoronerVeronica Hamilton-Deeley
Coroner areaCity of Brighton and Hove
CategoryPolice related deaths · Road (Highways Safety) related deaths
Sourcejudiciary.uk record · original PDF
Responses published2

The report

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.

VERONICA HAMILTON-DEELEY DL, THE CORONER’S OFFICE

LL.B. WOODVALE, LEWES ROAD
Her Majesty’s Senior Coroner BRIGHTON
for the City of Brighton & Hove BN2 3QB

CORONERS SOCIETY OF ENGLAND AND WALES

ANNEX A
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)

NOTE: This form is to be used after an inquest.

THIS REPORT IS BEING SENT TO:

1. Chief Constable of Sussex Police —
2. NPCC Lead for Police Driving Training —- DCC

1 CORONER

| am Veronica HAMILTON-DEELEY, HM Senior Coroner, for the City of Brighton
and Hove

2 CORONER’S LEGAL POWERS

| 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 5'* September 2017 | commenced an investigation into the death of David
Conway ORMESHER. The investigation concluded at the end of the inquest on 17"
My 2021. The conclusion of the inquest was Narrative.

4 CIRCUMSTANCES OF THE DEATH
See Record of Inquest

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 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: —

In the light of Inspector IN evidence and from the conclusions of the Jury,
the following points were identified as being relevant:

(1) The in-car radio should be switched on at all times

(2) The siren should have been deployed

VERONICA HAMILTON-DEELEY DL, THE CORONER’S OFFICE

LL.B. WOOPVALE, LEWES ROAD
Her Majesty’s Senior Coroner BRIGHTON
for the City of Brighton & Hove BN2 3QB

(3) The personal radio should not be handed to the passenger in the police vehicle
and not returned immediately

(4) The speed was found to be excessive and drivers in training need reminding of
the Regulations:
‘Drive appropriately and justify the manner of driving’
‘Plan the journey using all available information’

Perhaps this tragic case will prompt a review of the existing driver training.

6 ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and | 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 2" August 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

| have sent a copy of my report to the Chief Coroner and to the following Interested
Persons

(for onward transmission to other family members)

—
PC
HE - Sussex Police Professional Standards

. Inspector ii
ne

ME — 10
HE — Police Federation

| am also under a duty to send the Chief Coroner a copy of your response.

DONOARWN>

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.

VERONICA HAMILTON-DEELEY DL, THE CORONER’S OFFICE

LL.B. WOODVALE, LEWES ROAD
Her Majesty’s Senior Coroner BRIGHTON
for the City of Brighton & Hove BN2 3QB

9 Date: 4 June 2021 SIGNED BY: \ocle
Norn Arar ef

Senior Coroner Brighton and H

Responses

2 responses 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.

Response from Npcc (PDF)
®

f @ & National Police Chiefs’ Council

Deputy Chief Constable

Lancashire Constabula Hutton Preston Lancashire PR4 5SB

Miss Veronica Hamilton-Deeley, DL.
LL.B.

Her Majesty’s Senior Coroner

for the City of Brighton & Hove

The Coroner’s Office

Woodvale

Lewes Road

Brighton BN2 3QB

Your Ref i

14 June 2021

Dear Miss Hamilton-Deeley
Re: Inquest into the death of David Conway ORMESHER

| write to acknowledge receipt of your letter dated 4!" June 2021, the contents of which are
noted.

Yours sincerely

= = Constable, Lancashire Constabulary

NPCC Lead for Police Driving

1st Floor, 10 Victoria Street, London SW1H ONN
Response from Sussex Police (PDF)
Veronica Hamilton-Deeley, DL.LL.B.

Her Majesty’s Senior Coroner for the City of Brighton & Hove
The Coroner's Office

Woodvale,

Lewes Road

Brighton

BN2 3QB

27 July 2021

Dear Veronica,

| write in response to the Regulation 28 Preventing Future Deaths report dated 4" June 2021 that was
issued following the inquest into the death of David Ormesher in August 2017. I note that the report

has also been sent to my colleague in at the NPCC in his capacity as National Police
driver training lead.

| have considered the position of Sussex Police and our procedures in response to the
recommendations that you have made. In doing so | have consulted our Driver Training Department,
our driving standards manager EEE who gave evidence at the Inquest) and our Learning &
Professional Development department, all of whom have a responsibility to deliver the most accurate
and up to date driver training to our officers and staff on my behalf to equip them to drive safely and
effectively in a policing context.

Sussex Police is committed to providing the safest possible response to all incidents requiring Police
attendance and will where appropriate review and amend our training & procedures as necessary.

In response to the four recommendations:

Recommendation 1 - The in-car radio should be switched on at all times.

The in-car radio (as with the personal hand-held radio issued to officers) is part of the ‘Airwave’ mobile
communications network which is used throughout the UK by all emergency services. Having
reviewed our policies and procedures governing their use | am satisfied that Sussex Police policy
594/2021 gives a sufficiently robust direction to all Airwave users to ensure that both their personal
handsets and vehicle sets are switched on and operational at all times;

‘All on duty staff using police vehicles will ensure that the Airwave terminal is turned on at all times
unless leaving the vehicle unattended.’

In this particular case it would appear that this policy was not followed by the occupants of the police
vehicle which, as the jury found, sadly contributed to Mr Ormesher’s death.

| have instructed Re: conjunction with our Learning & Professional Development
team to design a bespoke training package relating to the use of the vehicle radio. This will be
mandated to all members of Sussex Police officers and staff who hold a driving permit to complete. It
will include the operation of the radio, a reminder of the Sussex Police policy and roles and
responsibilities of any passenger within the vehicle. This is already in the later stages of development
and rollout should be completed by the end of October 2021.

| have also instructed our Learning & Professional Development team to include a mandated input on
vehicle radio use and procedure to all new starters as part of their foundation training with Sussex
Police. This is now included in the mandated teaching in all Dedicated Coaching Units, which will be
supported by an NCALT package that is in the process of being created.

Recommendations 2 & 4 - The sirens should have been deployed & that the speed was excessive

The jury found that [I speed at the location was too high and that he should have had his
sirens activated.

Having reviewed the training that is delivered to response drivers by Sussex Police | am satisfied that
we are delivering training that is commensurate with direction given by the College of Policing and the
NPCC Driver Training lead.

Response drivers are taught to risk assess every situation and drive accordingly in line with the risks
and hazards that are presented to them. This includes the use of all their emergency equipment. In
line with national guidance, it is for the driver to justify the use (or lack thereof) of any blue lights and
sirens and also their speed throughout.

The College of Policing Authorised Professional Practice for Police Drivers states;

“Even where a statutory exemption exists, an officer must always give due regard to their driving
manner and behaviour which should not put other road users or members of the public at a risk which
cannot be justified.”

This is reinforced by Sussex Police Policy 616/2020 which states;

“There is a public expectation on the police to respond promptly to calls for assistance. Police officers
must do so as safely as possible and never allow the apparent urgency of such a call to put the public,
their colleagues or themselves at unnecessary risk because of their manner of driving. Safety is
paramount and cannot be compromised.

Police drivers should always drive having regard to their training, the limitations of their vehicle, the
prevailing circumstances and within the constraints of the restrictions imposed by their category of
driving permit and groups authorised.”

lam satisfied that in this particular case the officer was taught in line with national and Sussex Police
standards. a: found both at inquest but also at a Misconduct Hearing, chaired by an
independent, Legally Qualified Chair, to have been driving inappropriately and was found to have
breached the standards of professional behaviour in relation to “Orders and Instructions” and “Duties
and Responsibilities.”

| been found guilty of misconduct against these standards.

This was tragic case that was found to be caused by a combination of factors, including the driving of

m7 | do not believe that these failings are systemic in Sussex Police and nor are they as a result
of our driver training.

Whilst | shall not be recommending any fundamental changes to our driver training, we are in close
contact with the national lead on Driver Training and will ensure that Sussex Police adopts any relevant
good practise.

| have also instructed MM to reinforce to all police drivers, the need to drive

appropriately, justify their actions and plan their journey using all available information. As well as
highlight that under the code of ethics, it is a passengers’ duty to report any dangerous driving they
witness that may put themselves or the public at risk. This will take the form of force wide messaging
to all relevant officers in the force. Sussex Police has invested in Telematics, a vehicle management
system which provides information about vehicles so the force can monitor how vehicles are being
driven and track vehicle movements. A Driver Behaviour Working Group is also in place which reviews
trends shown by Telematics, driver training, police vehicle incidents, pursuit learning and health and
safety. A Police Vehicle Incidents meeting oversees new policy, reviews vehicle incidents and share
lessons learnt. The panel also reviews behaviour of drivers and moderate this through a full range of
sanctions or learning outcomes. A point system has been introduced with the aim of making
interventions at lower levels and avoiding more serious incidences occurring in future.

Recommendation 3 - The personal radio should not be handed to the passenger in the police vehicle
and not returned immediately.

The use of the handheld radio is for the officer in possession of it to ensure its security at all times. In
this case TE faites to return the radio oT. This was an incredibly rare failing between
these particular two officers; | do not believe that our policies or procedures are able to cover such
eventualities.

Notwithstanding this, Sussex Police do have the opportunity to raise awareness of this matter. The
aforementioned training package that is in development will not only contain training pertaining to
the vehicle radio set but will also contain a timely reminder to all staff as to their responsibilities
concerning their personal radios and their duty as a passenger in a police vehicle to ensure that all
information is passed appropriately to the driver to ensure that they can amend their driving plan
appropriately.

Sussex Police absolutely recognise that this was a tragic case in which a man lost his life and his family
lost a cherished member. Lessons can always be learnt, both by the officers involved, by the force and
by national policing.

Yours Sincerely,

Sussex Police

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