Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0320, written 23 Sep 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 23 Sep 2021 |
|---|---|
| Reference | 2021-0320 |
| Deceased | Hamish Howitt |
| Coroner | Fiona King |
| Coroner area | West Sussex |
| Category | Police related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Home Office : The Right Honourable Kit Malthouse M.P., Minister for Crime and Policing 2 National Police Chief Council: 3 College for Policing (Training) 4 Chief Constable Avon and Somerset Police: 1 CORONER: I am, Fiona M. King, Assistant Coroner for the area of West Sussex 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 06 June 2018 I commenced an investigation into the death of Hamish John Cameron HOWITT aged 20. Hamish had died in Frome in Somerset on 1st July 2016 the Investigation and subsequent Inquest being transferred in 2018 at the request of his parents who lived in West Sussex. The investigation concluded at the end of the inquest on 22 July 2021. The conclusion of the inquest was that: Hamish, a previously fit young university student died unexpectedly overnight following an evening spent with friends in Frome going to a concert and drinking. The medical cause of death established that he died from the combined effects of Alcohol, a Traumatic Brain injury and self - administered Ketamine. None of these 3 causes would have individually resulted in his death. The alcohol and ketamine consumed were considered to be at relatively low levels. 4 CIRCUMSTANCES OF THE DEATH : While walking home at approximately 23:35 there was an altercation on the street in Frome with another group of males. Hamish immediately complained that he was injured and bystanders called the police. Police Officers attended and spoke to Hamish for approximately 7 minutes. They concluded that Hamish had been drinking, was coherent and understood them. He told them that one of his friends had been involved in an incident and that he had intervened to prevent a fight and had been hit in the face. Hamish showed the officers his face and pointed to his forehead. The Officers recorded that they could see no injury. Concluding that Hamish was suffering the effects of alcohol they advised him to go home with his friends, which he did. Once he returned to he was in pain and before going to bed took an amount of Ketamine that resulted in a of blood. Low therapeutic doses of ketamine in post mortem finding of a hospital setting were given to be at a waking level average of blood. Ketamine at such a level would not alone have caused death. of 5 CORONER’S CONCERNS During the course of the investigation my inquiries 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. Regulation 28 – After Inquest Document Template Updated 30/07/2021 The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) (1) it is highly unlikely that Hamish would have died had he gone to hospital when the police saw him after the incident. Police at the scene did not recommend or encourage this course of action. (2) The apparent effects of alcohol when assessed by police (who are not medically qualified) can frequently mask serious underlying conditions such as traumatic brain injury (in this case) but also symptoms of post epileptic attack; diabetic high/low; and drug taking (either prescribed or illegally used). (3) Police Officers who come into contact with the public are not medically qualified but must be trained at both a national and local level to take steps to ensure those who appear inebriated and are complaining of injury are taken to hospital/seen by ambulance services. (4) Police training material and national policy setting should include directives to this effect. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or 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 17th November, 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: 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 person who I believe may find it useful or of interest. 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. 9 Dated: 23/09/2021 Fiona KING for West Sussex Coroners Service Regulation 28 – After Inquest Document Template Updated 30/07/2021
3 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.
Coroner’s Office Centenary House Durrington Lane Worthing West Sussex BN13 2PQ 17 November 2021 Dear Regulation 28 Report – Mr Hamish John Cameron Howitt We write on behalf of the College of Policing (the College) and National Police Chiefs Council (NPCC) 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, and the prevention of future deaths reports sent to the College and to the NPCC, both dated the 23rd September 2021. Whilst the College and the NPCC have separate and distinct responsibilities, the two organisations frequently work together on national approaches to policing policy. As such, this response is provided jointly in respect of both organisations’ separate prevention of future deaths reports. The notice sets out concerns that arose from the information received during the inquest in to the death of Mr Howitt. We are very sorry to read of the circumstances of Hamish’s death. Our sympathies are with his family and friends and we share your commitment to addressing the issues that contributed to his untimely loss. The notice sets out your principal concerns which were in respect of the recognition of Hamish’s condition as a matter requiring a medical response and the ramifications for future first aid training provided to police officers. You specifically asked for a response in relation to a number of matters of concern in which the College and NPCC would have involvement. The College licences the First Aid Learning Programme (FALP) used by Home Office Forces, including Avon and Somerset Police. The programme is endorsed by the 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 and staff in public facing roles receive a minimum of Module 2 training (the equivalent to the qualification of a HSE Emergency First Aider) – this is the minimum required for frontline response officers. The FALP does include a high level learning outcome for managing head injuries, but this is only a requirement in higher modules (Modules 3 - developed for first aid in a custody setting and Module 4 - the equivalent to the qualification of a HSE First Aid at Work). As long as individual forces achieve the learning outcomes contained within the FALP modules they will be compliant with the College’s licence. The FALP does include the scope for Chief Officers to deliver additional training to their officers but we recognise that the management of head injuries is not currently in the standard for Module 2. With regards to the matter of concern relating to alcohol, module 2 includes a high-level learning outcome to enable officers to assess the casualty, and modules 3 and 4 address issues of poisoning. However, it is noted that there is no explicit reference to the potential impact of alcohol on recognising conditions. As a matter of course, all coroner reports and inquests related to the provision of first aid by police officers are reviewed by the NPCC First Aid Forum as a standing agenda item. The College is also working with clinical leads to review the high-level learning outcomes within the FALP with the aim of placing greater emphasis on the training elements that preserve life. The review is already considering addressing the issue of acute alcohol intoxication and intentional overdoses within Module 2. It is also considering extending the learning in relation to head injuries to Module 2. The matters of concern you raise with relation to the impact of alcohol and the assessment of head injuries will be raised formally at the next meeting (13th December) to assess whether it is feasible and practicable to address these concerns within the scope of the licence. Officers are called on to provide first aid in a wide range of incidents as part of their role. The range of incidents they attend mean 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. That said, as detailed in this response, we acknowledge there is more that we can do to standardise our training and I trust that we have provided you with assurances that the matters of concern you have raised will be addressed. Yours sincerely CC CEO, College of Policing Chair, National Police Chiefs’ Council
Avon and Somerset Constabulary, Police and Fire HQ, PO Box 37, Valley Road, Portishead, Bristol BS20 8QJ T/Chief Constable 16th November 2021 HM Coroner Fiona King County of West Sussex C/O Mr Geoff Charnock Coroner’s Office Centenary House Durrington Lane Worthing West Sussex BN132PQ Dear Ms King, Chief Constable of Avon and Somerset Constabulary’s Response to Regulation 28 Report to Prevent Future Deaths following the Inquest into the death of Hamish Howitt 1. I write to respond to your Report to prevent other deaths dated 23 September 2021, in accordance with paragraph 7, Schedule 5 of the Coroners and Justice Act 2009, and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 2. Avon and Somerset Constabulary take the matters raised in your Report extremely seriously, and careful consideration has been given to your Report and our response to it. I hope that the actions detailed below reflect the Constabulary’s commitment to ensuring that all of the matters of concern and risks identified in your Report are effectively addressed. 3. As explained below, we will continue to keep these matters under review, and to work with the College of Policing (CoP) and National Police Chiefs’ Council (NPCC) to ensure that any recommended changes to training, policy and guidance are promptly and fully implemented by Avon and Somerset Constabulary. Matters of Concern 4. The matters of concern identified in your Report have been reviewed by relevant Constabulary officers, including the force lead for first-aid training. Officers have also met with representatives of the CoP and the NPCC to discuss these matters. 5. The Constabulary is aware that two police officers encountered Hamish after an altercation on the street involving the group Hamish was with and another group of males. One police officer gave evidence that he had spoken to Hamish, and noted that it appeared he had been drinking. Hamish informed him that he had been hit to his face. The police officer looked at Hamish’s face and could not see any signs of trauma, and Hamish was not advised that he should attend hospital. 6. Consideration has been given to the statement in your Report that “it is highly unlikely that Hamish would have died had he gone to hospital when the police saw him after the incident”. The expert medical evidence and your Ruling dated 25 March 2021 following the hearing of expert evidence on 25-26 February 2021, as well as your findings and conclusion following the hearing of 19-23 July 2021 have been re-reviewed. No expert or other medical evidence, or any Ruling, finding or conclusion has been identified which supports this statement, and it has been noted that paragraphs 17 and 18 of your Ruling dated 25 March 2021 determined that no further medical expert evidence would be obtained. 7. Regardless, I share your concern that the effects of alcohol may mask other underlying conditions (in particular head injury), and that police officer first aid training should provide appropriate guidance and / or directives in relation to responding to this. Position in relation to training 8. Avon and Somerset Constabulary officers are provided with first aid training as part of their initial training. They are then provided with refresher first aid training on an annual basis. 9. The First Aid Learning Programme (FALP) which is used by Avon and Somerset Constabulary to train its officers is licensed by the CoP, and endorsed by the NPCC and the Health and Safety Executive. Avon and Somerset Constabulary is compliant with the CoP’s licence, and all frontline response officers receive a minimum of Module 2 first aid training, as recommended by the CoP. 10. The FALP Module 2 training includes a requirement for training on casualty assessment. It does not currently require specific training on managing head injuries. 11. Module 3 and Module 4 of the FALP training (which are provided to certain officers in specialist roles, but are not provided as standard to all frontline officers) does require training on head injuries. All first aid trainers are required to hold a Module 4 qualification. 12. The FALP training does not currently require training on the potential effect of alcohol in masking symptoms of other conditions. Actions following Inquest and Report 13. Following the hearing of 19-23 July 2021, and prior to receiving your Report, the Constabulary had identified the absence of specific training for frontline officers on head injury as a matter of concern, and this issue was under review, which has continued following receipt of your Report. 14. The following actions have been taken by the Constabulary: i. An internal communications bulletin has been sent to all officers which identified head injuries as a matter of concern, and provided a link to “essential guidance” on head injuries. This was included in the “Must know” section of the bulletin, which all officers are required to read. The linked guidance states that if an officer or staff member has any suspicion, or is told in good faith, that a person may have a head injury, they should treat the person as such in the absence of clear evidence to dispel that suspicion. The guidance makes clear that no visible marking is not an acceptable level of evidence that a head injury has not been sustained. It states that in circumstances involving a potential head injury, medical assistance should be requested and / or facilitated by officers (whilst acknowledging that officers would not in all circumstances have the power to detain or require members of the public to remain and engage with any medical intervention). ii. All first aid trainers have been sent the essential guidance on head injuries. iii. The lesson plan for Modules 1, 2 and 4 for “Assess a Casualty (Primary and Secondary survey)” has been amended to require this training to provide the same essential guidance on head injuries. iv. The Module 3 and 4 first aid training on head injuries has been amended to incorporate the same essential guidance on head injuries. v. Avon and Somerset Constabulary officers with responsibility for leading force training in relation to Taser, Personal Safety Training and Public Order training have also been made aware of the Report and of the first aid guidance on head injuries, which have been incorporated into their training programmes. 15. Since receiving your Report, representatives of the Constabulary, including the force lead for first aid training, have met twice with CoP and NPCC representatives to discuss the matters of concern identified and the actions to be taken in response to your Report. 16. The CoP has confirmed that Module 2 FALP training does not currently include the management of head injuries, and that there is no explicit reference in FALP training requirements to the potential impact of alcohol on recognising conditions. The NPCC and CoP have confirmed that: i. Your Report will be reviewed by the NPCC First Aid Forum. ii. The CoP is working with clinical leads to review the high level learning outcomes with the aim of placing greater emphasis on the training elements that preserve life, and is presently considering: a. Addressing the issue of acute alcohol intoxication and international overdoses within Module 2. b. Extending the learning in relation to head injuries to Module 2. iii. The matters of concern raised in your report in relation to the impact of alcohol and the assessment of head injuries will be raised formally at the next CoP review meeting, and consideration will be given to whether and how the matters you have identified can be addressed within the scope of the FALP. 17. It is understood that all matters of concern identified at Part 5 of your Report will be reviewed by the NPCC and CoP, including provision of training on head injury, the potential impact of alcohol in masking other underlying conditions, and your recommendations in relation to training material and national policy setting. 18. Avon and Somerset Constabulary will update its training provision immediately on receipt of any updated guidance from the CoP and / or NPCC. 19. A copy of this response, and relevant updated force guidance and training documents, will also be sent to the CoP and the NPCC so that they are aware of all of the changes that have been made internally by Avon and Somerset Constabulary, and can take these into consideration when determining whether any additional national guidance, or amendments to training provision are required. 20. We will continue to keep these matters under review, and will work with the CoP and NPCC to ensure that any recommended changes to training, policy and guidance are promptly and fully implemented by Avon and Somerset Constabulary. Summary of Actions Taken and to be Taken Action Person Date Responsible 1 Circulate memorandum to all officers Avon and Somerset Completed with guidance to ensure they are Constabulary First 14 October 2021 aware of the risk of head injury and Aid Training Lead the requirement that medical assistance is sought (“the essential guidance on head injuries”). 2 Send the essential guidance on head Avon and Somerset Completed injuries directly to all first aid trainers. Constabulary First October 2021 Aid Training Lead 3 Add the essential guidance on head Avon and Somerset Completed injuries to Module 1, 2 and 4 first aid Constabulary First October 2021 training for assessing a casualty Aid Training Lead (provided to all frontline officers). 4 Add the essential guidance on head Avon and Somerset Completed injuries to Module 3 and 4 first aid Constabulary First October 2021 training on head injuries. Aid Training Lead 5 Training on appropriate response to Leads for Taser, Completed head injury to be incorporated into Public Safety and October 2021 Taser, Public Safety and Public Order Public Order training. training. 6 NPCC First Aid Forum to review NPCC 9 December 2021 Report. 7 CoP review of training provision with CoP Ongoing clinical leads, and consideration of amendments to scope of FALP to address matters raised in Report. 8 Update Avon and Somerset Avon and Somerset To be actioned Constabulary first aid training Constabulary First immediately on provision / policy / guidance in Aid Training Lead receipt of any accordance with NPCC / CoP updated guidance. updated CoP FALP training requirements and / or CoP / NPCC policy or guidance. Yours sincerely, T/Chief Constable Avon and Somerset Constabulary Avon and Somerset Constabulary Privacy Notice, which relates to the use of personal information, can be viewed via the force website https://www.avonandsomerset.police.uk/privacy
Fiona King HM Coroners Service County of West Sussex Coroner's Office, Worthing By email only Rt Hon Kit Malthouse MP Minister of State for Crime, Policing and Probation 2 Marsham Street London SW1P 4DF www.gov.uk/home-office 16 November 2021 Thank you for your letter of 23 September. As requested, I am responding to your formal report in relation to paragraph 7(2) of Schedule 5 to the Coroners and Justice Act 2009 and Regulation 29 of The Coroners (Investigations) Regulations 2013. I should like to start by expressing my sincerest condolences to the family and friends of Hamish John Cameron Howitt on his untimely death. The College of Policing is independent from Government and its role is clear: setting high professional standards sharing what works best; acting as the national voice of policing; and ensuring police training and ethics is of the highest possible quality. This includes setting standards for police training on encountering those with injuries or who are otherwise vulnerable. My officials have consulted College of Policing and National Police Chiefs Council (NPCC) on their response to your report. As mentioned in their joint letter, front line response police officers receive training at least equivalent to HSE Emergency First Aider level. Our police are required to deal with a wide range of situations on a daily basis and this includes working closely with ambulance services and other medical colleagues when responding to certain medical incidents, where appropriate. The College continually reviews the content of the curriculum for officers and I am assured that the concerns you have raised will be addressed through the formal policing First Aid governance routes. I should like to thank you for bringing this issue to my attention. Rt Hon Kit Malthouse MP
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