Richard Boateng

Jonathan Landau 
South London Coroner’s Office 
Floor 2 Davis House 
Robert Street 
Croydon 
CR0 1QQ 

10  November 2021 

Dear Mr Landau  

Regulation 28 Report – Mr Richard Boateng 

I 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 26th February 2021. 

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

The report sets out your principle considerations in respect of the current guidance provided to forces in 
respect of the conveyance of patients to hospital in an emergency if no ambulances are available. More 
specifically your letter provides the following information. 

College of Policing - Due to the Covid pandemic, no ambulances were available when police attended 
to Richard. The Metropolitan Police Service had a policy that permitted conveying patients to hospital in 
an emergency if no ambulances were available. However, the policy included no practical guidance as to 
how that could be achieved mitigating the risks. I heard that the Metropolitan Police Service is updating 
the guidance. However, I am concerned that other forces across the country may also lack such practical 
guidance, which is of particular concern due to ongoing pandemic and the demands that may continue of 
ambulance services 

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. 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. However, transportation of casualties to hospital are not 
within the scope of the responsibility of a first aider (and therefore the FALP). 

The transportation of casualties in police vehicles carries inherent risks to the casualty, requiring skills 
and responsibilities significantly above those of a first aider, and significant liabilities to the officers 
themselves. For these reasons instances of police transporting casualties should be kept to the absolute 
minimum and there is concern that development of College issued guidance would not only ‘normalise’ 
such practices but add to an unrealistic expectation being placed on officers at the scene. 

That said, there will be instances when this may be necessary, and in those scenarios I would expect 
officers to conduct a dynamic risk assessment at the scene. The College has developed Authorised 
Professional Practice (APP) to aid decision making National Decision Model (college.police.uk); this 
practical guidance guides officers through a process of considering the information, assessing the risks, 
considering policy and available powers, identifying options and finally taking action. In the absence of 
an ambulance and taking account of the prevailing circumstances (in particular the risk to the patient), I 
consider that the APP already provides appropriate guidance.  

In considering the response, my team has also liaised with the NPCC portfolio leads for Response 
Policing (Chief Constable 

) and Health and Safety (Asst. Chief Constable 
). Both are in agreement with my response, and I understand that Chief Constable 

 is 

going to discuss the issue of the availability of ambulances with her NPCC colleagues to explore the 
national context.  

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. My staff have spoken 
with the forum chair and have agreed to escalate this issue to the Forum for consideration as to what 
practical advice can be offered to forces. 

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 Boateng’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  

Chief Constable 
Chief Executive Officer 
College of Policing

Mr. Jonathan Landau 
Assistant HM Coroner for South London 
South London Coroner’s Office 
2nd Floor, Davis House 
Robert Street 
Croydon 
CR0 1QQ 

Legal Services 
Headquarters 
220 Waterloo Road 
London 
SE1 8SD 

www.londonambulance.nhs.uk 

16th November 2021 

Dear Sir

Regulation 28 Prevention of Future Deaths Report, arising from the inquest 
in to the death of Mr. Richard Boateng 

Thank you for your Regulation 28 PFD Report dated 24th September 2021, setting 
out your concerns to be addressed. 

I  would  like  to  begin  by  expressing  London  Ambulance  Service  NHS  Trust’s 
sincere condolences to Mr. Boateng’s family. 

The issue you have asked LAS to consider in the PFD report is as follows:  
The GP called LAS concerned about Richard’s welfare. LAS attended his home 
address. Richard was not there. The LAS paramedic advised his sister to call the 
police.  The  LAS  quality  manager  accepted  in  evidence  that  it  would  have  been 
better to have taken her number and to pass it on to the police to make contact. I 
was  told  that  national guidance  on  this  issue  was  published  in  the  summer.  To 
date, neither guidance to crews nor to control had been updated to make the LAS 
guidance clearer to those applying it. 

 
 
 
 
 I set out below the actions that have been, and continue to be, taken in relation to 
our policies and procedures and staff awareness, in light of this case. 

Immediate Action Taken: Staff Bulletins 

We gave evidence at the inquest confirming that the relevant LAS policies dealing 
with ‘no trace’ calls are OP14 (Managing the Conveyance of Patients – for frontline 
staff)  and  and  OP23  (Dispatch  of  Resources  –  for  control  room  emergency 
operations centre, ‘EOC’ staff). Those polices are being updated, and I give further 
information below about this. 

Pending finalisation of the updates to those policies we have developed bulletins 
for the above cohorts of staff, which have been issued.  

The frontline staff bulletin details the actions to be taken when a patient cannot be 
located, namely:  

  conducting a thorough area search;  
  contacting EOC to confirm the address; 
 

requesting that EOC check with local hospitals if there is a concern that the 
patient is at risk from an illness or injury (physical or mental health); 

  contacting EOC to request the assistance of the Metropolitan Police, if the 
above  actions  have  not  been  fruitful  in  locating  the  patient,  and  if  there 
continues to be a concern that the patient is at risk from an illness or injury 
(physical or mental health).  

The bulletin emphasises that the request for the police must be made by the LAS 
on scene, via EOC, and must not be left to members of the public to undertake.  

These  actions must  be  documented  on  the call  log  (‘CAD’)  by  EOC and  on  the 
patient record (’ePCR’) by frontline staff. 

The EOC staff bulletin corresponds with the above. It makes it mandatory where 
there is a concern for risk, or where the patient is deemed to be vulnerable,  that 
EOC contact the police and provide all available information. It also states that this 
must not be left to member of the public or staff from other agencies to undertake, 
and should be made via EOC.  

Both bulletins also clarify that the police will accept a missing report of a vulnerable 
(at risk) person immediately. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Each bulletin provides non-exhaustive, detailed guidance as to types of vulnerable 
patients. 

The bulletins have been sent out by our communications team and added to the 
LAS intranet, ‘The Pulse’. Awareness will be reinforced when they are covered on 
our  regular  intranet  ‘LAS  TV  Live’  session  on  17th  November  2021,  and  in  our 
Routine Information Bulletin, ‘The RIB’, on 16th November 2021. In addition, they 
will  be  communicated to  all  staff  via  the  weekly  ‘LAS  Roundup’ email  on  Friday 
19th November 2021.  

LAS  has  established  processes  for  sharing  updated  guidance  and  information 
digitally with staff via personally issued i-pads and the frontline bulletin has been 
disseminated  to  the  ‘JRCALC+’  app  (where  clinical  guidance  is  held,  and  also 
covers  safeguarding  issues)  section  on  the  crew  staff  tablets,  which  has  to  be 
acknowledged as received. 

Bulletins are attached into this app so they can be seen by all staff. It will also alert 
them, when they next open the app, that there is something they have not yet read. 

In addition, EOC staff receive weekly emails with all bulletins attached.  

Updates to Policies OP14 and OP23 

We  gave  evidence  at  the  inquest  that  national  guidance  for  dealing  with 
missing/absconded  patients  was  issued  to  ambulance  Trusts  in  April  2021. 
Although our policies OP14 and OP23 are already compliant with that guidance, it 
was accepted in evidence that it would be beneficial to update them to include a 
specific step by step process to be actioned by control room in conjunction with 
frontline staff.  

Both policies, OP14 and OP23, were already in the process of being updated prior 
to  this  case.  The  learning  from  this  case  will  be  incorporated  into  the  updated 
policies, in corresponding wording to the respective bulletins. 

Work was already underway to make OP14 a unified document that would be a 
single  ‘point  of  truth’  for  information  when  staff  have  a  specific  policy  or  clinical 
question, with hyperlinks to relevant information and documents.  This means that 
it will be a ‘live’ document on line which can be updated quickly. It can be accessed 
by staff via their tablets when on scene. 

Policy OP14 is expected to be finalised by the end of 2021, and OP23 is expected 
to be finalised in early 2022. 

When the new policies are released, this will be communicated in the same ways  

 
 
 
 
 
 
 
 
 
 
 
 
 
 as the staff bulletins, as set out above. New starters will also be provided with them 
and the policies will be embedded in training for new entrants to the relevant teams 
at LAS. 

I hope this response is helpful in describing the immediate and ongoing work the 
LAS  is  engaged  in  relating  to  ‘no  trace’  calls  involving  vulnerable  patients, 
encompassing bulletins for both frontline and control room staff, and corresponding 
amendments to our policies for those groups of staff. 

Yours sincerely 

Chief Executive, London Ambulance Service NHS Trust

Jonathan Landau 
South London Coroner’s Service, 
2nd Floor,  Davis House, 
Robert Street, 
Croydon 
CR0 1QQ 

National Medical Director and Interim 
Chief Executive, NHS Improvement 
Skipton House 
80 London Road 
London 
SE1 6LH 

18th February 2022 

admin.support@londonsouthcoroner.org.uk 

Dear Mr Laundau, 

Re: Regulation 28 Report to Prevent Future Deaths – Richard Boateng 
who died on 31 March 2021.  

Thank you for your Regulation 28 Report (hereinafter ‘Report’) dated 28 November 
2021 concerning the death of Mr Richard Boateng on 31 March 2021. Firstly, I would 
like to express my deep condolences to Mr Boateng’s’s family.  

I note the conclusion of the recent inquest was as follows: 

Mr Richard Boateng phoned his GP surgery on 30 March 2020.  He was very unwell.  
A GP called him the next morning and although he answered the phone, he was not 
able to complete sentences or give his full name.  He was on a bench in the street 
from at least 10.30am that day.  Police were called and attended at 4pm.  An 
ambulance arrived at 6.23.  Despite attempts at resuscitation, Richard died from 
Covid 19 shortly after his arrival at Croydon University Hospital on the evening of 31 
March 2021. 

Following the inquest you raised concerns in your Report to NHS England regarding: 

A call to the GP surgery the day before Richard’s death was taken by a 
receptionist who arranged a routine appointment.  She was not a clinician and 
only had on the job training.  The surgery has since introduced a system 
called Klinic which is safer.  It prompts questions and uses an algorithm to 
alert any urgent or emergency calls that are then flagged.  All calls are also 
reviewed by clinicians.  However, I am concerned that other surgeries may 
employ non-clinicians who may be required to make judgments as to the 
urgency of appointments, and there is no guidance available to surgeries as 
to how to mitigate the risks of this. 

GP practices employ non-clinical staff in receptionist roles. The receptionist role is 
vitally important as first point of contact for patients and has long been relied on to 

NHS England and NHS Improvement 

 manage requests for urgent and routine appointments, and patients who may call 
with medical emergencies.  

It is the responsibility of each individual GP practice to ensure all staff are suitably 
trained and experienced to undertake the tasks that they are delegated. 

I can confirm that ‘Care Navigation’ as undertaken by receptionists, was fully 
supported in the NHSE GP Forward View, with further training material and funding 
provided to support its implementation: https://www.england.nhs.uk/blog/plotting-the-
right-path-with-care-navigators/. 

We have developed a training pack for administrative staff which is intended to help 
support them with information gathering, care navigation and identifying emergency 
symptoms. The training pack is attached. 

We are also currently working with Health Education England (HEE) to develop a 
training programme for both clinical and non-clinical staff to support them further. 

I can confirm that a significant increase in remote triaging, as used in general 
practice during the Covid-19 pandemic, has introduced a number of digital triage 
platforms and processes which can further support care navigation, including 
management of ‘red flag’ symptoms. 

From a digital tools perspective, suppliers and deploying organisations (with support 
from their clinical safety officers) need to comply with clinical safety risk assessment 
standards. We have developed and made available a draft hazard log for digital total 
triage, a clinical safety risk assessment template for practices and commissioners 
and further assurance guidance is attached.    

NHSEI also have a clinical safety officer forum where we discuss risks and issues, 
and collaboratively look at preventative measures. 

Our Digital First Primary Care (DFPC) guidance for the implementation of Online 
Consultations puts a lot of focus on safety, though not specifically on the role of non-
clinical staff: https://www.england.nhs.uk/wp-content/uploads/2020/01/online-
consultations-implementation-toolkit-v1.1-updated.pdf. This provides guidance on: 

•  Safety and clinical risk management standards for Suppliers on the Dynamic 

Purchasing System framework are required to meet. 

•  Code of conduct for practices, including on Risk management, Clinical safety 

officers, Reporting incidents and near misses and more. 

•  Guidance to Practices to not rely on online access for all clinical triage and that in 
some practices, admin staff do directly schedule an appointment without the need 
for triage, with examples such as: Need for a clinical examination, investigation or 
collection of certain physiological data to provide safe care; A high risk of 
deterioration.  

Thank you for bringing this important patient safety issue to my attention, and I do 
hope the above information sets out the work that we at NHSEI have been doing in 

 
 
 answer to your concern. Please do not hesitate to contact me should you need any 
further information. 

Yours sincerely, 

National Medical Director &  
Interim Chief Executive, NHSI