Trevor Smith

Coroner’s Court 

50 Newton Street 

Birmingham 

B4 6NE 

12 January 2022 

Dear Mrs Louise Hunt (HM Senior Coroner), 

Regulation 28 Report – Mr Trevor Smith 

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 17th November 
2021. 

The report sets out two primary concerns that arose from the information received during the 
inquest into the death of Mr Trevor Smith. I was very sorry to read of the circumstances of Mr 
Smith’s death. My sympathies are with his family and friends and I share your commitment to 
addressing the concerns that you raise.  

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 first concern raised in the report relates to the MARAC process undertaken by West 
Midlands police, and specifically that potentially significant information disclosed at a meeting to 
discuss Mr Smith was not effectively cascaded to the SIO or firearms team prior to the policing 
operation to arrest him. I understand that West Midlands police has provided a response to your 
concern.  

Police forces implement localised policies and practice in terms of the recording and 
dissemination of information and intelligence. The College Authorised Professional Practice for 
Armed Policing (APP-AP) Armed policing (college.police.uk) provides guidance to firearms 
commanders in respect of information and intelligence gathering, and the importance of 
considering the potential that the subject of an operation may be emotionally or mentally 
distressed. I consider the relevant APP-AP content to be appropriate. My Armed Policing Team 
has, however, agreed with the National Police Chiefs’ Council (NPCC) portfolio lead for armed 
policing (Chief Constable Simon Chesterman), to publish a national circular for dissemination to 
chief officers. The intention is that the circular, which will be sent out imminently, will raise 
awareness of both of your concerns and will recommend that forces consider local policy and 
practice in respect of recording and sharing information disclosed during the MARAC process.     

Your second concern relates to the provision of CPR to Mr Smith and your report states: 

The evidence at the inquest confirmed that officers appeared confused about the need for 
rescue breaths to be given to Mr Smith during resuscitation. The inquest also heard how 
appointing one person to coordinate the resuscitation (if there are sufficient personnel) would 
have been of benefit. Consideration should be given to amending policies, procedures and 
training to ensure one person is allocated to coordinate CPR if it is required. 

The College licences the First Aid Learning Programme (FALP) used by Home Office Forces, 
including West Midlands 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 requirement in respect of first aid training provided to armed officers is included in the 
National Police Firearms Training Curriculum (NPFTC). Armed officers receive an enhanced 
level of training to deal with ballistic injuries and other first aid interventions that may be required 
during an armed deployment, or indeed any other incident. 

 
 
 
 
 While the College sets the required learning standards to be achieved by armed officers, the 
training to support these outcomes is developed and delivered under local ‘clinical governance’ 
arrangements. This ensures the appropriate clinical expertise, and the currency and credibility 
of the first aid interventions that are included. The first aid training delivered to armed officers 
also has to be delivered within the context of armed operations to ensure its relevance to 
operational situations. Armed officers must receive first aid refresher training every year, during 
which they are assessed for their continued competence. The national training and policy do not 
currently include or mandate the appointment of a CPR or first aid coordinator.       

Depending on their role and deployment profile, armed officers may deploy in pairs or relatively 
small numbers. During any incident that involves the use of force, and particularly the discharge 
of a police firearm, there may be a variety of tasks required of officers (e.g. to mitigate continued 
threat to the public or the preserve evidence at the scene). First aid provision will always be a 
primary consideration, however the number of officers, and/or other responsibilities, may impact 
the ability for a dedicated first aid or CPR coordinator to be identified. That said, I accept that it 
would be good practice, and there will be instances when it would be either necessary or 
achievable for a coordinator to be appointed.  

The APP-AP is regularly reviewed often in response to recommendation and investigation 
findings, and includes a requirement to prioritise medical assistance and some of the associated 
considerations for commanders. It was revised in May 2021, and the revised version contains 
additional guidance in respect of ensuring the prompt attendance of ambulance service staff in 
the event of police firearms discharge. This amendment was made in response to findings 
identified by the Independent Office for Police Conduct (IOPC) in their investigation into the fatal 
shooting of Mr Smith. I consider that the APP-AP already provides appropriate operational 
guidance. However I do feel that amendments to training could be considered.  

As a matter of course all coroner reports and inquests related to the provision of first aid by 
police officers is reviewed by the NPCC First Aid Forum as a standing agenda item. At the 
NPCC First Aid Forum meeting on the 9th December 2021 the chair raised the issue of 
establishing a ‘safety officer’ where, if possible, an officer at the scene might provide oversight 
for colleagues administering first aid. These discussions were not related to the inquest in 
question but in reflection of possible organisational learning from a similar role being considered 
for officer personal safety training, specifically when conducting restraint. There was broad 
support for the idea, and further discussions will take place at the next meeting on 25th March. 
As a result of your report, the issue of establishing a first aid (CPR) coordinator will also be 
raised formally as a substantive issue at this meeting. 

The concept of a coordinator for first aid provision has potentially wider application than armed 
policing and that wider application, and the policy and training considerations will be progressed 
by the NPCC First Aid Forum to ensure that national standards and consistency are achieved. 

 
 
 The introduction of a new role will require clear guidance on the responsibilities to be 
discharged by an officer performing the role and consideration of any additional training 
requirements.  As I have previously indicated the national circular will however raise awareness 
of your concerns so that forces can consider a coordinator role in appropriate circumstances 
while the associated national guidance and training is considered.  

The College works proactively 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 Smith’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 Executive Officer 
College of Policing

CHIEF CONSTABLE 

POLICE HEADQUARTERS 
PO  Box52 
Colmore Circus Queensway 
BIRMINGHAM 
B46NQ 

Switchboard: 101 

Coroner's Court 
50 Newton Street 
Birmingham 
B46NE 

17th  January 2022 

Dear Mrs Louise  Hunt (HM  Senior Coroner), 

Regulation 28 Report to Prevent Future Deaths. 

I am  writing  in  relation  to  the  above  report  that  the  Coroner's  Office  commissioned  on  the 
17th  November  2021.  This  report  was  commissioned  as  a  result  of the  investigation  and 
inquest into the death of Mr Trevor Alton Smith. 

Outlined  within  the  report  is  matters  of concerns  raised  by  the  Coroner's  Office,  which  has 
been noted as a risk that future deaths will occur unless action is taken. 

This  letter addresses the  concerns  highlighted  detailing  the  action  taken,  or proposed  to  be 
taken,  setting out the timetable for action. 

Recommendation one: MARAC Information 

With regard to concerns raised  on MARAC, our response is detailed below. 

It should  be  noted  that at the time that this MARAC meeting took place on  12th March  2019, 
WMP had  no role  in the coordination or administration of Solihull's MARAC meetings. 

The  agency  responsible  for  minute-taking  and  coordination  in  this  case  was  Coventry 
Haven,  who  were  commissioned  to  perform  this  duty  up  until  the  31 st  March  2019,  two 
weeks after the MARAC meeting in  question took place.  It was after this time that WMP took 
responsibility  for  the  coordination  and  administration  of  all  seven  local  authority  areas, 
including Solihull, from  1 st April 2019. 

At  the  time  that  the  meeting  involving  Mr  Smith  was  taking  place,  in  an  unrelated  but 
extremely timely and  relevant piece of work,  the regional  MARAC process was being revised 
ready  for  WMP  to  take  over  as  one  regional  function.  The  centralisation  of the  MARAC 
the  introduction  of  trained  minute  takers,  MARAC 
function  in  this  way,  along  with 
Coordinators  and  one  regional  lead,  meant  that  many  of the  issues  identified  in  this  case 
were  coincidentally  already  beginning  to  be  addressed  before  Mr Smith  was  killed.  Sadly, 
there  was  no  possibility  these  improvements  could  have  impacted  this  particular  MARAC 
case. 

 
 
 With regard to the specific concerns raised  by H.M Coroner our responses are as follows: 

Concern:  It was  likely that the  mental  health  agency in  question shared  specific information 
at the MARAC meeting which was not then recorded. 

Response:  All  MARAC  agencies  are  encouraged  to  submit written  copies  of their intended 
MARAC updates in  advance.  Whilst the primary reason for this is to improve the pace of the 
meeting from  a minuting  perspective,  there is  a natural benefit in that a record  of submission 
is available alongside a record  of the conversation itself. 

Further,  all  MARAC  agencies  are  offered  guidance  and  support  from  their  local  MARAC 
Coordinator around  how  best to  engage  with  and  prepare  for the  MARAC  process.  Whilst 
we  cannot govern  every  single  piece  of data  which  comes  into  the  process,  we  do  seek to 
ensure  that partners  researching  cases  have  the  best understanding  possible  to  ensure the 
information  is  relevant and  appropriate.  Partner agencies must take responsibility thereafter 
for what is submitted and  how it is presented in the meeting. 

Concern:  Information shared  at the meeting was  not properly minuted, or not minuted at all. 

Response:  Since  taking  over  responsibility  for  minuting  MARAC  meetings  from  1st  April 
2019,  WMP  has  recruited  and  trained  a  team  of  six  dedicated  minute  takers  who  are 
experienced  in  the  role  and  well-supported  by  supervision.  As  of  summer  2021,  MARAC 
minutes  have  been  subject  to  regular  dip  samples  and  audits  to  ensure  the  continued 
improvement of staff involved in the recording  process. 

In  addition to  this,  partner engagement with the MARAC process  has improved  significantly, 
with  open  communication  channels  for  any  challenge  regarding  the  quality  of  minutes. 
Further,  WMP  is  committed  to  the  continued  improvement  and  development  of staff in  the 
minute-taking role,  including ongoing auditing and  dip-sampling around quality of recording. 

Concern: The information shared at the MARAC meeting was not shared with the S10 of the 
Firearms Team. 

Response:  All  MARAC  Chairs  are  aware  that  there  may  be  a  need  to  share  MARAC 
information  more  widely  than  via  the  MARAC  minutes  alone.  They  are  encouraged  to  set 
specific actions around  this  if a risk  has  been  identified whereby the  MARAC  minutes  being 
shared  alone will  not suffice. 

However,  as  all  MARAC  information  is  recorded  on  a system  separate to  Connect,  which  is 
where  the  vast majority of Police  information  is  stored,  this  impacts  upon  transparency and 
speed of information sharing. 

Further,  at  the  current  time  WMP  is  reviewing  how  existing  links  between  the  MARAC 
system  and  wider  WMP  systems  and  departments  can  be  improved  in  order  to  more 
promptly,  and  confidently,  capture  and  record  key  information  around  warning  markers  and 
significant MARAC information. 

Concern: There is  no  clear process for ensuring  relevant information  is  cascaded to officers 
involved in  MARAC cases. 

Response:  In  cases  where  there  is  an  Officer  in  the  Case  (OIC),  MARAC  staff  are  set 
actions  to  share  documents  with  them  in  order  that  information  relevant  to  triggers,  risks, 
warning  markers  etc  may  be  properly  recorded  by  the  officer.  In  cases  with  there  is  no 
allocated  OIC, the same steps are taken directly with the relevant supervision. 

 Concern:  There  is  no  clear  guidance  or  process  for  accurately  recording  information  at 
MARAC by WMP. 

Response:  There  is  a  regional  MARAC  Operating  Protocol  which  has  been  in  place  since 
It  governs  WMP  and  wider  agency  engagement with  the  MARAC  process 
1 st  April  2019. 
and  offers  clear  guidance  on  what  is  expected  of  them  and  what  they  can  expect  of 
Information  Sharing  within  the  process.  Further,  the  MARAC  Coordination  team  are 
responsible  for  ongoing  MARAC  training  across  the  region  which  ensures  that  partners 
engaging  with  the  process  have  staff trained  and  prepared  to  do  so.  In  addition  all  MARAC 
minute  takers  are  intensively  trained  when  in  role  and  are  not  permitted  to  take  minutes 
alone until training  is complete to the satisfaction of the local  MARAC Coordinator. 

Recommendation two:  CPR Coordinator 

With  regard to concerns raised  on  D13 co-ordinator,  our response is detailed  below. 

D13  is the module in the  National Police  Firearms Training Curriculum (NPFTC) that focuses 
on  the first aid  procedures  to  be  adopted  by Authorised  Firearms Officers (AFOs) and  those 
that deliver firearms  training.  Enhanced  training  is  provided  to  officers  identified  in  a forces 
armed  policing  strategic  threat  and  risk  assessment.  The  module  covers  first  aid  and 
enhanced first aid. 

The  Chief  Firearms  Instructor  (CFI)  and  Head  of  Firearms  Unit  have  reviewed  the 
recommendation  and the following  actions have been carried  out: 

1.  The  CFI  has  contacted  the  College  of  Policing 

  (Armed  Policing 
Lead). 
  is  reviewing  the  recommendation  and  will  review  the  National 
Police  Firearms  Training  Curriculum  (NPFTC)  (as  role  is  currently  not  included  in 
Authorised  Professional  Practice - Armed  Policing  or the  NPFTC) with  consideration 
regarding  the  Operational  Firearms  Commander  (OFC)  role  profile,  and  whether to 
include  a  recommendation  for  providing  a  D13  coordinator  where  operational 
circumstances allow. 

In the meantime West Midlands Police: 

2.  Have  ensured  that  all  Strategic  and  Tactical  Firearms  Commanders  (S&TFCs), 
Operational  Firearms  Commanders  (OFCs),  Firearms  Tactical  Advisers  (FTAs)  and 
all  Authorised  Firearms  Officers  (AFOs)  are  aware  of  this  recommendation.  All 
officers  have  been  reminded  of  the  importance  of  nominating  a  CPR  coordinator 
where  resources  allow.  There  may  be  circumstances  where  the  operational  need 
and  level  of resourcing  at  an  incident  do  not  allow  an  officer to  perform  the  role  of 
coordinator.  This  will  be  a  dynamic  assessment  for  the  officers  at  the  scene.  All 
team  briefing  sheets  have  been  updated  and  version  controlled  and  now  include 
reference  to  the  coordinator  role.  These  briefing  sheets  are  used  as  a  template  in 
firearms briefings which are recorded. 

Medical Plan 

The  Medical  Plan  details  actions  to  be  completed  when  medical  care  is  required,  and  the 
location  of available  equipment  and  now  includes  the  following  direction  regarding  the  co­
ordination of care. 

Nominated  Medics are all  D13 trained and  can assist. 

 Medical  equipment  will  be  stored  at  the  most  tactical  advantageous  position  having 
considered  the  tactical  ground  assessment.  Where  deployments require  officers to  be  away 
from  their  support  vehicle,  medical  equipment  should  be  taken  to  the  most  appropriate 
location i.e.  in  a high rise  block this maybe on the landing of the subject address. 

In  instances  where  tactical  medical  care  is  being  delivered,  officers  are  reminded  of  the 
benefit  of a  co-ordinator  being  identified  to  oversee  the  effective  delivery  of care.  Where 
resources allow,  one person should take on the role of co-ordinating the response.  This may 
not always be  possible due to  numbers of officers deployed/engaged in  an  incident.  Where 
a  co-ordinator has  been  identified,  they would  normally fall  under the  direction  of the  OFC, 
but  it  is  accepted  that the  OFC  may  be  otherwise  engaged  elsewhere  in  the  incident.  Any 
co-ordinator will  act in  accordance with their D13 training. 

Chief Constable