Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0393, written 19 Nov 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 Nov 2021 |
|---|---|
| Reference | 2021-0393 |
| Deceased | Mustafa Abdelkarim |
| Coroner | Caroline Saunders |
| Coroner area | Gwent |
| Category | Wales prevention of future deaths reports (2019 onwards) · Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. (cid:9) The Home Office 1 CORONER 2 3 I am Caroline Saunders, Senior Coroner for the Area of Gwent 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 INVESTIGATION AND INQUEST On 2/8/2018 an investigation was opened into the death of Mustafa Dawood Bakhat ABDELKARIM (Mustafa Dawood) The investigation concluded at the end of the inquest on: 5/11/21 when a jury determined the following: The conclusion of the inquest was recorded as a narrative in the following terms On 30th June 2018 Mustafa Dawood was working at the Shaftesbury Hand Car Wash on Albany Street in Newport. At 10:08 Immigration Officers attended to undertake an enforcement visit. Mustafa ran away from the Officer in Charge and was pursued into a warehouse. Mustafa climbed on shelving and then though a metal door eventually accessing the roof of the building. Mustafa ran across the roof and fell through some plastic roofing material into the room below. Mustafa sustained severe fatal head injuries and was conveyed to hospital. Despite the efforts of the officers at the scene to resuscitate Mustafa and the clinical teams, Mustafa died from his injuries at the University Hospital of Wales in Cardiff at 14:45 on 30th June 2018. 1. During the pursuit Mustafa started to climb and it was determined that the pursuit should be abandoned. Nonetheless officers remained relatively close and did not withdraw to a distance away from him. We consider that maintaining this proximity contributed to Mustafa's death. 2. We consider that the decision to abandon the pursuit was not effectively communicated to all officers and that could have been a contributing factor to Mustafa's death. 3. The decision for the officer to keep his baton in a racked position could have contributed to Mustafa's death 4. The officers were not appropriately trained in pursuit procedures, and this could have contributed to Mustafa's death. The medical cause of death was: 1a) Traumatic subarachnoid haemorrhage. 4 CIRCUMSTANCES OF THE DEATH The circumstances of Mustafa's Dawood's death are set out in the narrative provided by the jury and need no further explanation 5 CORONER'S CONCERNS During the course of the inquest, 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. (cid:9) Training in Pursuit for Immigration Officers. The jury heard that during the induction process all Immigration Officers are introduced to the Pursuit Policy. However none of the Officers had undergone training in pursuit or in how to make decisions in those stressful situations. The jury determined that the lack of training could have contributed to Mustafa Dawood's death as has been reflected in their conclusion. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. I should be grateful if the following information be provided to me: 1. (cid:9) Confirm whether any steps have or will be taken to provide practical training to Immigration Officers in pursuit situations. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely 14/01/2022, I, the Coroner, may extend this 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 necessary. 8 COPIES AND PUBLICATION I have sent a copy of my report to the Chief Coroner and the following Interested Person (s) The family of Mustafa Dawood Bakhat ABDELKARIM 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 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 DATE 19/11/21 Signed Caroline Saunders Her Majesty's Senior Coroner for the Area of Gwent.
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.
Inquest touching the death of Mustafa Dawood Bakhat Abdelkarim (Mustafa Dawood) Response to Regulation 28 Report 1. This letter is sent on behalf of Immigration Enforcement (IE) in response to the Regulation 28 Report to Prevent Future Deaths. 2. In providing this response to the Coroner's Report, IE wishes to repeat the offering of their sincere condolences to Mustafa Dawood's family, and emphasise their commitment to addressing the matters of concern raised by the Coroner. 3. The jury determined at the end of the inquest that the lack of pursuit training for Immigration Officers could have contributed to Mustafa Dawood's death. The coroner highlighted that whilst officers are introduced to the Pursuit Policy during induction training, they are not trained in pursuit or in how to make decisions in those stressful situations. It was determined there is a continuing risk of accidents or death unless action is taken to provide more practical training to Immigration Officers involved in pursuit situations. The current position 4. Pursuit Policy guidance is in place and, as noted by the coroner, Immigration Officers are introduced to the policy during induction training as part of the National Decision Model learning which includes operational considerations. Officer training covers the pursuit policy with an emphasis on safety and communication during typical immigration operations. The induction package and a five day Officer in Charge (OIC) course also provide training for officers on the roles and responsibilities of team members during operational activity. Action to be taken 5. As a result of the coroner's findings, IE has carried out a thorough review of the existing guidance and training. Going forward the learning will provide greater focus and clarity on situations where dynamic decision making may be required. In particular: • Legal powers. Officers will be reminded of the powers available to them during immigration operations and in the event that a pursuit situation may arise; • Dynamic decision making and communication at pace. The learning will cover potential pursuit situations and the need to consider contingencies and other options besides pursuit. The training material will be reviewed on an ongoing and continuous basis to ensure it remains relevant and is aligned with any policy changes and the most current guidance. 6. The training will be mandatory for all officers with Personal Safety Training at Level 3 and will be delivered by Immigration Enforcement Business Embedded Trainers who are immigration officers experienced in the operational role. The training will be delivered: • from April 2022 to all new officers as part of their induction course with a refresher annually thereafter • to existing staff as part of their annual arrest refresher training from April 2022. All existing operational staff will therefore receive the training over the course of 12 months and by the end of April 2023. 7. Pursuit policy will be incorporated into the operational assurance framework to ensure that officers' awareness, knowledge, understanding and application of the policy are tested and evaluated on an ongoing basis. The content of the policy will be reviewed on an ongoing and continuous basis and, if there are changes made to guidance or legislation, an update will be sent out directly to every operational officer providing detailed instructions. Where there is a major policy change, this update may be supplemented by ad hoc training which would be delivered by Business Expert Trainers (BETs). Evaluation is carried out by operational managers within each Immigration Compliance and Enforcement team. There is also a national operational assurance team which assures the work of arrest teams both remotely and by attending operational visits, producing reports outlining any areas for improvement. There are also knowledge checks included as part of all induction and refresher training to test understanding. Conclusion 8. IE hopes that the action set out above adequately addresses the concerns raised by the coroner. If, however, further information or clarification would be of assistance IE will of course endeavour to provide further detail.
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