Ian Taylor

From Will Quince 
Minister of State for  
Health and Secondary Care 
39 Victoria Street 
London 
SW1H 0EU 

Dr Andrew Harris 
HM Senior Coroner, London Inner South 
HM Coroners Court 
1 Tennis Street 
Southwark 
London SE1 1YD 

                                                                                                                       27 February 2023 

Dear Dr Harris,  

Thank you for your letter of 8 June 2022 to the then Secretary of State for Health and Social 
Care, Sajid Javid, about the death of Ian Taylor.  I am replying as Minister with responsibility 
for Health and Secondary Care, and thank you for the additional time allowed.     

Firstly, I would like to say how saddened I was to read of the circumstances of  Mr Taylor’s 
death and I offer my sincere condolences to his family and loved ones.  The circumstances 
your report describes are very concerning and I am grateful to you for bringing these matters 
to my attention.  

You may wish to note that allowing non-prescribed storage of salbutamol inhalers1 by police 
officers  will  require  a  change  in  legislation  -  which  in  this  case  is  the  Human  Medicines 
Regulations 2012.  The Medicines and Healthcare products Regulatory Agency (MHRA) own 
these  regulations,  and  will  need  to  be  presented  with  evidence  that  supports  the  case  for 
making a change to the regulations. 

With  regard  to  the  use  of  inhalers,  there  are  several  considerations  that  need  to  be  well-
thought-out:  

•  salbutamol inhalers are single use devices, therefore, there would need to be means 

by which Police Officer could obtain replacement devices   
•  monitoring on the use of the inhalers would also be essential   
•  multiple inhalers will need to be stored by the police, to ensure one is always available 
for use and to meet the needs of each salbutamol inhaler user in a given situation 
•  specific people would have to be trained and responsible for the device in each police 
setting - this training will be essential to ensure that the inhalers are used appropriately 
and  not  as  interventions  for  unrelated  emergencies  such  a  blocked  windpipe  for 
example 

In order for these legislative changes to be considered evidence would need to be gathered 
to support the need for the change to show that the medicine could be safely handled and 
used  in  the  proposed  emergency  circumstances,  and  that  risks  identified  have  been 
satisfactorily mitigated. 

1 Short-acting bronchodilator inhalers, also known as blue inhalers.  

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 You may wish to note that in 2015 the legislation was amended to allow schools to procure 
and  store  non-prescribed  salbutamol  inhalers.  These  changes  were  made  following  an 
evidence  gathering  exercise  by  the  Department  for  Education,  including  information  being 
collected by surveys of patients, as well as, teachers and schools.  The potential advantages 
and  disadvantages  of  storing  non-prescribed  salbutamol  were  considered  and  informed  by 
pilot schemes of holding inhalers in some schools.  

The  evidence  would  also  need  to  demonstrate  that  wider  availability  of  non-prescribed 
salbutamol  inhalers  would  have  in  reducing  severe  asthma  attacks  and  deaths,  and  would 
outweigh any risks that would arise from non-prescribed use of salbutamol inhalers. 

Once  all  relevant  evidence  is  collected,  a  paper  would  need  to  be  presented  to  the 
Commission for Human Medicines (CHM) for consideration.  If the advice of the CHM is that 
the benefits of the wider availability of inhalers outweigh the risks, then the Department would 
then undertake public consultation on changing the Human Medicines Act Regulations 2012.  
The feedback from the public consultation would also be taken on board before a final decision 
on implementing the legislative change is made.  

In terms of process for considering whether inhalers should be available to police officers, this 
would need to be undertaken by the Home Office (as the sponsor department for the police 
services) supported by the Department.  

Part  of the  argument  as  to  why  schools  were allowed  to  have  access  to  inhalers,  was that 
these are controlled environments.  Schools require parents to inform them if their children 
need an inhaler, which in turn enables the school to maintain a stock of inhalers respective to 
the  number  of  children  with  that  need.    Local  police  services  would  need  to  undertake  an 
assessment of the frequency of arrests involving individuals where the need for a salbutamol 
inhaler was identified, to gauge the stock of inhalers which would need to be maintained.  

Finally, you may wish to note that NHS England has placed a particular focus in encouraging 
the use of preventer inhalers, inhaled corticosteroid inhalers, and reducing overuse of reliever 
inhalers,  short-acting  bronchodilator  inhalers.  However,  overuse  of  reliever  inhalers  is 
associated with poorer clinical outcomes. The MHRA has noted that asthma suffers who use 
the inhalers must visit their GP to request one.  This means that a GP could monitor a patient’s 
asthma, their exacerbations, and whether they have an overreliance on inhalers.  Ad hoc use 
of reliever inhalers, such as during a police arrest, may prevent GPs from fully monitoring a 
patient’s asthma. 

I hope this response is helpful. Thank you for bringing these concerns to my attention.  

Yours sincerely,   

WILL QUINCE MP   
MINISTER OF STATE

OFFICIAL 

Andrew Harris 
HM Senior Coroner 
London Inner South 
Southwark Coroner’s Court 
1 Tennis Street 
Southwark 
SE1 1YD 

And by email to :

30 June 2022 

Dear Sir 

Inquest touching on the death of Ian Taylor 
Case Ref: 159801 
Prevention of future death report 

I write on behalf of the Director General of the IOPC 
the first matter of concern raised in your Prevention of Future Death report arising from the 
inquest into the death of Mr Taylor, which concluded on 19 May 2022. This letter is the 
IOPC’s formal response to your report in accordance with Regulation 29 of the Coroners 
(Investigations) Regulations 2013.  

, with regards to 

Matter of concern: the current fitness of 

 to serve as a police officer 

In your report you highlighted the following evidence heard in court from officers in person 
and the body worn footage (BWV): 

• At 18.18hrs officers decided to move Mr Taylor to the police car where it was

cooler. Mr Taylor was lying down and had to be assisted to stand. My Taylor told
officers that he was going to die and asked them to help him stand up. 
reassured Mr Taylor that he was not doing to die and told the court that officers had
to support Mr Taylor to walk to the car as he initially did not support his own weight.

 BWV captured Mr Taylor saying something like ‘I’m fading’ and ‘I’m

going to die now’.

• Shortly before the above interaction (at 18.14hrs) while 

 was away from

Mr Taylor he stated to his sergeant on the radio that ‘[Mr Taylor] was currently on

 
 OFFICIAL 

the floor playing the whole poor me poor me; he’s going to have to go to hospital 
though as a matter of course.’ 

•  Shortly after the above interaction (at 18.24hrs) 

 also stated to his 
sergeant on the radio that ‘[Mr Taylor was] saying he has chest pains he can’t 
breathe blah blah; it’s a load of nonsense but there we go’. 
In his evidence to the court 
faking illness and stated he formed the views (relayed to the Sergeant) as Mr Taylor 
seemed iller than he would expect from the nature of the previous altercation.  
•  He further gave evidence that his views were influenced by a previous incident in 

 denied that he thought Mr Taylor was 

• 

• 

• 

• 

which a man sprang to violence from previous calmness.  

 claimed to have made a continual risk assessment, but there was no 

record or evidence of this before the court. 

 stated the views he expressed to his sergeant were not his final 

conclusion but there was no evidence suggesting he formed a different conclusion 
in the 8 minutes between his radio comments and Mr Taylor’s cardiac arrest. 

 did not acknowledge that he had learnt any lessons from the incident 

and, in response to questioning about whether he would do anything different in 
future, made excuses for his comments and said that he would be more sensitive in 
future.  

•  He did not accept that he had made an inadequate risk assessment or that such 
comments could have or might in future contribute to death by indicating a lack of 
urgency to a sergeant not at the scene.  

•  Although given an opportunity to make any other comment, 

 did not 

apologise to Mr Taylor’s family.  

In your report you also highlighted the level of the family’s concern with regards to public 
safety arising from these matters.  

In light of the above, you asked the IOPC to consider whether further investigations or 
reports are warranted to give reassurance to the public about the fitness of this officer to 
serve. 

Action taken 

In response to your report, I have considered whether the matters raised by the inquest 
with regards to 
 would require any further handling under the Police Reform 
Act 2002.  

Under this legislation, concerns about the conduct of a person serving with police may be 
recorded and referred (subject to meeting the relevant statutory criteria) to the IOPC for 
consideration whether an investigation is necessary, and if so, whether an independent 
investigation is required. Decisions to record and refer are usually made by the force with 

 
 
 
 
 
 
 
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whom the officer in question is serving (known as the appropriate authority). However, the 
IOPC can also require an appropriate authority to refer a matter or, in some 
circumstances, treat a matter as having been referred.  

Conduct matters are defined in the legislation as any matter which is not and has not been 
the subject of a complaint where there is an indication that a person serving with the police 
may have committed a criminal offence or behaved in a manner which would justify the 
bringing of disciplinary proceedings. Disciplinary proceedings are justified where the 
conduct, if proven, would justify a sanction of at least a written warning.  

Conduct matters which must be referred to the IOPC are: 

•  matters which relate to any incident or circumstances in which (or in consequence 

of which) a person has died or suffered a serious injury;  

•  serious assaults; 
•  serious sexual offences; 
•  serious corruption; 
•  a criminal offence of behaviour liable to lead to disciplinary proceedings which was 

aggravated by discriminatory behaviour; 

•  a relevant offence; 
•  conduct alleged to have taken place in the same incident as one in which one or 

more of the foregoing types of conduct is alleged.  

I have given careful consideration as to whether the matters reported in respect of 
 would meet the definition of a conduct matter described above.    

 comments to his Sergeant, and the lack of insight and 

The distress that 
reflection shown in his evidence to the inquest, will have caused to Mr Taylor’s family, is a 
harm resulting from his behaviour which will also be capable of harming public confidence 
in the police service more widely. I agree that this behaviour does need appropriate 
intervention. Balanced against this, this appears to be a one off incident rather than a 
pattern of behaviour and while the inquest jury concluded that the dynamic risk 
assessment of the officers present was not adequate, the evidence did not suggest that 

 comments to his Sergeant delayed or otherwise affected the treatment of Mr 

Taylor. Taking all these factors into account, I have concluded that the behaviour would 
not meet the threshold for justifying disciplinary proceedings for the purpose of being 
treated as a conduct matter under the 2002 Act.  

The appropriate authority, the MPS, have informed the IOPC that they propose to refer 

 to the reflective practice review process, a formal but non disciplinary process set 

out in Part 6 of the Police (Conduct) Regulations 2020. This process can be used where 
the appropriate authority has identified ‘practice requiring improvement’, defined as 
underperformance or conduct not amounting to misconduct justifying disciplinary 

 
 
 
 
 
 
 
 
 
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proceedings or gross misconduct, which falls short of the expectations of the public and 
the police service as set out in the Code of Ethics issued by the College of Policing.  

 behaviour is evidenced in the 
I agree that this is an appropriate intervention. 
BWV capturing his comments at the time, and the record of his evidence to the inquest. A 
further investigation therefore does not appear to be necessary in order to establish the 
extent of his behaviour or test the evidence. Under the Police (Conduct) Regulations 2020, 
the appropriate authority has the power to refer an officer to the reflective practice review 
process without an investigation. The Home Office Guidance on Conduct, Efficiency and 
Effectiveness 2020 states that the reflective practice review process is intended to: 

“involve accountability for actions and taking responsibility by individual officers and the 
organisation. The process is intended to provide an open and reflective environment to 
approach issues and mistakes that have arisen. There should therefore follow a greater 
willingness to discuss the facts at issue and a positive attitude about taking steps to put 
things right and improve for the future.”1 

The reflective practice review process leads to a reflective review development report, 
which (among other things) must contain key actions to be undertaken within a specified 
time period, any lessons identified for the participating officer (and for the line 
management or police force concerned) and specify a period of time for reviewing the 
report and the actions taken.  

I am satisfied that this process can be used effectively to prompt the reflection and insight 
into this incident lacking in 
potential for future harm were his behaviour to be repeated. It is not for the IOPC to set the 
terms of the intervention, but I express my hope that among other things there may be 
reflection on the missed opportunity to offer an apology to Mr Taylor’s family which you 
highlighted in your report.  

 testimony and lead to a recognition of the 

Conclusion 

I would like to myself express my sincere condolences to the family of Mr Taylor.  

I am grateful to you for raising this issue with the IOPC and trust this response provides 
reassurance that I have considered the matter of concern raised in your report. Please do 
not hesitate to contact me if you have any queries arising from this letter.  

1 Paragraph 13.8, p154 Home Office Guidance Home_Office_Statutory_Guidance_0502.pdf 
(publishing.service.gov.uk) 

 
 
 
 
 
 
 
 
 
 
 
 
 
 OFFICIAL 

Yours sincerely, 

Regional Director 
For the Director General

PROFESSIONALISM HQ 

Mr Andrew Harris Senior Coroner                      
Southwark Coroners Court                                            
1 Tennis Street                                                       
Southwark                                                                          Victoria Embankment 
SE1 1YD                                                                          

           New Scotland Yard 

London   SW1A 2JL 

Deputy Assistant Commissioner 

Email: 

Tel: 

Our Ref: IX/3494/19 

Date:  26 July 2022 

Dear Mr Harris 

I  am  the  Deputy  Assistant  Commissioner  for  the  Directorate  of  Professionalism  in  the 
Metropolitan Police Service (MPS), and I am responding on behalf of the Commissioner of 
Police of the Metropolis in relation to the matters of concerns raised following the conclusion 
of the inquest into the death of Mr Ian McDonald Taylor who sadly died on 29th June 2019. 

Matters of concern: Given the evidence heard in court before the family and members 
of the press, it is in the public interest that statutory bodies consider whether further 
investigations  or  reports  are  warranted  to  give  reassurance  to  the  public  about  the 
fitness of this officer to serve by 

1.  The IOPC, not only on the basis of conduct at the scene, but the evidence of his 

attitude, insight and extent of learning in court. 

2.  The  Metropolitan  Police  Service  as  to  his  supervision  after  the  incident, 

assessment of training needs and provision of any further training. 

You will note from the IOPC’s response to matter of concern 1 in their letter dated 30th June 
2022, that the MPS has reviewed the evidence provided and concluded that the officer should 
be  referred  to  the  reflective  practice  review  process.    In  coming  to  this  conclusion,  the 
Appropriate Authority (AA) for the MPS considered whether the matters you have highlighted 
require any further handling under the Police Reform Act 2002 (PRA).  

The AA carefully considered whether the matter should be recorded as a public complaint. 
This was considered during the original review which was handled as a Death or Serious Injury 
incident.  The  AA  is  unaware  of  any  person  who  meets  the  definition  of  complainant  as 
described in the PRA as ever having made a complaint. However, given that the coroner has 
relayed the family’s continued concern it remains open to them to make a complaint to the 
MPS, and should they wish to do so, it will be handled under the provisions of the PRA.   

/… 

 
 
 
 
 
                                                     
                                                                                   
 
 
                                                                                   
 
 
    
                                                                                      
 
 
 
 
 
 
 
 
 
 
 Mr Andrew Harris/2 

In the absence of a public complaint, the AA has applied the PRA using the Police (Complaints 
and Misconduct) Regulations 2020 (PCMR). The following definition of conduct can be found 
within the PCMR.  

“A  conduct matter  is  any  matter  which  is  not  and  has  not been  the subject  of  a complaint, 
where  there  is  an  indication  (whether  from  the  circumstances  or  otherwise)  that  a  person 
serving with the police may have committed a criminal offence or behaved in a manner which 
would justify disciplinary proceedings. Section 12, Police Reform Act 2002”. 

The PCMR also includes a duty to refer certain conduct matters to the IOPC. 

Conduct matters which must be referred to the IOPC are: 

•  matters which relate to any incident or circumstances in which (or in consequence of 

which) a person has died or suffered a serious injury;  

•  serious assaults; 
•  serious sexual offences; 
•  serious corruption; 
•  a  criminal  offence  of  behaviour  liable  to  lead  to  disciplinary  proceedings  which  was 

aggravated by discriminatory behaviour; 

•  a relevant offence; 
•  conduct alleged to have taken place in the same incident as one in which one or more 

of the foregoing types of conduct is alleged.  

The AA has considered whether the matters reported would meet the definition of a conduct 
matter described above. There are two occasions when one of the attending officers makes 
comments. On the first occasion he is speaking to a supervisor on a private call. Mr Taylor 
can be seen in the background of the footage lying on the pavement in handcuffs, he is being 
tended to by two other officers. The officer is providing an update on the scene and explains 
that he does not believe that the breathing difficulties Mr Taylor is complaining of are genuine. 
His tone is flippant when he states; “poor me, poor me,” however he confirms that they will be 
taking Mr Taylor to hospital. Later on in the footage when he is not in the vicinity of Mr Taylor, 
he is on a further private call on his radio and again expresses the opinion that the breathing 
difficulties  are  not  genuine  by  using  the  phrase;  ‘chest  pains,  blah,  blah,  blah  all  a  load  of 
nonsense’. The AA recognises the severe distress that these comments made at the scene 
and the lack of reflection shown by the subject officer at the inquest, will have caused to Mr 
Taylor’s family. This is conduct which could damage public confidence in the police service.  

It  is  the  position  of  the  AA  that  whilst  the  officer’s  comments  had  no  bearing  on  the 
circumstances  of  the  incident,  the  flippant  nature  of  the  words  demonstrate  a  lack  of 
professionalism and are in breach of the standards of professional behaviour outlined in the 
code of ethics issued by the college of policing.  

The  AA  also  considered  whether  the  comments  made  indicated  a  racial  prejudice.  The 
Angiolini Report, was referenced in the Inquest. The AA understands that the report suggests 
that  officers  are  more  likely  to  believe  a  person  is  faking  illness  if  they  are  black.  There  is 
nothing in the words or behaviour that indicate that the comments made were due to the fact 
that he was treating Mr Taylor differently. In support of this opinion the AA took note of the  

/… 

 
 
 
 
 
 
 
 
 
 
 
 Mr Andrew Harris/3 

officer’s actions when Mr Taylor’s condition deteriorated. The officer reacted in accordance 
with his emergency life support training assisting his colleagues in administering the first aid.  

The AA has determined that the conduct does not meet the threshold for justifying disciplinary 
proceedings. The AA has identified practice requiring improvement and determined that the 
officer will be referred the reflective practice review process, as set out in Part 6 of the Police 
(Conduct) Regulations 2020. In particular the AA has determined that the reflective practice 
review process will include an opportunity for the officer to reflect on the missed opportunity 
to offer an apology to Mr Taylor’s family. 

Therefore, in response to your matter of concern, “The Metropolitan Police Service as to his 
supervision  after  the  incident,  assessment  of  training  needs  and  provision  of  any  further 
training”, the Reflective Practice Review Process (RPRP) will be implemented for this officer.  
It is a reflective practice designed to give officers, line managers and Forces an opportunity to 
discuss, learn and develop when things could have gone better, with a view to improving ways 
of  working  in  the  future  and  look  for  ways  of  addressing  issues.  It  should  demonstrate  the 
officer’s ability to reflect, learn and improve.  As part of the process, the officer’s line manager 
will identify whether there are any additional training needs for the officer.   

In Conclusion 

I wish to express my sincere condolences to the family of Mr Taylor. I trust this provides the 
reassurance  that  the  MPS  has  considered  the  matters  of  concern  raised  by  Her  Majesty’s 
Coroner and that they have been addressed in relation to this matter. Please do not hesitate 
in contacting me should you have any queries. 

Yours sincerely 

Deputy Assistant Commissioner

RCEM 
Royal  College 
~f Eme11 gency 
Medicine 

Patron:  HRH  Princess Royal 

Octavia  House, 

54 Ayres Street, 

London,  SE1  1EU 

17.08.2022 

Dear 

Re:  Prevention  Future Deaths Report for Ian Taylor 
DoD 30.06.2019  Case Ref:15980 

Further to your letter of the  13th  June 2022,  I was sorry to  hear about the death  of Mr Taylor and  I have 
read the associated  report on  the prevention of future deaths. 

The provision medical  cover to police custodial units does  not fall within the remit of the  Royal  College 
of  Emergency  Medicine  (RCEM).  RCEM  does  not  have  responsibility  for  either  determining  in  the 
access to  healthcare staff within  police custody units or the training  of these staff.  With  regards to  any 
decision  concerning  statutory  changes  to  allow  Police  Officers  to  administer medication;  RCEM  is  of 
the  opinion  that the  safest approach  to  this  issue would  be  to  ensure  adequate  and  timely  access  to 
healthcare assessment to  police custody units for the whole 24hr period. 

Yours, 

Chair of the Quality in  Emergency Care Committee, 
Royal College of Emergency Medicine 

Excellence in  Emergency Care 

Incorporated by Royal Charter, 2008 
Registered Chnrity Number: 1122689 

VAT  Reg.  No.  17320[i823 
Scottish Chnrity Number: SC044373