Prevention of Future Deaths reports · 2022

Louise Bailey

Regulation 28 report to prevent future deaths, reference 2022-0200, written 29 Jun 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report29 Jun 2022
Reference2022-0200
DeceasedLouise Bailey
CoronerJonathan Landau
Coroner areaLondon Inner (South)
CategoryRoad (Highways Safety) related deaths · Police related deaths
Sourcejudiciary.uk record · original PDF
Responses published2

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS 

. 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

THIS REPORT IS BEING SENT TO: 

1. Metropolitan Police Service
2. The College of Policing
3. The National Police Chief Council

1 

CORONER 

I am Jonathan Landau, assistant coroner for the coroner area of South London 

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 5 August 2019 an investigation was commenced into the death of Louise Theresa 
Bailey.  The investigation concluded at the end of the inquest on 9 June 2022.  The jury’s 
conclusion of the  inquest was: 

“Accident.  The death of Louise Bailey is both sad and a tragic accident. The jury 
recognise that the unit responding to the request did not communicate with control but 
this is not a direct contributing factor to her death. The driver acted in accordance to the 
standard expected of an advanced driver when he entered the contraflow and when the 
accident occurred.” 

4 

CIRCUMSTANCES OF THE DEATH 

Two police officers stopped a suspected shoplifter who then turned and fled.  One of the 
officers chased the suspect on foot and called for assistance.  Some units assigned 
themselves to the call.  A unit in a car responded to the incident using exemptions and 
blue lights and sirens.  The police car crossed to the contraflow to avoid traffic and 
collided with the deceased, who was running across the road to catch a bus.  She was 
not visible to the driver as she entered the road behind a bus. 

1 

 5 

CORONER’S CONCERNS 

During the course of the inquest the evidence 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. 

The MATTER OF CONCERN is as follows.  – 

Chapter 13 of Roadcraft, the Police Driver’s Handbook, provides that before 
officers begin their response to an emergency call, they should go through a 
process of risk assessment.  That includes consideration of whether other units are 
closer.  However, in this case the driver and operator did not know the answer to 
that question.  In part that was due to the fact that officers are encouraged to avoid 
assigning themselves over the radio during an ongoing incident to prevent clogging 
up of airwaves.  However, I heard evidence that several units did in fact assign 
themselves over the radio, though not all with their location, and that no training is 
provided as to when to assign over the radio and when not to.  Moreover, there is 
an emergency button which allows the originating officer to override other 
broadcasts if needed mitigating any risk of clogged up airwaves.  My concern is 
that the current system and training does not facilitate drivers being provided with 
the information they need to answer the question “are other units closer?” which 
means they are unable to complete a full risk assessment. 

6 

ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I believe your 
organisations 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 24 August 2022.   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 am 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 other 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. 

2 

 9 

Jonathan Landau, HM Assistant Coroner 
29 June 2022. 

3

Responses

2 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.

Response from Metropolitan Police Service (PDF)
PROFESSIONALISM HQ 

Mr Jonathan Landau 
HM Assistant Coroner 
South London Coroner’s Court 
2nd Floor, Davis House 
Croydon 
CR0 1QQ 

Deputy Assistant Commissioner 
New Scotland Yard 
Victoria Embankment 
London  SW1A 2JL 

Date: 17th August 2022 

Dear Mr Landau 

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 Louise Theresa Bailey who sadly died on 1st August 2019. 

Matter of concern:  

Chapter  13  of  Roadcraft,  the  Police  Driver’s  Handbook,  provides  that  before  officers 
begin their response to an emergency call, they should go through a process of risk
assessment. That includes consideration of whether other units are closer. However, 
in this case the driver and operator did not know the answer to that question. In part
that  was  due  to  the  fact  that  officers  are  encouraged  to  avoid  assigning  themselves 
over the radio during an ongoing incident to prevent clogging up of airwaves. However, 
I heard evidence that several units did in fact assign themselves over the radio, though 
not all with their location, and that no training is provided as to when to assign over the
radio  and  when  not  to.  Moreover,  there  is  an  emergency  button  which  allows  the 
originating officer to override other broadcasts if needed mitigating any risk of clogged 
up airwaves.  

My  concern  is  that  the  current  system  and  training  does  not  facilitate  drivers  being 
provided  with  the  information  they  need  to  answer  the  question  “are  other  units 
closer?” which means they are unable to complete a full risk assessment.  

In  response  to  the  matter  of  concern  regarding  MPS  driver  training,  it  is  the  MPS  Driving 
School which is responsible for preparing and delivering the emergency response aspect of 
all MPS driving courses in line with national minimum requirements. Due to the complex nature 
and volume of practical training required, attendees are required to complete the theory aspect 
of  learning  and  pass  an  exam  prior  to  attending  the  practical  training  module.  Specific 
reference  is  not  made  in  training  to  the  Roadcraft  Handbook,  however  the  principles  of 
Roadcraft  are  embedded  within  MPS  driver  training,  including  the  standards  of  emergency 
response driving outlined in Chapter 13.   

 
 
 
 
 
 
 
 
                        
                                                   
 
                                            
 
 
 
 
                    
 
  
                                                                                
 
                                                                                    
 
    
                                                                                      
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Prior to the emergency response aspect of the course, officers are provided with classroom 
input  covering  the  use  of  their  exemptions  under  the  Road  Traffic  Act,  including  use  of 
emergency equipment (blue lights and two tone sirens) and the personal considerations that 
must  be  taken  before  activating  them.  Drivers  are  taught  to  continually  risk  assess  the 
circumstances  before  them,  which  requires  consideration  of  all  the  facts  available  to  them 
before utilising exemptions. The nature of the incident, the route to take, and the proximity and 
abilities  of  other  attending  units  should  all  be  considered.  The  training  officers  receive 
encourages them to conduct a dynamic risk assessment prior to and during an emergency 
response. 

MetCC 

Met Command and Control (MetCC) is made up of two very distinct and completely separate 
sections. These are “First Contact”, the department responsible for answering all emergency 
and non-emergency calls made by the public to 999 or 101 and more recently any form of 
digital  enquiry  (text,  email,  online  submission);  and  “Despatch”,  the  function  of  which  is  to 
assign incidents requiring attendance based on urgency, to co-ordinate and control on-going 
incidents and ensure police units on the streets have the information they require. A Despatch 
Officer otherwise known as an operator, is responsible for dispatching police officers to deal 
with incidents across London. Their main function is to ensure incidents are despatched in 
accordance with priority, and that the appropriate level and amount of resources are assigned. 
Once those resources are assigned, the Operator ensures that any updates or information 
regarding the incident is logged appropriately and passed to units on scene.  It is the on-going 
role  of  the  Supervisor  to  ensure  the  wider  oversight  and  control  of  not  only  an  individual 
incident,  but  the  whole  Basic  Command  Unit  (BCU).  This  includes:  the  management  of 
resources  at  every  incident;  ensuring  incidents  and  calls  are  assigned  within  designated 
charter  times;  ensuring  information  and  safety  notices  are  communicated;  making  BCU 
supervisors aware of any risks or issues and the wider general management of all resources 
and radio transmissions on the talk groups assigned to that BCU.  This ensures that in the 
event of an urgent assistance, emergency activation or serious incident, the BCU is able to 
respond efficiently and effectively.  In the event of an issue with any of the above functions, 
the MetCC duty officer has direct communication with their BCU counterpart.   

The relationship between MetCC and a BCU is an extremely close one, the performance of 
both departments is dependent on the effectiveness of this relationship, and in the event of 
any  serious  incident  both  MetCC  and  the  BCU  work  together  to  form  part  of  the  debrief 
process. It is common for MetCC to direct units to attend a location, to de-assign units if they 
are not required and to challenge inappropriate radio use, but the fluidity of incidents means 
it is impractical for this to always be done.  

Given the importance of the role of MetCC in monitoring and managing the response and on-
going resourcing of incidents, in the event of a request for urgent assistance, among other 
things,  MetCC  operators  will  always  have  primacy  over  the  Radio  Channel  (Talkgroup) 
regardless  of  an  emergency  activation,  therefore  all  radio  transmissions  in  the  event  of  a 
request for assistance must be kept to a minimum, including by MetCC operators. 

CAD 

The  MPS  uses  the  CAD  (Computer  Aided  Despatch)  system  for  command  and  control 
functions, which has a mapping function built into it. The system generates data collected from 
police  vehicle  GPS,  known  as  IVMA  (In  Vehicle  Mobile  Application)  and  from  the  officer’s 
Airwave radio, APLS (Automated Personal Location Service) and plots the vehicle’s location 
onto a map to assist with location based deployment and management of units deployed to 
incidents  such  as  cordons  or  road  closures.  Location  updates  are  received  at  90  second 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 intervals which are then reflected on the CAD mapping system to give an estimation of vehicle 
location. There are limitations to the CAD mapping technology as the GPS signal received to 
provide the location, whether IVMA or APLS, is solely reliant on mobile data, therefore the 
reception or signal strength of the IVMA/APLS can restrict the effectiveness of the system as 
an accurate method of despatch.  

The CAD mapping system is accessed and monitored in the MetCC control rooms. Its use is 
encouraged when despatching incidents and is widely used by MetCC operators to ensure 
efficiency and to limit travel time. It is acknowledged that there is a lack of formal instruction 
around self-assignment with regards to what is deemed an urgent assistance CAD. To resolve 
this issue and ensure a consistent approach across the organisation, the MPS is in the process 
of amending the “Standards of Radio Procedure” section of the Airwave manual to state that 
the radio should not be used as a tool for officers to assign themselves to emergency incidents. 
This  will  ensure  a  consistent  and  corporate  approach  across  all  12  BCU’s  and  reduce 
unnecessary radio traffic in the event of an emergency assistance 

There is a facility within the IVMA in-car system which allows supervisors to view where local 
resources are, however, the accuracy of this depends on the signal strength received by the 
vehicle  and  its  consistency  is  location  dependent.  However,  Regulation  109  of  the  Road 
Vehicles  (Construction and  Use)  Regulations  1986  makes  it  unlawful  for  display  screens 
within vehicles, which show text, to be deployed in a position where the equipment can be 
seen by and potentially distract the driver. This means the IVMA in vehicles can only be viewed 
below a speed of 5 mph limiting the ability of the IVMA in fast time or spontaneous incidents. 

The MPS is currently in the process of procuring a replacement Command and Control system 
to  replace  the  current  CAD  system.  The  proposed  replacement,  “OnCall”  is  a  map  based 
despatch  programme  which  is  designed  to  drive  efficiency  in  deployment  of  officers  to 
incidents. The function of the OnCall system means that more control and responsibility will 
be given to MetCC Despatch Operators. 

The  OnCall  system  will  have  the  ability  to  calculate  the  travelling  times  of  units  and  show 
information  surrounding  the  policing  skills  of  the  officers  in  each  vehicle,  which  in  turn  will 
enable a more intelligence based approach to deployments. It is the MPS’ view that the OnCall 
system will address the concerns raised by HM Assistant Coroner in his report, by ensuring 
appropriate  assignment  of  vehicles  based  on  distance  and  skill  set.  The  system  will  not, 
however, change the expected response by officers to incidents of urgent assistance, for the 
reasons outlined. Due to the individual nature of those incidents, this will still require an initial 
multi-unit response in accordance with current practice. 

The deployment protocol for officers when dealing with requests for urgent assistance is that 
all  available  vehicles  should  make  their  way  to  the  scene  until  notified  that  no  further 
assistance is required. MetCC is responsible for monitoring those transmissions, updating the 
CAD  and  ensuring  that  all  information  is  passed  to  those  attending,  including  updates  and 
ensuring  any  message  to  cancel  the  need  for  more  assistance  is  broadcast.  Ordinarily, 
notification  that  no  further  assistance  is  required  comes  from  a  cancellation  from  the 
requesting officer, an update from the first officer(s) on scene or from a third party such as 
CCTV or another emergency service, such as the London Ambulance Service, or London Fire 
Brigade. It is rare for officers attending an urgent assistance to be cancelled other than by a 
police officer at the scene.  

Every  request  for  urgent  assistance  is  unique.  It  cannot  be  assessed  against  previous 
incidents or intelligence, and the existence of other units attending does not negate the need 
for  officers  continuing  to  make  progress.  It  is  of  paramount  importance  that  appropriate 
resourced response is provided to officers without delay. Any delay increases the risk of injury 
to officers, suspects and to the public.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 As detailed above, there is a requirement for all  officers to assign themselves to calls until 
informed  otherwise  and  to  keep  all  radio  transmissions  to  an  absolute  minimum.  It  is  not 
practical  to  control  the  incident  based  on  mapping  data,  nor  is  it  appropriate  to  select  or 
deselect vehicles or officers to attend based on location. 

Airwaves/ Radio 

All  MPS  officers  and  MetCC  operators  are  trained  in  the  use  of  Airwave  radio  procedures 
during initial training, this includes the process surrounding an emergency activation. This is 
to ensure Airwaves are kept clear.  

The MPS Airwave Standard Operating Procedure (SOP) “Standards of Radio Discipline” is in 
place to ensure the best working capacity of the network by governing and restricting use. All 
officers are taught the principles of the SOP as part of initial officer training whilst learning how 
to use the radio. Standards of radio discipline are based upon the “Radio ABCD” principle 
and must be adhered to. 

It is down to the individual officer to ensure they are aware of and follow the “Radio ABCD” 
principles,  and  it  is  the  responsibility  of  MetCC  controllers  and  supervisors  to  manage  the 
talkgroups they are controlling. A copy of the Radio ABCD principles are enclosed with this 
response. The principles are:  Accuracy, Brevity, Clarity and Disciplined. In respect of a 
request for emergency assistance or use of the emergency button function, the SOP states: 

“In the event of an emergency activation or request for urgent assistance; all other traffic 
should  immediately  cease.  Use  of  this  status  is  reserved  for  incidents  of  imminent 
threat or harm”. 

In addition, the MPS “Urgent Assistance” SOP assists MetCC operators in the actions to take 
in the event of a request for urgent assistance or activation of the emergency button.  When a 
particular incident has a SOP in relation to it, a message is auto generated onto the CAD to 
assist and guide the operator. This aide-memoir style message is there to ensure all actions 
in accordance with the SOP are followed. The Urgent Assistance SOP states: “Keep radio 
transmissions  to  absolute  minimum  except  those  requiring  assistance”  and  “All 
resources deployed are done so as a priority”. 

Emergency activation 

The  Coroner’s  report  references  the  emergency  activation  button  featured  on  the  Airwave 
radio; otherwise referred to as either the Emer button, Emer activation or Urgent assistance. 
The emergency function on the Airwave radio is a safety feature which allows officers requiring 
urgent assistance and who are unable to transmit normally to have priority over the Airwaves 
with  a  single  push  of  a  button.  Upon  initial  activation  the  requesting  officer  is  immediately 
placed at the top of the transmission list and has a period of 10 seconds during which their 
radio microphone is open. The officers have an initial period where they can give a location 
and reason for assistance without having to manually use the “talk button”, (otherwise known 
as the transmit button) freeing up their hands to deal with the issue they are facing.  This is 
known  as  a  “hot  mic  period”.  The  activation  is  accompanied  by  persistent  beeps  and  a 
vibration of all radios attached to the talkgroup which notifies others to the emergency call. 
After the initial 10 second hot mic period, the officer will be required to push the transmit button 
as normal in order to continue transmission, and will continue to take primacy of the radio. The 
officer will automatically transmit until the activation has been reset by MetCC operators. 

The purpose of the emergency activation button is to inform all users of an urgent assistance 
and to allow the officer a 10 second period to broadcast details of the situation and location 

 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 whilst having the use of both hands to deal with the threat or issue they are facing. This initial 
10 second period will override all other radio traffic including MetCC, however after the initial 
period,  whilst  the  activated  radio  will  continue  to  override  other  radios  it  does  not  override 
MetCC transmissions. This is to ensure MetCC can co-ordinate the response to the incident 
and ensure units attending are kept up to date without interruption or confusion. The ability of 
MetCC to be able to transmit is vital as there have been circumstances when a talk button has 
become stuck or a suspect has held the button to disable communications. The use of the 
emergency activation function must only be used in specific cases where there is an imminent 
threat of harm and should not be used to simply transmit on a busy talkgroup. Correct use and 
resetting of the emergency activation procedure is the responsibility of the MetCC controller 
for the talkgroup affected. 

In Conclusion 

The MPS delivers training to all MPS drivers in line with the national minimum requirements. 
Our drivers are taught to continually risk assess the circumstances before them which requires 
consideration  of  all  the  facts  available  to  them.    MetCC  ensure  the  appropriate  level  and 
amount of resources are assigned to each incident and once those resources are assigned, 
the Operator provides updates and information regarding the incident to units on scene and 
de-assigns units if they are not required.  However, the fluidity of incidents means that it is not 
always practical for this to be done. 

It  is  acknowledged  that  there  is  a  lack  of  formal  instruction  around  self-assignment  with 
regards to what is deemed an urgent assistance CAD. To resolve this issue, the MPS is in the 
process of amending the “Standards of Radio Procedure” section of the Airwave manual to 
state that the radio should not be used as a tool for officers to assign themselves to emergency 
incidents.  The  MPS  is  procuring  a  replacement  Command  and  Control  System  which  will 
replace  the  current  CAD  system.    It  is  envisaged  that  the  new  system  will  assign  vehicles 
based on distance and skill set. However, this will not prevent officers responding to urgent 
assistance requests where all available vehicles should make their way to the scene, or other 
incidents requiring the rapid attendance of numerous resources (for example, a major incident) 
until notified that they are no longer required.  

I  wish  to  express  my  sincere  condolences  to  the  family  of  Mrs  Bailey.  I  trust  the  above 
information provides 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 

Enc.
Response from Npcc (PDF)
Mr Jonathan Landau,  

Assistant Coroner  

South London Coroner’s Court 

Email only: 

Dear Mr Landau, 

Date: 9th August 2022 

Regulation 28 Report – Ms Louise Theresa Bailey 

We  write  on  behalf  of  the  National  Police  Chiefs  Council  (NPCC)  and  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, and the prevention of future deaths 
reports sent to the NPCC and the College, both received on the 29th June 2022.  

Whilst the NPCC and the College 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 into the death of Ms Bailey. 
We are very sorry to read of the circumstances of  Ms Bailey’s death. Our sympathies are with her 
family and friends and we share your commitment to addressing the issues that contributed to her 
untimely loss.  

The notice sets out your principal concern which states: 

“Chapter 13 of Roadcraft, the Police Driver’s Handbook, provides that before officers begin their 
response to an emergency call, they should go through a process of risk assessment. That includes 
consideration of whether other units are closer. However, in this case the driver and operator did 
not know the answer to that question. In part that was due to the fact that officers are encouraged 
to avoid assigning themselves over the radio during an ongoing incident to prevent clogging up of 
airwaves. However, I heard evidence that several units did in fact assign themselves over the radio, 
though not all with their location, and that no training is provided as to when to assign over the 
radio and when not to. Moreover, there is an emergency button which allows the originating officer 
to override other broadcasts if needed mitigating any risk of clogged up airwaves. My concern is 
that the current system and training does not facilitate drivers being provided with the information 
they need to answer the question “are other units closer?” which means they are unable to complete 
a full risk assessment”. 

Within the  concern that you raise,  you  specifically  mention Roadcraft and  the  use of the Airwave 
emergency button.  We would like to highlight the following in relation to these; 

 
 
 
  
 
 
 
 
 
 
 Roadcraft: 

Roadcraft  is  not  the  definitive  document  for  police  policy.   It  is  owned  and  run  by  a  non-police 
organisation Police Foundation and is used by many emergency services around the world.  It is used 
primarily for driver training and not for force policy.   

The  Police  Foundation  describe  their  publication  as;  “Roadcraft,  the  police  drivers  handbook  and 
Roadcraft, the police riders handbook, have become essential guides for better safer driving and riding 
incorporating  current  best  practice,  they  are  recognised  as  the  gold  standard  in  advanced  police 
driver/rider training and are used by all police forces, other emergency services, the armed services 
and the general public………..” 

Police Driving do use Roadcraft as a reference tool to teach emergency response driving.  In Chapter 
13 the section entitled “Risk Assessment” is relevant, but it is not an exhaustive list.   

Airwave Radio – Emergency Button 

All handheld airwave radio devices have an emergency button that is enabled for use.  The use of this 
button is restricted to life threatening (Officer in danger) or critical safety messages when access to 
the talk group is denied, usually caused by other patrols using the group.  When an individual activates 
the button, this makes the handheld device microphone live for a period of ten seconds, enough time 
for an officer in need of assistance to give the information.   

In  the  event  that  officers  wish  to  support  their  colleagues  when  a  call  for  assistance  is  made  it  is 
difficult  to  know  how  many  resources  will  be  required  until  that  incident  is  under  control.    It  will 
therefore be for the officers being assigned/assigning themselves to assess the risk, and dispatchers 
within control rooms to manage their resources appropriately.  

We hope that this addresses the concern you raise.  Should you have any further questions in relation 
to our response please send this to 

Yours sincerely,  

Chair, National Police Chiefs’ Council 

CEO, College of Policing

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