Prevention of Future Deaths reports · 2022
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 report | 29 Jun 2022 |
|---|---|
| Reference | 2022-0200 |
| Deceased | Louise Bailey |
| Coroner | Jonathan Landau |
| Coroner area | London Inner (South) |
| Category | Road (Highways Safety) related deaths · Police related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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
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.
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.
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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