Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0371, written 21 Nov 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 Nov 2022 |
|---|---|
| Reference | 2022-0371 |
| Deceased | Andrew Brown |
| Coroner | Anton Van Dellen |
| Coroner area | West London |
| Category | Road (Highways Safety) 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Commissioner of Police of the Metropolis 1 CORONER I am Dr Anton van Dellen, HM Assistant Coroner, for the coroner area of West 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 An investigation was commenced into the death of Andrew MacIntyre Brown, aged 23. The investigation concluded on 18 November 2022. The conclusion of the jury in the inquest was: Road Traffic Collision: The [Police] driver made a reasonable decision to follow a suspect vehicle, then carried out an inadequate risk assessment, in doing so he drove at an unsuitable speed and inappropriately decided not to use lights and sirens. At 0.6 seconds prior to the collision, the driver applied the brakes at the speed of 61mph which was 16.1 metres from the pedestrian crossing. The police car then collided with two pedestrians on the pedestrian crossing; this led to the death of Andrew MacIntyre Brown on the 5th November 2019. Considering the evidence, there were inadequacies in the policies and training in regards to the use of blue lights and sirens at night. The medical cause of death was 1a Head injury 4 CIRCUMSTANCES OF THE DEATH Before undertaking response driver trainer, the Police driver needed to have read material which included Police policies relating to response driving. These policies were also available on the Police intranet. The Police driver passed the written examination (which included questions on Police policies) to commence Police response driver training course and passed the course in September 2018. On 1st November 2019, the Police driver struck the deceased at a pedestrian crossing whilst driving at night over the speed limit and whilst not using blue lights and sirens, severely injuring the deceased. The Police driver was subsequently convicted of causing death by careless or inconsiderate driving and was dismissed by the Police for gross misconduct. The inquest was heard before a jury and the jury was asked whether the Police policies in 2019 regarding the use by response-trained drivers of speed exemptions, activation of blue lights or sirens, and/or night-time emergency response driving was inadequate. The jury’s findings were that the Police policy was inadequate in that there was insufficient reference to other road users and pedestrians and their safety in the policy and the policy was also too open to interpretation, both which possibly contributed to the death. 1 5 CORONER’S CONCERNS During 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 MATTERS OF CONCERN are as follows. – 1. There is insufficient reference to other road users and pedestrians and their safety in the Metropolitan Police Service Police Driver & Vehicle Policy - Vehicle and Equipment Standard Operating Procedure (SOP). 2. The Metropolitan Police Service Police Driver & Vehicle Policy - Vehicle and Equipment Standard Operating Procedure (SOP) is too open to interpretation in the section on “silent approach” in section 1.55 Warning equipment – (sirens, blue lights and headlamp flasher) and the first three paragraphs of section 1.57 Blue Lights. The scope or threshold of the exception in the two sections is not clear and it is also not clear whether the exception in the latter section applied to response drivers. 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. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 16th January 2023. 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. 2 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: 1. 2. 4. The Commissioner of the Metropolis 5. 6. National Police Chief’s Council 7. Independent Office for Police Conduct I am also 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. 21st November 2022 9 3
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.
PROFESSIONALISM HQ
Dr Anton van Dellen
HM Assistant Coroner
West London Coroner’s Court
25 Bagley’s Lane
Fulham
London
SW6 2QA
Deputy Assistant Commissioner
New Scotland Yard
Victoria Embankment
London
SW1A 2JL
Date: 06.01.2023
I am the Deputy Assistant Commissioner for the Directorate of Professionalism in the
Metropolitan Police Service (MPS). I write to provide the response on behalf of the
Commissioner of Police of the Metropolis to the matters of concern addressed to the MPS in
the Report to Prevent Future Deaths dated 21st November 2022.
On behalf of the MPS may I first of all express my sincere condolences to Mr Brown’s family.
Our thoughts and sympathies are very much with them.
Matter of Concern 1
There is insufficient reference to other road users and pedestrians and their safety in
the Metropolitan Police Service Police Driver & Vehicle Policy - Vehicle and Equipment
Standard Operating Procedure (SOP).
Response
The MPS Police Driver and Vehicle Policy – Vehicle and Equipment SOP provides guidance
to officers and staff on the use of vehicles and equipment provided by the MPS and supports
safe driving within the MPS. It details clearly the step-by-step processes that should be
undertaken when using MPS vehicles and the equipment carried either in or on the vehicle,
and informs officers / staff of any risks associated with the process. Although this SOP is
predominantly focussed on the required actions of MPS officers and staff when using police
vehicles and equipment, in relation to the use of warning equipment (blue lights, sirens,
headlamp flashers), guidance is provided to officers and staff concerning the safety of other
road users and pedestrians.
Specifically, section 1.55 of the MPS Police Driver and Vehicle Policy – Vehicle and
Equipment SOP contains the following statements:
‘The use of warning equipment does not give a police vehicle the right of way but the driver
may, however, take advantage of any precedence offered by other road users and
pedestrians, if it is safe to do so.’
I can confirm that the MPS have carefully considered the Coroner’s concerns and whether
there are any helpful amendments which we could make to the policy. However, on this
occasion it was agreed that any amendment would make the policy too prescriptive. As
outlined in the evidence to the Court during the inquest, police driving is based on the Highway
Code and Road Craft, both of which are focussed on the safety of road users and pedestrians.
A delicate balance must therefore be struck as to the level of detail within the MPS policy to
ensure that it is not unworkable.
Matter of Concern 2
The Metropolitan Police Service Police Driver & Vehicle Policy - Vehicle and Equipment
Standard Operating Procedure (SOP) is too open to interpretation in the section on
“silent approach” in section 1.55 Warning equipment – (sirens, blue lights and
headlamp flasher) and the first three paragraphs of section 1.57 Blue Lights. The scope
or threshold of the exception in the two sections is not clear and it is also not clear
whether the exception in the latter section applied to response drivers.
Police drivers deal with a wide range of incidents on a daily basis, each with their own set of
unique circumstances resulting in drivers facing numerous decisions regarding their driving
response choices and the different methods that can be used, whether that be the use of full
warning equipment, part warning equipment or a silent approach. The use of this equipment
cannot be prescriptive as the decision whether to make use of any exemptions or use
warning equipment will always rest with the driver who is responsible for ensuring the
vehicle is driven in a safe manner in line with their training and skill level.
It would not be possible to provide a prescriptive list to police drivers of all foreseeable
circumstances that it would be appropriate to use a ‘silent approach’. Accordingly the threshold
is not set in the policy because it would restrict officers in using their professional judgement,
during dynamic situations, as to the most appropriate manner of driving when responding to
an incident.
The use of exemptions (observing speed limits, observing keep left / right signs, complying
with traffic lights (including pedestrian controlled crossings and red X matrix signs) for a
policing purpose, is only available to Response level drivers and above. Basic drivers are not
afforded the use of exemptions for a policing purpose and this is documented within the
Vehicle and Equipment SOP, People SOP and within the MPS internal website pages
Please do not hesitate to contact me should you have any queries.
Yours sincerely
Deputy Assistant Commissioner
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