Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0021, written 19 Jan 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 Jan 2023 |
|---|---|
| Reference | 2023-0021 |
| Deceased | Nicholas Dumphreys |
| Coroner | Robert Cohen |
| Coroner area | Cumbria |
| 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.
Kally Cheema LLB | Senior Coroner| Cumbria
Fairfield, Station Road, Cockermouth, Cumbria CA13 9PT
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO: The National Police Chiefs Council
CORONER
I am Mr Robert Cohen, HM Assistant Coroner for Cumbria
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.
1
2
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
INVESTIGATION and INQUEST
On 29 January 2020 I commenced an investigation into the death of Nicholas Dumphreys.
The investigation concluded at the end of the inquest on 20th December 2022. The
conclusion of the inquest was
Accident
3
1a Severe Head Injury
1b
1c
II
CIRCUMSTANCES OF THE DEATH
4
Nicholas Dumphreys was 47 years old. He was a serving police officer with
Cumbria Police. On 26th January 2020 he was on duty. He elected to respond to an
emergency call. He drove a police issue BMW, at speed, down the M6. After PC
Dumphreys passed junction 44, the engine of the vehicle failed catastrophically. This
failure was very similar to other engine failures that have occurred in UK police vehicles
with the same engine. As a result of the engine failure, the car veered across
the carriageway, overturned, and crashed onto
the crash PC
Dumphreys sustained fatal head injuries. His death was confirmed by the roadside at
14:24.
the verge.
In
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 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) In the course of the inquest I heard evidence about the role of the National Association
of Police Fleet Managers ('NAPFM'). BMW UK made several presentations to NAPFM
with a view to them publicising concerns about the N57 engine to their members.
However, I heard evidence from the current chair of NAPFM and it is important to make
two observations. First, NAPFM membership is not mandatory. There are police fleet
managers who, for whatever reason, might not choose to join. Second, NAPFM has no
official standing, status, or budget. It is largely reliant on the goodwill of its members to
function. I am concerned that this informal approach may not be sufficiently robust. It may
not ensure that safety critical information is passed to individual police forces.
5
(2) Evidence was given as to how 'end of life' police vehicles are disposed of. It was
explained that quite frequently such vehicles are sold at auction. In relation to vehicles
with N57 engines I heard that a particular effort was made to ensure that they were not
auctioned but were destroyed. However, this appeared to me to be an ad hoc
arrangement. I am concerned that there is no policy or guidance which ensures that
equipment which is known to be faulty is not auctioned off and purchased by
unsuspecting members of the public.
(3) The evidence that I heard indicated that there are no national standards for police
garages and mechanics. I can understand that overly prescriptive guidelines might not be
fit for purpose; the nature of different police areas may place very different demands on
vehicles. A 'one size fits all' policy could be problematic. However, I am concerned that
the absence of any standards risks inadequate performance going unnoticed.
ACTION SHOULD BE TAKEN
6
In my opinion action should be taken to prevent future deaths and I believe you have the
power to take such action.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 16th March 2023. I, the coroner, may extend the period.
7
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.
COPIES and PUBLICATION
8
I have sent a copy of my report to the Chief Coroner and to the following Interested
Persons (1) The family of PC Dumphreys, (2) The Police Federation of England and
Wales, (3) The Chief Constable of Cumbria Police, (4) BMW UK Ltd, and (5) The Driver
and Vehicle Standards Agency
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 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 by the Chief Coroner.
19 January 2023
9
Signature
Robert Cohen, HM Assistant Coroner for Cumbria
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.
Deputy Chief Constable GMP
NPCC Lead for Police Driving
Robert Cohen
HM Assistant Coroner for Cumbria
Fairfield
Station Road
Cockermouth
Cumbria
CA13 9PT
Dear Mr Cohen
Re Regulation 28 Report to Prevent Future Deaths - Investigation into the death of Nicholas Dumphreys
I am writing in response to your letter dated 18th January 2023 and the matters of concern.
Firstly may I take this opportunity to assure you of the National Police Chiefs’ Council’s full support and commitment
to continued action concerning the issues you raise. In respect of all three areas you detail I had already instigated
work prior to the regulation 28 notice being sent but I fully accept the appropriateness of the notice and the rightful
focus the regulation 28 notices bring.
I am very confident that the actions taken already and plan going forward addresses the issues. I will detail actions and
plan under each area raised:
1. National Association of Police Fleet Managers (NAPFM) – no official status and robustness of the structure:
A reorganisation of the NPCC Fleet structure has taken place and a new NPCC led governance and delivery structure is
currently being established. This will ensure NPCC ownership and direction of all Police Fleet issues including the
dissemination of safety critical information.
At the time of the death of PC Dumphreys the NPCC had already in place a National Fleet Portfolio led by a Chief Officer.
NAPFM in essence sat under this portfolio, but as you rightly identify, most of the guidance and direction to fleet
managers was disseminated via NAPFM and not, in many cases, as obviously from the NPCC.
In Summer 2022 I was appointed the new NPCC Fleet lead and from that time over a period of months met with NAPFM
executive members to agree a new NPCC led governance and delivery structure. This is currently being progressed and
will include the formation of:
• NPCC Fleet governance - Strategic group (with Chief Officer representatives from every Region)
-
Tactical group (with fleet representatives from every Region)
1st Floor, 10 Victoria Street, London SW1H 0NN
-
This governance structure will agree and deliver the NPCC agreed strategy and
work plan.
• This governance structure will issue direction and guidance concerning Police Fleet to every NPCC Police
Force/Organisation. This will be issued by the NPCC and not from NAPFM.
2. End of life Police vehicles - policy or guidance concerning vehicles known to be faulty – specifically N57
effected engines:
Policy and guidance will be developed as part of the “National Police Fleet Standards”. This will define a
consistent approach for the disposal of any police vehicles that may pose a risk, through a common
standard, agreed and held by the NPCC. This policy will be delivered as a priority workstream.
In respect of the N57 engine equipped vehicles, guidance was sent to all Forces on 8th July 2022, with advice
from NAPFM and NPCC that any vehicle that had been classified as ‘red flagged’ should be disposed of in a
way that ensures the engine block could never be reused.
Whilst the guidance was from both NPCC and NAPFM, it was issued on NAPFM headed paperwork.
Therefore week commencing the 20th March 2023, I am going to write to each Chief Constable attaching
this response to your regulation 28 notice in order to highlight the importance of the issues you raise and
my response as NPCC lead. Within this correspondence I will also reissue the N57 disposal advice but put
this clearly under NPCC branded guidance.
3. No national standards for police garages and mechanics:
When I took ownership of the NPCC Fleet portfolio in Summer 2022 I asked for consistency and standards for
police garages to be considered as a workstream. Since that time this has been developed into a workstream
under the revised NPCC Fleet portfolio and structure as detailed in point one above.
The portfolio is now working on the Development and implementation of a National Police Vehicles Servicing /
Operating Standards and Code of Practice with the aim to be published and presented for adoption by all Forces.
This will reference industry best practice and minimum standards relevant to operating police vehicles,
alongside participation and awareness of emerging risks across sector and industry. This work includes the
development and implementation of Blue Light specific training and accreditation for technicians working on
police vehicles. I do not yet have an honest assessment on how long this will take to develop, or indeed if every
Chief Constable will agree to it. However, my commitment is that the NPCC Fleet portfolio will deliver options
for the Police Service within the initial priorities in the portfolio work plan.
I trust this provides you with assurance that we have taken the learning from the regulation 28 notice with the
acknowledgement that it deserves and remain committed to focusing on the actions as outlined above.
Yours sincerely
Deputy Chief Constable, Greater Manchester Police
NPCC Lead for Police Driving
1st Floor, 10 Victoria Street, London SW1H 0NN
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