Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0348, written 3 Jul 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 3 Jul 2023 |
|---|---|
| Reference | 2023-0348 |
| Deceased | Andre Moura |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Alcohol, drug and medication 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: The National Police Chiefs Council and the College of Policing 1 CORONER I am Alison Mutch, Senior Coroner, for the Coroner Area of Greater Manchester South 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 7th July 2018 I commenced an investigation into the death of Andre Felipe Mendes Moura. The investigation concluded on the 15th December 2022 and the conclusion of the jury was one of Narrative: Andre Moura had taken cocaine in the hours leading up to his death. There was a significant struggle with Greater Manchester Police Officers as he was restrained, during which an episode of acute behavioural disturbance developed. He was put in the back of a police van for transportation. He suffered a cardiac arrest in the back of the van and died after attempts to resuscitate him were unsuccessful. The medical cause of death was 1a) Cocaine toxicity resulting in hyperthermia and acute behaviour disturbance in association with obesity and struggling against restraint. 4 CIRCUMSTANCES OF THE DEATH On the 7th July 2018 Andre Moura was declared dead at Tameside General Hospital. He had a cardiac arrest in a police vehicle whilst under police arrest to prevent a breach of the peace. Attempts to resuscitate him were unsuccessful. He had high levels of cocaine in his system, resulting in cocaine toxicity. Acute behavioural disturbance in association with hyperthermia, obesity and a prolonged, high stressing and physical struggle were all contributory factors. 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 will occur unless action is taken. In the circumstances it is my statutory duty to report to you. 1 The MATTERS OF CONCERN are as follows. – 1. During the course of the Inquest, evidence was heard about the understanding and training in relation to Acute Behaviour Disturbance (ABD). All of the officers who had received their College of Policing Personal Safety Training had been trained on the ABD module within that package. However it was clear that the training package had not achieved the objective i.e. to recognise ABD in a real life setting. The Inquest heard that ABD is an umbrella term and not all of the symptoms need to be present for someone to be suffering from ABD. It was clear from the officers’ evidence that the videos played in the training particularly of extreme examples of ABD had led them to not consider or recognise ABD in this situation. The Inquest heard that it could be difficult to recognise ABD in a dynamic situation but the training was there to ensure officers considered it in situations where it was a possible explanation for behaviour seen by officers. An emphasis on the nuances and less on extreme examples may assist in improving the recognition of ABD; 2. The Inquest heard that the ABD training did not have any formal way of measuring/testing knowledge but was reliant of the perception of the trainer. A more formalised approach may have increased the ability of officers to recognise ABD; 3. The role for a safety officer which is part of the College of Policing training in a situation such as this was not recognised. The Inquest heard evidence from an expert witness that a safety officer plays a key role in an incident such as the one involving Mr Moura and ensures key information is not lost/shared. This lack of an officer at his head taking on such a role emphasised the fact that although officers had attended the PST training key points had not been retained. Greater emphasis on this role in training would be beneficial in reducing the risk to prisoners being restrained; 4. Many of the officers who gave evidence indicated that they believed that Mr Moura was feigning his lack of responsiveness. This was despite the fact that there was very limited evidence of officers carrying out the recognised AVPU checks. Officers relied on their own perceptions rather than AVPU. An officer who did carry out AVPU did not clearly share his lack of responsiveness with other officers. The Inquest heard that there is no formal training on what officers should do if they believe a prisoner under arrest is feigning unresponsiveness. Clarification and enforcement of the need for objective use of AVPU may well prevent subjective assessments leading to erroneous and potentially fatal conclusions that a prisoner is feigning lack of responsiveness; 5. The officers escorting Mr Moura to the police station did not have their body worn cameras on. Greater Manchester Police (GMP) at the time did not have a policy at that time requiring escorting officers to switch on their Body Worn Video (BWV) cameras. GMP do now require that BWV cameras are on. This is an important change but it was not clear if all forces have implemented such a change. Given that the evidence before the inquest made it clear 2 that the change in practice by GMP was important in allowing clarity around how a prisoner is behaving whilst being escorted to custody it is important that its use at all times should be promoted nationally. 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 28th August 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely; 1) Southerns Solicitors on behalf of the Family; 2) Greater Manchester Police; 3) the Independent Office for Police Conduct; 4) RJW Legal and 5) Precedence Law who may find it useful or of interest. 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. 9 Alison Mutch OBE HM Senior Coroner 03.07.2023 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.
Alison Mutch HM Senior Coroner By email 23rd August 2023 Dear Ms Mutch Re: Regulation 28 Report into the death of Andre Moura I am writing in response to your Regulation 28 report following the investigation and inquest into the tragic circumstances of the death of Andre Moura on 7th July 2018. I hope to answer the concerns you raised that are listed within section 5 of your report, which are listed as follows: 1. During the course of the Inquest, evidence was heard about the understanding and training in relation to Acute Behaviour Disturbance (ABD). All of the officers who had received their College of Policing Personal Safety Training had been trained on the ABD module within that package. However it was clear that the training package had not achieved the objective i.e. to recognise ABD in a real life setting. The Inquest heard that ABD is an umbrella term and not all of the symptoms need to be present for someone to be suffering from ABD. It was clear from the officers’ evidence that the videos played in the training particularly of extreme examples of ABD had led them to not consider or recognise ABD in this situation. The Inquest heard that it could be difficult to recognise ABD in a dynamic situation but the training was there to ensure officers considered it in situations where it was a possible explanation for behaviour seen by officers. An emphasis on the nuances and less on extreme examples may assist in improving the recognition of ABD; In 2020, the College of Policing commenced a national working group to update the First took place considered The Aid Learning Programme recommendations made by Coroners and the IOPC, including the detail of learning outcomes on Acute Behavioural Disturbance and treatment of head injuries. (FALP). review that The FALP has now been published and includes a revised learning outcome “recognise the signs and symptoms of acute behavioural disturbance” The new Public and Personal Safety Training (PPST) for all police officers has recently been developed with the emphasis on de-escalation. It is a scenario-based method of delivering training and is focused on learning, decision making, understanding decisions and de-briefing decisions. The updated training will include identification of the signs and symptoms of ABD and management of the incident with the focus now being on de- escalation and ‘contain rather than restrain’, where officers suspect a person to be experiencing ABD. There will also be an emphasis on treating ABD as a medical emergency and seeking immediate medical assistance. 2. The Inquest heard that the ABD training did not have any formal way of measuring/testing knowledge but was reliant of the perception of the trainer. A more formalised approach may have increased the ability of officers to recognise ABD; The new PPST is designed to be an interventionailist style of training delivery. The trainers observe the students managing the scenarios. The training is stopped at regular intervals when the trainers will test the knowledge of the students and get the students to explain the rationale for their decisions. PPST is a pass or fail course. 3. The role for a safety officer which is part of the College of Policing training in a situation such as this was not recognised. The Inquest heard evidence from an expert witness that a safety officer plays a key role in an incident such as the one involving Mr Moura and ensures key information is not lost/shared. This lack of an officer at his head taking on such a role emphasised the fact that although officers had attended the PST training key points had not been retained. Greater emphasis on this role in training would be beneficial in reducing the risk to prisoners being restrained; Assessment criteria for the new PPST includes a requirement that officers must be able to demonstrate to trainers the correct response to a person experiencing ABD. This includes the appropriate use of a Safety Officer. The requirement for the use of a Safety Officer is also a learning outcome for all multi-officer restraints within the PPST programme. From April 2024, the College of Policing will be conducting a quality assurance process and will undertake licence moderation visits to ensure that forces comply with the new national standards. 4. Many of the officers who gave evidence indicated that they believed that Mr Moura was feigning his lack of responsiveness. This was despite the fact that there was very limited evidence of officers carrying out the recognised AVPU checks. Officers relied on their own perceptions rather than AVPU. An officer who did carry out AVPU did not clearly share his lack of responsiveness with other officers. The Inquest heard that there is no formal training on what officers should do if they believe a prisoner under arrest is feigning unresponsiveness. Clarification and enforcement of the need for objective use of AVPU may well prevent subjective assessments leading to erroneous and potentially fatal conclusions that a prisoner is feigning lack of responsiveness; The College guidance does not support any change in approach where officers may believe that someone is feigning a lack of responsiveness. All ABD guidance is focused on how to treat the displayed symptoms and should be followed regardless of any suspicions that symptoms are feigned. The new PPST training implementation went live in 2023 and forces are required to have implemented or be in the process of implementation by April 2024. The revised ABD training package will be published mid-September 2023. I hope this helps to answer the points that were raised but if we can assist with anything further, please do not hesitate to contact me. Yours sincerely Head of Delivery – Uniformed Policing College of Policing
Alison Mutch OBE
HM Senior Coroner
Coroners Court
1 Mount Tabour Street
Stockport
SK1 3AG
Date: 14th September 2023
Dear Ms Mutch,
Regulation 28 Report – Mr Andre Moura
I write on behalf of the National Police Chiefs Council (NPCC) 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, in relation to the prevention of future deaths report sent via email to the NPCC
dated 10th July 2023.
The notice sets out concerns that arose from the information received during the inquest into the
death of Mr Moura which occurred in July 2018. I am very sorry to read of the circumstances of
Andre’s death. My sympathies are with his family and friends, and I share your commitment to
addressing the issues you have highlighted.
I note you set out five areas of concern, four of which focus on College of Policing Personal Safety
Training, with particular focus on Acute Behaviour Disturbance (ABD). I am aware the College of
Policing have written to you separately to address these points and have shared the timeframes for
implementation of new Public and Personal Safety Training and revised ABD training.
In relation to point 5, we are in the process of re-writing and revising the NPCC Body Worn Video
(BWV) guidance and it has been agreed that we would include that BWV should be left running during
periods of prisoner transport, due to the vulnerability of officers and subjects during that process, and
to provide a documented account of that journey. This guidance will be published in October, and I
share the relevant draft wording below:
“Recent national events and feedback from HM Coroner have identified vulnerability when
transporting prisoners/subjects to custody centres or places of safety. All transporting and escorting
officers should have their BWV activated during this journey as a record of that journey and any
1st Floor, 10 Victoria Street, London SW1H 0NN | 0203 276 3796 | www.npcc.police.uk
incidents that occurred within. Any decision made not to record a journey should be strongly justified
on their camera prior to stopping recording.
This is to include any transport within vehicles that may have a separate camera system within them,
such as caged vans, as there may be limitations to some of these systems, such as no audio and a short
retention period that means footage may be auto deleted before its requirement is known. Forces
should check who manages the data from these camera systems and how long footage is stored for,
and ensure that between the use of BWV and in-vehicle solutions, that a journey is covered by
both/either, and data can be accessed and processed efficiently.”
I hope that the information that has been provided goes some way to reassure you that the matters
of concern you have raised have been addressed and will be subject to continual review.
For any further information please contact my Staff Officer
who will be happy to address any concerns and answer any questions.
Yours sincerely,
Chair, National Police Chiefs’ Council
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