Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0408, written 25 Oct 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 25 Oct 2023 |
|---|---|
| Reference | 2023-0408 |
| Deceased | Carl Fullalove |
| Coroner | Jacqueline Devonish |
| Coroner area | Cheshire |
| Category | Other 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 DEATHS THIS REPORT IS BEING SENT TO: , Chair of National Police Chiefs Council , CEO College of Policing 1 CORONER I am Jacqueline DEVONISH, Senior Coroner for the coroner area of Cheshire 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 04 January 2016 I commenced an investigation into the death of Carl FULLALOVE aged 29. The investigation concluded at the end of the inquest on 11 October 2023. The conclusion of the inquest was that: Narrative Conclusion - On the night of 13 December 2015 at 00:12, Carl Fullalove was witnessed jumping on cars by residents of Melverley Drive. Officers arrived to find Carl leaning against a wall with a calm demeanour although his conversations led officers to believe he was under the influence of a substance. Signs of ABD were not present to officers for them to have considered Carl a medical emergency as he could walk and talk and did not otherwise appear unwell. All available information to the officers was passed to control and subsequently custody suite so an FME was not requested on standby. Carl was adequately assessed by all within the custody suite and within cell 9. Prone restraint in cell was necessary and justified however it is felt that it did contribute to the death of Carl negligibly on the balance of probabilities. 4 CIRCUMSTANCES OF THE DEATH On the night of 13 December 2015 at 00:12 Carl Fullalove came to his death: i. He was observed jumping on cars in Melverley Drive at 00:12. This caused local residents to call the police. ii. Carl was shouting about dogs and behaving bizarrely. iii. Carl was under the influence of a substance. iv. Carl was handcuffed, arrested and taken into police custody where he was placed in cell 9 in Blacon Custody Suite. v. Carl was placed in prone restraint onto a mattress to enable disrobing and a search to be carried out. During this, he was found to be non-responsive and suffering from cardiac arrest by the FME. vi. The ambulance arrived and took Carl to the Countess of Chester Hospital having secured Regulation 28 – After Inquest Document Template Updated 30/07/2021 a return of spontaneous circulation. vii. He subsequently died on 14 December 2015 at 14:13 hours. 5 CORONER’S CONCERNS During the course of the investigation my inquiries 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)Whilst the jury did not make any finding of acute behavioural disturbance (ABD) in this case, much evidence was heard about the training in identification of the signs and symptoms. National training of police officers on the identification of ABD is focused on a triad of warning flags being, hot to touch, exhibiting constant or near constant activity and extreme agitation or aggression. Some evidence identified that Carl Fullalove did not exhibit these triad symptoms but did exhibit other nuanced symptoms in the long list delivered in training. It was evident that his symptoms were not recognised as ABD due to drug intoxication, and that the consequential risks associated with prone restraint were not therefore considered. Prone restraint ultimately led to his death. There were six experts providing evidence to the inquest two of whom identified that Carl would not have died had he been recognised as unwell at the point of arrest and assessed by a health care practitioner. Such attention would have provided a calming intervention for his heart rate and breathing prior to being placed in prone restraint, which exerted additional pressure on his ability to breath freely. (2)A research paper before the inquest, namely ‘Consensus on Acute Behavioural Disturbance in the UK, September 2023 recommends that the focus remain on the triad of warning signs. ABD is clearly difficult to distinguish from drug intoxication by a non-medical practitioner. The rigidity of the training with focus on specific symptoms can cause police officers to miss other signs. The Superintendent, and head of ‘Protecting Vulnerable People’ for Cheshire accepted that with hindsight the use of prone restraint was inadvisable in this case. (3)Significant training on ABD had been delivered by Cheshire Constabulary through the College of Policing Personal Safety Training package module, the key to which was to identify an underlying medical condition to refer to a health care practitioner. That may be a lot to expect of police officers in a dynamic fast paced setting. The use of the term ABD may be a distraction. (4)The effect of stimulant drugs and the need for calming de-escalation in an upright position, rather than prone restraint, had not been noted in either the training material or the research paper presented to the Court. This is on the background of recognising from College of Policing guidance that a high percentage of deaths in prone restraint are in drug related cases. (5)The First Aid Learning Programme (FALP) will be in place within Forces by April 2024 and includes amongst other things positional asphyxia, unconscious and not breathing, and ABD but does not mention training in calming intervention that on balance of probabilities may have led to a different outcome in this case. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. 7 YOUR RESPONSE Regulation 28 – After Inquest Document Template Updated 30/07/2021 You are under a duty to respond to this report within 56 days of the date of this report, namely by December 12, 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 Carl Fullalove’s parents Cheshire Constabulary I have also sent it to The Rt Hon Chris Philp MP, Minister for Policing, UK Parliament who may find it useful or of interest. 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 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 by the Chief Coroner. 9 Dated: 25/10/2023 Jacqueline DEVONISH Senior Coroner for Cheshire Regulation 28 – After Inquest Document Template Updated 30/07/2021
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.
Jacqueline Devonish
HM Senior Coroner for Cheshire
Coroner’s Office
St James Business Centre
Warrington
WA4 6PS
11 December 2023
Ref: Regulation 28 report into the death of Carl Fullalove
Dear HM Senior Coroner Jacqueline Devonish
We write in response to your Regulation 28 report following the investigation and inquest into the tragic
circumstances of the death of Carl Fullalove on the 13th December 2015.
We hope to answer the concerns you raised that are listed within section 5 of your report, which are
listed as follows:
(1) Whilst the jury did not make any finding of acute behavioural disturbance (ABD) in this
case, much evidence was heard about the training in identification of the signs and
symptoms. National training of police officers on the identification of ABD is focused on a
triad of warning flags being, hot to touch, exhibiting constant or near constant activity and
extreme agitation or aggression. Some evidence identified that Carl Fullalove did not exhibit
these triad symptoms but did exhibit other nuanced symptoms in the long list delivered in
training. It was evident that his symptoms were not recognised as ABD due to drug
intoxication, and that the consequential risks associated with prone restraint were not
therefore considered. Prone restraint ultimately led to his death. There were six experts
providing evidence to the inquest two of whom identified that Carl would not have died had
he been recognised as unwell at the point of arrest and assessed by a health care
practitioner. Such attention would have provided a calming intervention for his heart rate and
breathing prior to being placed in prone restraint, which exerted additional pressure on his
ability to breath freely.
In 2020, the College of Policing commenced a national working group to update the First Aid Learning
Programme (FALP). The review that took place considered recommendations made by Coroners and
the IOPC, including the detail of learning outcomes on Acute Behavioural Disturbance (ABD). The FALP
has now been published and includes a revised learning outcome “recognise the signs and symptoms of
acute behavioural disturbance”.
The College of Policing have designed and developed a new Public and Personal Safety Training
(PPST) package for all police officers with the emphasis on de-escalation. It is twelve hours, scenario-
based method of delivering training and is focused on learning, decision making, understanding
decisions and de-briefing decisions. Some forces have already implemented the new training package,
and all forces are to go live with this training in April 2024. From the evaluation of the training pilot, early,
statistically significant data shows a reduction in police use of force incidents. The updated training will
include a recently updated training package for ABD. The new ABD training includes an understanding
of the signs, symptoms and possible causes of ABD, management of the incident with the focus now
being on de-escalation, ‘contain rather than restrain’, whilst highlighting the risks of restraint where
officers suspect a person to be experiencing ABD. There is an emphasis within the training that ABD can
present in many ways and to always treat ABD as a medical emergency, seeking immediate, medical
assistance.
(2)A research paper before the inquest, namely ‘Consensus on Acute Behavioural
Disturbance in the UK, September 2023 recommends that the focus remain on the triad of
warning signs. ABD is clearly difficult to distinguish from drug intoxication by a non-medical
practitioner. The rigidity of the training with focus on specific symptoms can cause police
officers to miss other signs. The Superintendent, and head of ‘Protecting Vulnerable People’
for Cheshire accepted that with hindsight the use of prone restraint was inadvisable in this
case.
The College of Policing have recently updated their training package for ABD with the emphasis being
on the different ways that ABD can present, including confused behaviour and incoherent speech. The
training also covers the different, possible causes of ABD, including medical conditions and intoxication
through drink or drugs.
(3) Significant training on ABD had been delivered by Cheshire Constabulary through the
College of Policing Personal Safety Training package module, the key to which was to
identify an underlying medical condition to refer to a health care practitioner. That may be a
lot to expect of police officers in a dynamic fast paced setting. The use of the term ABD may
be a distraction.
Assessment criteria for the new ABD training included within the new PPST includes a requirement that
officers must be able to demonstrate to trainers the correct response to a person experiencing ABD and
to provide details of the actual symptoms being displayed, not to attempt to diagnose ABD to medical
professionals. Whilst knowledge of underlying medical conditions may be helpful, the emphasis is on
continuous monitoring of a person’s condition and relaying this current information to ambulance or
medical professionals.
(4) The effect of stimulant drugs and the need for calming de-escalation in an upright
position, rather than prone restraint, had not been noted in either the training material or the
research paper presented to the Court. This is on the background of recognising from
College of Policing guidance that a high percentage of deaths in prone restraint are in drug
related cases. (5) The First Aid Learning Programme (FALP) will be in place within Forces by
April 2024 and includes amongst other things positional asphyxia, unconscious and not
breathing, and ABD but does not mention training in calming intervention that on balance of
probabilities may have led to a different outcome in this case.
The recently updated College of Policing ABD training package includes specific reference to:
• Providing reassurance.
• Talking to the person calmly.
• Avoid restraint.
The methodology of training delivery of the new PPST is a scenario based, intermittent style of training
whereby the trainers will stop the scenario and the officers will be asked to provide their understanding of
the legislation, the risks and ask the officers to provide their rationale for their decisions. It is a coaching
style of training that focuses on learning and knowledge retention rather than the previous training style
of teaching of tactics.
We hope this helps to answer the points that were raised but if we can assist with anything further,
please do not hesitate to contact us.
Yours sincerely
Chief Executive Officer
College of Policing
Chair
National Police Chiefs’ Council (NPCC)
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