Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0079, written 12 Feb 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 Feb 2024 |
|---|---|
| Reference | 2024-0079 |
| Deceased | Mouayed Bashir |
| Coroner | Caroline Saunders |
| Coroner area | Gwent |
| Category | Alcohol, drug and medication related deaths · Wales prevention of future deaths reports (2019 onwards) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulations 28 and 29 of the Coroners’ (Investigations) Regulations 2013 REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 1 2 3 THIS REPORT IS BEING SENT TO: The Chief Constable of Gwent Police. CORONER I am Caroline Saunders, Senior Coroner for the Area of Gwent 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 INVESTIGATION AND INQUEST On 25/02/2021, an investigation was opened touching upon the death of Mouayed Mamoun Bashir. The investigation concluded at the end of the inquest on 02/02/2024. The conclusion of the inquest was recorded as a narrative conclusion in the following terms: On the 17th February 2021, Mouayed Mamoun Bashir took an unknown quantity of cocaine. This resulted in him developing symptoms in keeping with Acute Behavioural Disturbance (ABD). Mouayed barricaded himself in his bedroom and was heard banging, shouting and breaking objects. At 08:50, Mouayed’s family were concerned for his welfare and proceeded to contact emergency services. At 09:01 the first police officer arrived and informed the control room that the ambulance was required. Gaining entry Mouayed was agitated, police officers restrained him for his own safety and for the safety of others. We believe from the evidence we heard that there was insufficient knowledge and understanding around identifying some of the signs of Acute Behavioural Disturbance. Throughout, Mouayed’s condition was deteriorating, police officers and family continued to update the ambulance service. An ambulance arrived at 10:04. The priority was to transfer Mouayed to hospital, but it was difficult to manoeuvre him out of the house. Shortly after he was transferred into the ambulance at 10:37, Mouayed went into cardiac arrest. Police and paramedics commenced cardiopulmonary resuscitation (CPR) and conveyed Mouayed to the Grange University Hospital, Llanfrechfa, where the clinicians continued to attempt to revive Mouayed. Sadly, they were unsuccessful and Mouayed died at 11:41 on 17/02/2021. In conclusion, Mouayed’s death was caused by cocaine intoxication, this was contributed to by the effects of ABD following a period of restraint. The medical cause of death was: 1a) Intoxication with cocaine and the effects of cocaine, following a period of restraint. 4 CIRCUMSTANCES OF THE DEATH The circumstances of Mouayed’s death are best described in the narrative conclusion. As you can see the jury have referenced the police’s knowledge of ABD in their conclusion. 5 CORONER’S CONCERNS The MATTERS OF CONCERN are as follows: - At the inquest all the police officers who attended MB gave evidence and they all stated under oath that they did not consider that MB was suffering from ABD at the time. However, when completing the Use of Force forms afterwards, all bar one of the officers involved in restraint indicated that ABD had been an impact factor. There is an ambiguity which could not be properly explored at the inquest, largely due to the passage of time. However, this suggests that officers may have thought about ABD but did not mention it to others, which would be contrary to the “Speak Up and Speak Out” principle. This is a principle, the inquest heard, that is critical to ensuing that the voices of junior officers are heard in these difficult and potentially life-threatening situations. 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. I should be grateful if the following information be provided to me: Confirmation as to whether the training on ABD has been reviewed and the principle of “Speak Up and Speak Out” enshrined therein, reflecting the acknowledged difficulties in identifying ABD even by experienced officers. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely 08 April 2024. I, the Coroner, may extend this 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 necessary. COPIES AND PUBLICATION 8 I have sent a copy of my report to the Chief Coroner and the following Interested Person(s) • The family of Mouayed Mamoun Bashir • Welsh Ambulance Trust • • IOPC 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 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. DATE 12/02/2024 9 Signed: Caroline Saunders His Majesty’s Senior Coroner for the Area of Gwent.
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.
Pencadlys Heddlu Gwent Police Headquarters
Parc Ffordd Llantarnam / Llantarnam Park Way
Llantarnam
CWMBRÂN
Torfaen
NP44 3FW
Ms Caroline Saunders
HM Senior Coroner for the area of Gwent
Civic Centre
Godfrey Road
Newport
NP20 4UR
8th April 2024
Dear Ms Saunders
Re: Response to the Regulation 28 Report to Prevent Future Deaths
Inquest touching upon the Death of Mr Mouayed Bashir
I am the Deputy Chief Constable of Gwent Police and I write of behalf of the Chief
Constable to respond to the Report to Prevent Future Deaths issued under Regulation
28 of the Coroner’s (Investigations) Regulations 2013, following the tragic death of Mr
Mouayed Bashir on 17 February 2021.
May I also to take this opportunity to reaffirm the comments I made at the conclusion
of the Inquest on behalf of Gwent Police to extend my sympathies to the Mr Bashir
family for the loss of their loved one.
Turning to our response, for ease of reference, I have repeated below the
information you have requested be provided to you: -
“Confirmation as to whether the training on ABD has been reviewed and the
principle of “Speak Up and Speak Out” enshrined therein, reflecting the
acknowledged difficulties in identifying ABD even by experienced officers.”
I confirm that the national training for all police officers on Acute Behavioural
Disturbance (ABD) has been reviewed. The College of Policing has introduced a new
learning package, specifically on ABD. The training package consists of an ABD
PowerPoint which has been uploaded onto the “College Learn” system and made
available to police officers and relevant police staff officers from on 14 February 2024.
I have attached the training package consisting of Power Point Presentation and
accompanying Training Notes, which you will see is extensive. I confirm that training
package this has been incorporated into the mandatory Public and Personal Safety
Training programme and First Aid Training. This in effect means that from 14 February
2024 all officers and relevant police staff will have access to important updated
training.
In addition, as from 3 April 2024 onwards, in Gwent Police all frontline police officers
who have only recently completed their mandatory Public and Personal Safety
Training and First Aid Training will receive bespoke standalone specific ABD training
using the College of Policing Power Point.
The training as a whole fully reflects the acknowledged difficulties in identifying ABD
even by experienced officers. The combination of slide 11 and the accompanying
training notes evidence that the principle of “Speak Up and Speak Out” is enshrined
in ABD training.
In this regard, may I draw your attention to Slide 11 in the Power Point. In this slide,
under the heading “Restraint Considerations” there are the following bullet points: -
(cid:131) Where practicable avoid restraint.
(cid:131) Where practicable use a Safety Officer/s to monitor the subject.
(cid:131) Avoid any position that restricts breathing.
(cid:131) As soon as possible, sit person up or allow person to find most comfortable
position.
(cid:131) All “speak up and speak out” if concerned.
The last point is emboldened and in red so that it is clearly emphasized to all officers.
In addition, the accompanying training notes state: -
“Any person involved in the restraint irrespective of rank, role, or length of
service should speak up and speak out if they identify any issue or concern
in regard to the wellbeing of the person. Other officers may be too focused on
what they are doing and might inadvertently miss key signs.”
I hope that this response addresses the concerns that you set out in your report, and
I am grateful to for you bringing them to our attention.
Yours sincerely
Deputy Chief Constable
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