Samuel Curless

Anna Morris 
HM Assistant Coroner 
Greater Manchester South area 

15 April 2024 

Dear Assistant Coroner Anna Morris 

I am writing in response to your Regulation 28 report following the investigation and inquest into 
the tragic circumstances of the death of Samuel (Sam) Curless on the 24th October 2022. 

I can confirm that the College of Policing have liaised with Greater Manchester Police and are 
aware of the actions they have subsequently taken in response to the concerns raised in your 
report. 

I would like to update you regarding your concern at point 2 and point 4 in your report as 
follows: 

•  There was evidence given to me by Detective Superintendent 

that there is an 

unknown number of GMP officers who are not meeting the expectation of receiving First 
Aid refresher training within 12 months, which since May 2022 has included training on 
how to resuscitate a hanging casualty. I am therefore concerned that there remains a 
cohort of officers who have not had the post May 2022 training that includes how to 
provide Basic Life Support to this kind of casualty until the arrival of an ambulance. 
•  That the training delivered to the first two attending officers did not adequately prepare 
them for responding to a scene where someone is found hanging in a way which is 
consistent with their priority to preserve life of a hanging casualty. 

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 In 2020, the College of Policing commenced a national working group to review the First Aid 
Learning Programme (FALP). The review engaged and consulted with police clinical subject 
matter experts and input from clinical governance leads in forces, in addition to 
recommendations made by Coroners, the Independent Office for Police Conduct and the 
Manchester Arena Inquiry.  The FALP has now been published with a focus on casualty care, 
preserving life and providing police officers and staff with the first aid skills required as first 
responders. 

The FALP is not a scenario based curriculum. None of the high-level learning outcomes in the 
FALP modules are situation specific.  Police officers respond to varying incidents and the FALP 
has been developed to provide them with the required specific first aid skills for first responders. 

Police officers are required to follow their FALP training in all cases. 

The FALP does include learning outcomes for basic life support, including CPR, and performing 
manual airway techniques. 

Annual refresher training is a core requirement of the FALP licence, and as a result of the above 
mentioned review, the recommended training time for both refresher and initial training has 
been increased for all public facing officers. 

It has increased from four hours to six hours for annual refresher and nine hours to twelve hours 
for initial training. 

I hope this offers you reassurance with regards to your concerns raised in your report. 

Yours sincerely 

Chief Executive Officer 
College of Policing 

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Chief Constable

Anna Morris KC
HM Assistant Coroner
Coroner for Greater Manchester South

9" April 2024

Dear Ms Morris

Thank you for your report dated 19" February 2024 in respect of the death of Samuel Curless
and pursuant to Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 and
Paragraph 7, Schedule 5, of the Coroners and Justice Act 2009.

Having carefully considered your report and the evidence provided at the inquest | make the
following observations and recommendations to address your matters of concern.

1. That in respect of GMP Call Handlers being required to call an ambulance to attend
the scene, even where it is reported that someone is “dead” there has been no
institutional learning following this incident. | asked QE if there had been
any learning, reflection or training since this incident. He said that there hadn’t on
this issue.

As a result of the issues identified in this case GMP commissioned an audit of 33 similar incidents.
The purpose of the audit was to understand whether call handlers were following the correct
processes and taking the required action when dealing with these types of incidents or whether
the issue identified in this case was a symptom of a broader issue across the department. The
result of the audit identified one case where the call handler hadn't contacted the Northwest
Ambulance Service (NWAS) or asked a colleague to assist in making a call to NWAS. The call
handler in question has received individual feedback on the issue. The other 32 calls examined
each resulted in call handlers either asking colleagues to call NWAS or the call handler calling
NWAS themselves when the initial call had concluded.

When dealing with calls of this nature the expectation is that the call handler will stay on the line
with the person reporting the incident to gather the correct information to create and update the
incident log to accurately reflect the incident and record the actions taken. Call handlers will
normally seek assistance from colleagues in the control room or within the dispatch area to call
an ambulance via the Ambulance Emergency lines that are dedicated to the police for such
instances.

Due to the nature of calls received by GMP there will be instances of call handlers being able to
call the NWAS directly once they have gathered all the relevant information and assessed that
they are then able to make that call. The process is not prescriptive, call handlers are trained in
THRIVE (threat, harm, risk, investigation, vulnerability and engagement) and in line with that
training they will assess whether they are able to make the call to NWAS themselves, or whether
they are required to continue with the call and request assistance from colleagues and supervisors
to contact NWAS.

Postal address: Greater Manchester Police, Openshaw Complex, Lawton Street, Openshaw, Manchester M11 2NS

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Cont.d pg 2

All Call Handlers receive training in respect of what action to take when dealing with death and
the trainers thread the relevant processes throughout the training course, referring students to
the service standards expected of them. The service standards are available via the internal IT
solution called SHERLOCK which can be accessed by call handlers at any time.

While the result of the audit undertaken following the inquest doesn’t indicate a broader issue
across the branch, the Force Contact, Crime and Operations Branch will further reinforce the
requirements on call handlers to call an ambulance when faced with a scenario such as that which
presented in the case of Mr Curless. This will be achieved by way of an email being sent to all
call handlers and by including an item on each call handling team’s briefing site.

2. That the training delivered to the first two attending officers did not adequately
prepare them for responding to a scene where someone is found hanging in a way
which is consistent with their priority to preserve life of a hanging casualty.

GMP’s Police Education Qualifications Framework (PEQF) Learning Support Team has reviewed
the training provided to student officers in relation to the Dealing with Death Procedure.

All student officers receive a bespoke presentation on the Dealing with Death Procedure. In
advance of the session officers are required to complete pre-reading which includes College of
Policing Guidance, a Dealing with Death aide memoir, relevant handouts, and a copy of the
Dealing with Death procedure.

The lesson plan for the subject is detailed and addresses the different types of death that police
officers can expect to encounter during their service which includes deaths caused by hanging.

Trainers delivering the course emphasise that unless a person is clearly deceased, i.e. the head
is separated from the body, insect infestation or the body has been underwater for a long period
of time, offices should check for signs of life and take relevant action, including calling paramedics
who are able to pronounce life extinct.

The training details the ‘five building blocks’ that officers must apply and adhere to in the event of
a death. The number one building block that is always to be addressed first is preservation of life.
Preservation of the scene is subordinate to the requirement to preserve life. The training
addresses the fact that bodies may appear to be deceased when they are in fact not and officers
must always check for signs of life even when they may believe that the person is dead. The
training provides several examples of cases where bodies had not been checked assuming death
and were later found to be alive.

To support the implementation of this learning, dealing with death has been presented at GMP’s
monthy Tutor Constable Forum to support those who tutor students on District whilst responding
to incidents. Finally, our training Sergeants undertake periodical in-class observations to quality
assure both the training content and that the delivery is in line with best practice.

Postal address: Greater Manchester Police, Openshaw Complex, Lawton Street, Openshaw, Manchester M11 2NS

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Cont.d pg 2

All Call Handlers receive training in respect of what action to take when dealing with death and
the trainers thread the relevant processes throughout the training course, referring students to
the service standards expected of them. The service standards are available via the internal IT
solution called SHERLOCK which can be accessed by call handlers at any time.

While the result of the audit undertaken following the inquest doesn't indicate a broader issue
across the branch, the Force Contact, Crime and Operations Branch will further reinforce the
requirements on call handlers to call an ambulance when faced with a scenario such as that which
presented in the case of Mr Curless. This will be achieved by way of an email being sent to all
call handlers and by including an item on each call handling team’s briefing site.

2. That the training delivered to the first two attending officers did not adequately
prepare them for responding to a scene where someone is found hanging in a way
which is consistent with their priority to preserve life of a hanging casualty.

GMP'’s Police Education Qualifications Framework (PEQF) Learning Support Team has reviewed
the training provided to student officers in relation to the Dealing with Death Procedure.

All student officers receive a bespoke presentation on the Dealing with Death Procedure. In
advance of the session officers are required to complete pre-reading which includes College of
Policing Guidance, a Dealing with Death aide memoir, relevant handouts, and a copy of the
Dealing with Death procedure.

The lesson plan for the subject is detailed and addresses the different types of death that police
officers can expect to encounter during their service which includes deaths caused by hanging.

Trainers delivering the course emphasise that unless a person is clearly deceased, i.e. the head
is separated from the body, insect infestation or the body has been underwater for a long period
of time, offices should check for signs of life and take relevant action, including calling paramedics
who are able to pronounce life extinct.

The training details the ‘five building blocks’ that officers must apply and adhere to in the event of
a death. The number one building block that is always to be addressed first is preservation of life.
Preservation of the scene is subordinate to the requirement to preserve life. The training
addresses the fact that bodies may appear to be deceased when they are in fact not and officers
must always check for signs of life even when they may believe that the person is dead. The
training provides several examples of cases where bodies had not been checked assuming death
and were later found to be alive.

To support the implementation of this learning, dealing with death has been presented at GMP’s
monthy Tutor Constable Forum to support those who tutor students on District whilst responding
to incidents. Finally, our training Sergeants undertake periodical in-class observations to quality
assure both the training content and that the delivery is in line with best practice.

Postal address: Greater Manchester Police, Openshaw Complex, Lawton Street, Openshaw, Manchester M11 2NS

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Cont.d pg 3

This case has also been raised at the Tactical Organisational Learning Board (TOLB). The TOLB
is attended by representatives from across GMP with a view to sharing the learning and
reinforcing the key messages around preservation of life.

3. | heard evidence from Detective Superintendent HM that both attending officers
were part of a cohort of at least 650 officers within GMP (and a larger cohort
nationally) who received their initial police training entirely online. | am concerned
that both officers’ training on Sudden Death (and the training of others) was delivered
as one of over 15 online modules on a given day and that at the time of the inquest,
they had not received any classroom based or on the job training. | am concerned
that they are not the only officers within GMP who have received this level/method of
training input and therefore there is a risk that other officers on duty have inadequate
training on this issue.

A total of 650 student officers, across nine intakes, received online training between March 2020
and May 2021. The necessity to train officers online during this period was a direct consequence
of the COVID-19 pandemic and the public health measures prescribed by the Government in
response.

An additional 270 student officers, across four intakes, received a combination of online and in-
person training between July 2020 and August 2021. The hybrid nature of the training provided
to this cohort of officers reflected changes to the COVID-19 restrictions in place throughout the
officers’ training period.

In person training resumed in September 2021 for all subsequent student officer intakes.

The training provided to officers throughout the pandemic was delivered in line with College of
Policing guidance and licensing conditions and the online format provided by GMP reflected the
approach taken by Police Forces nationally to ensure officers could continue to be trained while
COVID-19 social distancing restrictions were in place.

While the officers’ actions in this case have given rise to questions in relation to the adequacy of
the training delivered via online methods there is nothing to suggest that this is a broader Force-
wide issue. However, in line with normal practice, the learning arising from the inquest has been
raised at the TOLB to ensure that learning is shared, and key messages are disseminated across
the force.

To further reinforce police officer and staff understanding of the Dealing with Death Policy and
the expected actions of those at the scene | have tasked the Organisational Learning Hub to
disseminate learning across the Force, using a variety of established communications channels,
which will include the following:

e Publication of a leading article on the intranet. All officers and staff have access to this site
and are able to read the article.

Postal address: Greater Manchester Police, Openshaw Complex, Lawton Street, Openshaw, Manchester M11 2NS

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Cont.d pg 4

e Including the information in the Organisational Learning Monthly Top Three Bulletin which
is e-mailed to every police officer and member of police staff member in GMP.

e Input at the Tactical Organisational Learning Meeting which includes a representative from
all districts, operational branches, People and Development Branch and other Subject
Matter Experts.

e Circulation to Organisational Learning Lead Officers and Deputy Organisational Learning
Lead Officers across the Force to ensure the messages are reinforced at a local level.

4. There was evidence given to me by Detective Superintendent that there is an
unknown number of GMP officers who are not meeting the expectation of receiving
First Aid refresher training within 12 months, which since May 2022 has included
training on how to resuscitate a hanging casualty. | am therefore concerned that there
remains a cohort of officers who have not had the post May 2022 training that
includes how to provide Basic Life Support to this kind of casualty until the arrival of
an ambulance.

All police officers receive the policing equivalent of the Health and Safety Executive's Emergency
First Aid at Work (EFAW) training certificate. This is known across all police forces as the ‘Module
1 & 2 First Aid’ training course and is derived from the College of Policing First Aid Learning
Programme (FALP) syllabus.

The FALP is split into 5 modules, with modules 1 and 2 being a universal requirement for all police
officers. Officers can go on to receive further first aid training depending on their role. Module 3
is specific training for those working in custody, Module 4 is the HSE First-Aid at Work training
and Module 5 covers enhanced training for those operating as firearms officers or police medics.
In the present case the officers who attended the scene would have been trained to Modules 1 &
2 (EFAW) level.

Basic Life Support (BLS) is taught at every level of first-aid training on both the initial and annual
refresher training. BLS is covered during the ‘no signs of life’ session and officers are taught that
first aid begins with the first opportunity they have to assess a casualty, in whatever circumstances
they are presented with which may include a suicide attempt, water rescue or any other incident
- BLS should then commence.

GMP uses the FALP as the core syllabus for its first aid training but in addition to the core syllabus
supplementary elements or scenarios are incorporated into the training based upon operational
risks and/or learning derived from incidents that have occurred in Greater Manchester or
nationally. From April 2022 one of the supplementary elements GMP introduced into the Module
1 and 2 initial and refresher training courses was ligature removal. This training will continue in
place moving forward.

In July 2023 GMP also introduced a ligature removal tool in every liveried police vehicle. To
ensure the tool remains available for use the presence of the tool in the vehicle forms part of the

Postal address: Greater Manchester Police, Openshaw Complex, Lawton Street, Openshaw, Manchester M11 2NS

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Cont.d pg 5

weekly vehicle checks. Alongside the introduction of this tool an instructional video was placed
on GMP'’s intranet that provided guidance on how to use the tool. The video remains accessible
on GMP’s Learning and Skills Hub which is a resource available to all police officers and staff.

The ligature removal tools were also provided to GMP’s First Aid training providers for
demonstration and use during first aid training for Modules 1 & 2. There are discussions underway
to further demonstrate this item of equipment within Police Personal Safety Training.

It is worthy of note that it is not a requirement of FALP Modules 1 & 2 for officers to be trained in
the use of a ligature removal tool. It is only at Module 3 of FALP that this training becomes
mandatory.

From May 2022 Module 1 & 2 training has been delivered in GMP on a 2-day initial course with a
1-day annual refresher requirement thereafter. Officers who fail to complete the 1-day refresher
training within a year of their initial training, and who therefore lapse in their EFAW compliance,
must begin the training cycle again by attending the 2-day initial training.

Prior to May 2022 Module 1 & 2 training was a blended learning approach consisting of 6-hour
contact training time and 3 hours e-learning. (Equating to 9 hours training each year as derived
from the previous version of the FALP).

The change to the delivery of first aid training in May 2022 brought with it a resource management
challenge with Districts balancing the amended training requirements with the need to maintain
safe staffing levels. This initially led to a larger number of officers failing to meet the annual
refresher requirement. There have been significant improvements with compliance over the last
two years as the training cycle has matured.

GMP has also improved the governance around first aid training to ensure that officers remain up
to date with their training requirements. The numbers are monitored by People & Development
Branch Learning Services Team and reported to the Clinical Governance Panel. Attendance data
is shared with GMP Districts and Branches on a regular basis, including individual officer details
and course booking dates. In addition, First Aid Training is a standing item at GMP’s monthly
Major Incident Response Governance Board (MIRGB) meeting which is chaired by the Deputy
Chief Constable (DCC). At the monthly meeting the DCC holds Districts and Branches to account
in respect of their compliance with the first aid training requirements. First Aid training will remain
a focus of the MIRGB moving forward.

| hope this response is helpful and demonstrates GMP’s commitment to learning from the tragic
death of Mr Curless.

Yours sincg¢ri

Postal address: Greater Manchester Police, Openshaw Complex, Lawton Street, Openshaw, Manchester M11 2NS

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