Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0176, written 27 Mar 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 27 Mar 2024 |
|---|---|
| Reference | 2024-0176 |
| Deceased | Matthew Terrill |
| Coroner | Alexandra Poutney |
| Coroner area | South Yorkshire (West) |
| Category | Alcohol, drug and medication 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.
ANNEX A
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
NOTE: This form is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. The Chief Constable, South Yorkshire Police Headquarters,
Carbrook House, 5 Carbrook Hall Road, Sheffield, S9 2EH
1 CORONER
I am Alexandra Pountney, Assistant Coroner, for the coroner area of South
Yorkshire (West District)
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 30 April 2020 an investigation was commenced into the death of Matthew
Terrill. An inquest started on 19 February 2024 and concluded on 8 March 2024.
The cause of death was:
1(a) Cardiorespiratory arrest.
1(b) Hypoxic ischemic brain injury.
1(c) Cocaine,
(synthetic
cannabinoids), heroin, pregabalin, gabapentin and dihydrocodeine toxicity (with
associated acute agitation), and ischemic heart disease.
4 CIRCUMSTANCES OF THE DEATH
On 22 April 2020, Matthew Terrill was taken into custody at Shepcote Lane
Custody Suite, Sheffield by officers from South Yorkshire Police who had
arrested him in the community.
1
At the time of his arrest, Matthew was intoxicated by drugs (including,
Cocaine,
(synthetic
cannabinoids), heroin, pregabalin, gabapentin and dihydrocodeine).
An ambulance was called by officers in the community at 11.27am and
cancelled at 11.43am. Matthew arrived at Shepcote Custody Suite at 11.56am.
There is an attempted booking in procedure for Matthew between
approximately 11.57am and 12.05pm, during which time Matthew was
exhibiting behaviour of drug intoxication, possibly combined with acute
mental health symptoms, and ultimately required restraint by officers.
Matthew was restrained and escorted to a cell before he was assessed by
healthcare professionals stationed at Shepcote Lane, of which there were two
on shift and available. Healthcare professionals were unable to assess Matthew
in his cell during the restraint by officers, which lasted for approximately 11
minutes. Matthew was then put on level 4 constant observations with two
police officers (including the arresting officer) assigned to him. This period of
observation lasted roughly between 12.16pm and 13.28pm, when it was noted
that Matthew was no longer breathing. No further medical assessment was
carried out during the period of observation. The evidence before the Court
was that the officers assigned to constant observations had limited experience
of carrying out the task and had not been briefed by the custody sergeant.
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 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. Lack of training in the First Aid or Personal Safety courses for
police officers in relation to recognising the signs and symptoms of
drug intoxication. Specifically, how to recognise a drug overdose or
the ill-effects of drug intoxication, and when it is appropriate for a
detainee to be taken to hospital.
I have been told that officers routinely come across persons who are
intoxicated through drugs, and that officers are routinely expected to risk
assess these persons and decide whether to transport to hospital or
custody. Without proper guidance in place for the officers, I am
concerned about the risk of future death to persons who are intoxicated
by drugs and requiring hospital treatment.
I note the circulation of the ‘Patient or Prisoner’ cards, but these do not
include reference to intoxication by drugs.
I note also that some training is given to trainee officers, but this does
not specifically cover intoxication by drugs and, even if it did, I am
concerned that training an officer once, at the beginning of their career,
2
leaves the door open to the development of bad practice and the
fallibility of human memory.
2. Lack of training in First Aid or Personal Safety courses for police
officers in relation to recognising the signs and symptoms of mental
health conditions and acute mental health crisis. Specifically, when
this may be impacting upon the behaviour of the detained person
and whether they require medical assistance from a hospital.
I have been told that officers are trained in methods of communication
with persons who are suffering from mental health episodes, but not how
to recognise the symptoms. There is training on ABD, and I am not
concerned about the officers’ ability to respond to persons with suicidal
ideation. Accepting that police officers are not medical professionals, I
am concerned that there is no guidance on recognition of symptoms of
mental health conditions falling short of crisis (in particular the way in
which this may affect behaviour) and appropriate management, then
detained persons suffering from a mental health episode, or with pre-
existing mental health conditions, may be at risk of future death.
3. Lack of training in First Aid or Personal Safety courses for police
officers in relation to the heightened risk of positional asphyxia and
intoxication.
I have seen guidance from the College of Policing that there is a
heightened risk of positional asphyxia in persons who are intoxicated. I
am concerned that without some guidance and training, police officers
will be unable to take steps to reduce the risk of positional asphyxia in
intoxicated persons which may cause a risk of future death.
4. Lack of refresher or mandatory annual training for police officers
in relation to constant observations.
I am told that there is no specific mandatory training for police officers
on constant observations, but that trainee police officers are now given
training on constant supervision as part of their introduction to the
custody suite. I have been told that there is an optional CPD module
available to officers on constant observation training. I am concerned
that police officers are being regularly asked to perform constant
observations on detainees of the highest risk levels without any
mandatory training or refresher training on the subject. Whilst the
Custody Sergeant is tasked with providing a briefing to officers who are
tasked with constant observations, I am concerned that there is no
evidence of consistency in this task being completed to an appropriate
standard or at all. There is a risk that in a busy custody suite, this briefing
will be overlooked or omitted (and in fact that was the evidence in this
case). There is no evidence to reassure me that this was a one-off
incident, rather the evidence before me suggested that it was not. This
gives rise to a risk of future death for detained persons on level 4 constant
observation.
3
5. Lack of refresher or mandatory annual training for police officers
in relation to information to be passed to the custody officers during
the booking in procedure.
I am told that there is no specific mandatory training for police officers
on the information expected of them at the custody suite desk during the
booking in procedure, but that trainee police officers are now given
training on constant supervision as part of their introduction to the
custody suite. I am concerned that police officers are regularly handing
over to custody officers without any mandatory training or refresher
training on the subject, which leaves the information that they decide to
pass over open to discretion. Training an officer once, at the beginning
of their career, leaves the door open to the development of bad practice
and the fallibility of human memory. This gives rise to a risk of future
death for detained persons if pertinent information is omitted, for
example health or intoxication information.
6. Lack of safety net for custody suit documentation, specifically the
constant supervision forms.
I am told that whilst there has been a welcomed change to the format of
the constant observation forms, there is no safety net for ensuring that
these forms are handed over in a timely manner or by the custody
sergeant. I am also told that there is no audit trail in place for checking
that these forms are being signed by police or custody officers to ensure
that the envisaged sergeant briefing is being given. I am concerned that
there is a risk of future death to detained persons on level 4 constant
supervision in circumstances where the sitting officers may not be
experienced in the task, have not been trained, and are not consistently
being briefed by the custody officers.
7. Jury concern – the design and format of the documentation,
specifically the level 4 supervision form, was unclear and poorly
structured.
This featured within the jury’s narrative conclusion, and whilst I heard
some evidence that certain elements of the form had changed. It is
broadly similar in its new format to the copy that the jury were presented
with.
6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe
your organisation have the power to take such action.
7 YOUR RESPONSE
4
You are under a duty to respond to this report within 56 days of the date of this
report, namely by 22 May 2024. 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 Interested
Persons.
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 other person who I believe may
find it useful or of interest. I have sent a copy to the College of Policing.
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.
9
27 March 2024 Alexandra Pountney
HM Assistant Coroner
5
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.
Alexandra Pountney, Assistant Coroner, Medico-Legal Centre Watery Street Sheffield S3 7ES PRIVATE Date: 17 May 2024 Chief Constable of South Yorkshire Police For the Attention of Ms A Poutney Dear Ms Poutney Inquest touching the death of Mr Matthew Terrill I write in response to the Regulation 28 Report to Prevent Future Deaths dated 27 March 2024. Your report raised the following Matters of Concern: 1. Lack of training in the First Aid or Personal Safety courses for police officers in relation to recognising the signs and symptoms of drug intoxication. Specifically, how to recognise a drug overdose or the ill-effects of drug intoxication, and when it is appropriate for a detainee to be taken to hospital. 2. Lack of training in First Aid or Personal Safety courses for police officers in relation to recognising the signs and symptoms of mental health conditions and acute mental health crisis. Specifically, when this may be impacting upon the behaviour of the detained person and whether they require medical assistance from a hospital. 3. Lack of training in First Aid or Personal Safety courses for police officers in relation to the heightened risk of positional asphyxia and intoxication. 4. Lack of refresher or mandatory annual training for police officers in relation to constant observations. 5. Lack of refresher or mandatory annual training for police officers in relation to information to be passed to the custody officers during the booking in procedure. 6. Lack of safety net for custody suit documentation, specifically the constant supervision forms. Legal Services South Yorkshire Police Headquarters Carbrook House 5 Carbrook Hall Road, Sheffield S9 2EH DX: 708870 Sheffield Tel: 0114 252 3588 For Sat. Navigation users S9 2EG Legal Services Humberside Police Headquarters Priory Road Hull HU5 5SF DX: 708885 Hull 18 Tel: 01482 578 266 E-Mail: LegalEnquiries@southyorks.pnn.police.uk Page 1 7. Jury concern – the design and format of the documentation, specifically the level 4 supervision form, was unclear and poorly structured. PRIVATE Response to Matters of Concern 1. Lack of training in the First Aid or Personal Safety courses for police officers in relation to recognising the signs and symptoms of drug intoxication. Specifically, how to recognise a drug overdose or the ill-effects of drug intoxication, and when it is appropriate for a detainee to be taken to hospital. Where we are now South Yorkshire Police officers receive a 2-day initial First Aid course (MOD 2 initial) as part of their initial training and thereafter an annual 4 hour First Aid (Mod2 refresher) course. The MOD 2 initial is covered again over a 3-year cycle. The MOD 2 module is equivalent to the HSE ‘Emergency First Aider at Work’ (EFAW) standard which is delivered throughout different organisations. The EFAW or College of Policing (CoP) does not cover managing a casualty who has been poisoned. The learning structure addresses emergency First Aid in the workplace and deals with a wide range of medical situations that personnel may be expected to deal with including, basic life support, trauma and other medical conditions and topics. As the module is equivalent to the EFAW, the delivery in terms of poisons only covers generic workplace toxins such as aspirin, alcohol, acids, and bleaches. Within the training a poison is described, looking at the ways it gets into the body and looking at certain aspects such as toxins, bleaches and alcohol. The training also looks at causes, signs and symptoms which vary widely and can differ dependant on the individual, and the treatment. The main objective of this course is the 3 P’s: Preserving life, Preventing injury from getting worse, and Promoting recovery. The key message throughout the first aid session is if there is any doubt at all in relation to a casualty’s condition they should be taken to A and E. Officers also receive a Qualsafe first aid book as part of their initial course which can be used as an aide memoir throughout their service. Future work Following the Manchester Arena incident, the first aid learning program have recognised that the learning requirements of delivering first aid in a policing context are significantly different to the application of first Legal Services South Yorkshire Police Headquarters Carbrook House 5 Carbrook Hall Road, Sheffield S9 2EH DX: 708870 Sheffield Tel: 0114 252 3588 For Sat. Navigation users S9 2EG Legal Services Humberside Police Headquarters Priory Road Hull HU5 5SF DX: 708885 Hull 18 Tel: 01482 578 266 E-Mail: LegalEnquiries@southyorks.pnn.police.uk Page 2 P RI V A T E ai d i n a t y pi c al w or k pl a c e , t he fir st ai d l e ar ni n g pr o gr a m c o nt e nt h a s t h er ef or e b e e n m o difi e d t o m e et t h e s e c h a n g e s. A c h a n g e t o t h e Fir st Ai d l e ar ni n g pr o gr a m f or n e xt y e ar i ntr o d u c e s p oi s o n w hi c h c o v er s : 7. 7 H o w t o m a n a g e a c a s u alt y w h o h a s b e e n p oi s o n e d. W h at it i s p er m/t W h at c a n R e c o g ni s e s y m pt o m s. A n d tr e at m e nt s g oi n g t o gi v e. e m p C a u s e s al c o h ol ? s o m e si g n s a n d � � � � R e c o g ni s e t h e si g n s a n d s y m pt o m s of p oi s o ni n g. Di s c u s s a c ut e al c o h ol i nt o xi c ati o n. Di s c u s s i nt e nti o n al dr u g o v er d o s e. M a n a g e a c a s u alt y wit h a n a p h yl a xi s. A lth o u g h t h e a b o v e c o nt e nt i s p art of t h e n e w fir st ai d l e ar ni n g pr o gr a m c urri c ul u m d u e t o c o m m e n c e i n A pril 2 0 2 5 , th e a b o v e p oi s o n m o d ul e h a s b e e n i ntr o d u c e d i n t o m o d ul e 2 y e ar 3 fr o m A pril 2 0 2 4 . S o ut h Y o r k s hire P oli c e will b e i ntr o d u ci n g t hi s i nt o t h e M O D 2 i niti al al s o fr om t h e 6 M a y 2 0 2 4. S o ut h Y or k s hir e P oli c e ar e c urr e ntl y w or ki n g wit h ot h er f or c e s o n d e pl o yi n g offi c er s wit h N al o x o n e. T hi s i s a n a nti- opi oi d n a s al s pr a y w hi c h r e v er s e s t h e eff e ct s of dr u g s o v er d o s e s. T hi s o nl y w or k s a g ai n st o pi at e s. T hi s i s i n t h e e arl y st a g e s of d e v el o p m e nt i n o ur f or c e a s w e l o o k t o u n d er st a n d w h at tr ai ni n g will b e r e q uir e d . Furt h er c o n s ult ati o n wit h p art n er s a n d r el e v a nt u ni o n s ar e c urr e ntl y u n d er w a y . W h at i s n ot p l a n n e d a n d wh y ? Offi c er s r e c ei v e a 4- h o ur tr ai ni n g refr e s h er c o ur s e a n n u all y . Fr o m 1 A pril 2 0 2 5 t h e n e w c urri c ul u m will b e 6 h o ur s c o nt a ct ti m e . It w o ul d b e e xtr e m el y c h all e n gi n g f or tr ai ni n g t o i n cl u d e all dr u g s gi v e n t h e e v er e v ol vi n g a n d c h a n gi n g n at ur e of t h e s e s u b st a n c e s . Offi c er s ar e n ot m e di c all y tr ai n ed a n d i n di vi d u al s u n d er t h e i nfl u e n c e of dr u g s c a n h a v e di s pl a y v ar yi n g s y m pt o m s a n d b e h a vi o ur s d e p e n di n g o n t h e dr u g s a n d q u a ntit y t h at h a v e b e e n t a k e n. T h e m e s s a g e t o offi c er s t hr o u g h o ut all of t h e fir st ai d c o ur s e s i s t h at if t h er e i s a n y d o u bt as t o w h et h er a d et ai n e d i n di vi d u al i s u n d er t h e i nfl u e n c e of dr u g s an d t h er e ar e c o n c er n s ar o u n d t h e i m p a ct t hi s i s h a vi n g u p o n t h e m, m e di c al a d vi c e s h o ul d b e s o u g ht. 2. L a c k of tr ai ni n g i n Fir st Ai d or P er s o n al S af et y c o ur s e s f or p oli c e offi c er s i n r el ati o n t o r e c o g ni si n g t h e si g n s a n d s y m pt o m s of m e nt al h e alt h c o n diti o n s a n d a c ut e m e nt al h e alt h cri si s. S p e cifi c all y, w h e n t hi s m a y b e i m p a cti n g u p o n t h e b e h a vi o ur of t h e d et ai n e d p er s o n a n d w h et h er t h e y r e q uir e m e di c al a s si st a n c e fr o m a h o s pit al . W h er e w e a r e n o w L e g al S er vi c e s S o ut h Y or k s hir e P oli c e H e a d q u art er s C ar br o o k H o u s e 5 C ar br o o k H all R o a d, S h effi el d S 9 2 E H D X: 7 0 8 8 7 0 S h effi el d T el: 0 1 1 4 2 5 2 3 5 8 8 F or S at. N a vi g a ti o n u s er s S 9 2 E G L e g al S er vi c e s H u m b er si d e P oli c e H e a d q u art er s Pri or y R o a d H ull H U 5 5 S F D X: 7 0 8 8 8 5 H ull 1 8 T el: 0 1 4 8 2 5 7 8 2 6 6 E- M ail: L e g al E n q uiri e s @ s o ut h y or k s. p n n. p oli c e. u k P a g e 3 PRIVATE The First Aid learning program curriculum does not provide content on symptoms of ‘generic’ mental health conditions. However, in both Personal Safety Training (PST) and First Aid training since 2014 officers have received an input on Acute Behavioural Disturbance (ABD) and on how to recognise signs and symptoms in both theory and practice. The College of Policing and NPCC developed a PowerPoint presentation on ABD which describe the behavioural and physical signs of ABD and makes clear rapid clinical assessment/intervention. This was last updated in 2019 and was delivered as part of the PST input. the need for Officers are encouraged to dynamically risk assess the situation presented to them in terms of how they will control and restrain the individual. The clear message throughout the courses is if officers think the individual is displaying signs of ABD. ‘ABD means A & E.’ Student officers receive an input on ABD as part of their PST input. Prior to starting their PST Input Students are sent a Learners Guide which directs the students to various links. One of these links is the detailed College of Policing PowerPoint presentation on ABD which is referred to above. The learning from the PowerPoint is assessed via a trainer led session and during their training. The students also cover ABD signs, symptoms, and treatment as part of the students MOD 2 First Aid Initial course and on their annual First Aid MOD 2 Refresher. The PST delivery for this year commencing in April 2024 is all scenario-based delivery. There are six different scenarios mandated by the College of Policing. One scenario is based on ‘vulnerable person.’ The Trainers can introduce ABD by slightly adapting the vulnerable person scenario, to having the role player displaying some of the signs and symptoms of ABD, with the trainer also providing input to the role player to display varying signs and symptoms of ABD such as, the person is hot to touch, incredibly strong or sweating heavily etc. From this the student should realise that they are dealing with someone who is having an ABD episode and deal with them accordingly. As part of the scenario training, the students will be shown how to try to use control rather than pain techniques to deal with someone in ABD. The Trainers will emphasise the risk of positional asphyxia if a subject is in ABD and positions to restrain on the ground other than in the prone position i.e., Supine position, rolling them onto their sides, kneeling or seated position. The students are also trained that if a subject is placed in handcuffs and limb restraints they must be observed by an officer at all times until the limb restraints and handcuffs are removed. Legal Services South Yorkshire Police Headquarters Carbrook House 5 Carbrook Hall Road, Sheffield S9 2EH DX: 708870 Sheffield Tel: 0114 252 3588 For Sat. Navigation users S9 2EG Legal Services Humberside Police Headquarters Priory Road Hull HU5 5SF DX: 708885 Hull 18 Tel: 01482 578 266 E-Mail: LegalEnquiries@southyorks.pnn.police.uk Page 4 PRIVATE Students will also complete a theory style questionnaire (Time on Tasks) to confirm their learning and understanding of ABD. We have a policy around the management and transportations of casualties, whilst this does not solely link to mental health. This policy covers decision making and steps to following when managing casualties, including handovers to medical professionals. This does not cover mental health but covers physical symptoms. Mental Health training was rolled out to all front line officers via Street Skills in 2018. This was developed and delivered with partners and individuals with lived experience. This gave officers guidance on recognising sign and symptoms of mental health issue including those falling short of a crisis. South Yorkshire Police delivers a 2 hour input to all new Force Control Room, custody and enquiry desk recruits as part of their initial training. There is a great deal of material and presentation around spotting the signs and how to deal with various situations which can be found under our mental health resource section. South Yorkshire Police CPD is currently booked up until December 2024, a further mental health CPD event will be considered in CPD training from early 2025 where we will look to deliver this force wide. PNC markers can be placed on anyone identified as suffering from mental health conditions who have previously been in contact with the police. In custody, further information can be held around their mental health via Liaison and Diversion and as part of the risk assessment carried out by the Custody Sergeants which covers aspects of mental health. We have across some districts Mental Health Service cars (SMED), these are run by mental health practitioners who can support officers by giving advice or attend incident reports of someone who is believed to suffering a mental health episode. This to ensure they are assessed and receive the relevant support they need. This is not available across the force due to funding from our local NHS partners. The use of SMED is reducing with the implementation of the Right Care Right Person policy. Within our custody suites we have a medical practitioner and Liaison and Diversion. They carry out assessments on anyone who is suffering from a medical episode or has any mental health issue. From this assessment it will be decided whether they can be managed whilst they are in custody. They may decide on occasions that hospital treatment is needed, therefore officers will take them directly to A&E. Further support can then be put in place including support within the community. Access to information around an individual’s previous/current mental health or pre- existing health conditions is not always available. Officers will make decisions in line with the National Decision Making Model, Code of Ethics, and the training received around how they treat and manage the detainee. This will be dependent on the circumstances, how that person is presenting and the risk they pose to themselves and members of the public. If they are in any doubt in terms of how a person is presenting Legal Services South Yorkshire Police Headquarters Carbrook House 5 Carbrook Hall Road, Sheffield S9 2EH DX: 708870 Sheffield Tel: 0114 252 3588 For Sat. Navigation users S9 2EG Legal Services Humberside Police Headquarters Priory Road Hull HU5 5SF DX: 708885 Hull 18 Tel: 01482 578 266 E-Mail: LegalEnquiries@southyorks.pnn.police.uk Page 5 PRIVATE and have significant concerns around their mental health then the advice is that medical advice should be sought. Officers and staff have access to a custody internet resource page, this has relevant information and presentations for officers which includes guidance for officers presenting a detainee at the custody suite, Patient or Prisoner Cards and other supportive guidance. Future Work The College of Policing ABD video could be mandated to all officers to complete as part of their CPD. CPD is at full capacity until 2025 where mental health will be listed for consideration in early 2025. What is not planned and why? In terms of first aid there is no change to curriculum in terms of introducing generic mental health conditions into first aid training. No requirement to change PST delivery in view of vulnerable person scenario described as above. A one-day mental health awareness course is delivered as part of the leadership academy which covers a wide range of mental health conditions. Officers can enrol themselves onto the course as part of their CPD. 3. Lack of training in First Aid or Personal Safety courses for police officers in relation to the heightened risk of positional asphyxia and intoxication. Where are we now Officers receive an input on the risks of positional asphyxia and intoxication as part of their initial course. Which is similar to the vulnerable person scenario except it will be set in the custody environment. This will be achieved by having the role player displaying some of the signs and symptoms of ABD, with the trainer also providing input stating the role player is displaying varying signs and symptoms of ABD such as, the person is hot to touch, incredibly strong or sweating heavily etc. From this, students should realise that they are dealing with someone who is in ABD and deal with them accordingly. As part of the scenario training, the students will be shown how to try to use control rather than pain techniques to deal with someone in ABD. The students are also trained that if a subject is placed in handcuffs and limb restraints they must be observed by an officer at all times until the limb restraints and handcuffs are removed. Legal Services South Yorkshire Police Headquarters Carbrook House 5 Carbrook Hall Road, Sheffield S9 2EH DX: 708870 Sheffield Tel: 0114 252 3588 For Sat. Navigation users S9 2EG Legal Services Humberside Police Headquarters Priory Road Hull HU5 5SF DX: 708885 Hull 18 Tel: 01482 578 266 E-Mail: LegalEnquiries@southyorks.pnn.police.uk Page 6 Future work PRIVATE Posters will be refreshed to offer officers guidance in relation to the risk of positional asphyxia, this will also be added to the observation document. The observation document will include clear bullet points and guidance to ensure what is required by the officer carrying out the constant observations and will include that no prisoner should be left on their front, under intoxicant whilst in handcuffs and leg restraints. 4. Lack of training or mandatory annual training for police officers in relation to constant observations. Where are we now There is currently no annual training for officers around constant observations. We have a constant observation document which should be briefed to the officer when carrying out this role. This details and documents the roles and responsibilities of the officer and Sergeant. This is then signed and dated by both the officer and the Sergeant following the briefing. I have noted the concerns raised by the coroner. Future Work South Yorkshire Police will review the document given to officers for constant observations. Discussions with other forces within the coming months is intended around this document, to see if there are other improved working practices around capturing this task. This will include the role of the Sergeant and the person observing the detainee. Training/ CPD will be given to all Custody Sergeants following this review setting out clear standards and expectations around their role and responsibilities of this document. Dip samples will be carried out by the Custody Inspectors to ensure compliance, this will include reviewing of CCTV to ensure that this document is briefed, relevant checks by the Sergeant are carried out for anyone under constant observations. The Custody lead for South Yorkshire Police is to have further consultation with the Performance and Governance team to look at whether BWV should be activated when observing a prisoner, this could then capture the briefing, roles and responsibilities, action of the officers and any behaviour of the detainee. South Yorkshire Police Professional Standards Department are delivering live custody table top exercises, this will feature a scenario of a death in police custody. The first one is due to be held in May 2024. This will include officers, staff, seniors officers who carry our cadre force responsibilities so that Legal Services South Yorkshire Police Headquarters Carbrook House 5 Carbrook Hall Road, Sheffield S9 2EH DX: 708870 Sheffield Tel: 0114 252 3588 For Sat. Navigation users S9 2EG Legal Services Humberside Police Headquarters Priory Road Hull HU5 5SF DX: 708885 Hull 18 Tel: 01482 578 266 E-Mail: LegalEnquiries@southyorks.pnn.police.uk Page 7 everyone can understand their role, responsibilities and actions that need to be taken following a death in custody. This will also include our partners. These will run annually to ensure everyone is trained. PRIVATE 5. Lack of refresher or mandatory annual training for police officers in relation to information to be passed to the custody Sgt during in the booking in procedure Where are we now South Yorkshire Police do not have an annual training or CPD around officers presenting detainees to custody officers. Student officers are trained around this during their initial training phase and they carry out practical scenarios around presenting to custody officers and the importance of this. This is then developed further when a student officer moves into their tutored phased, they will gain experience in presenting detainees to Custody Sergeants, under the observation of an experience tutor constable. Custody Sergeants will ask relevant questions of the officer should any information be missing around the booking in procedure. The Custody Sergeant completes the relevant risk assessment during this process. If anything has been missed, the Sergeant would ask further questions. This would then be debriefed at the end around that vital information missing to ensure the officer learns and develops. South Yorkshire Police have a custody resources section which is accessed by the force internet page. Within this section are presentations and guidance documentations around all aspects of custody. This includes how you should present a detainee to a Custody Sergeant. Future work South Yorkshire Police will review the booking in sheet that officers complete prior to presenting a detainee to the Custody Sergeant This will include relevant reminders around the information they must inform the Custody Sergeant around such as illness, injuries and intoxication. Posters will also be created and displayed in the holding areas, where detainees enter the custody suite as a further reminder. Force screen savers will be designed by the Custody Lead, incorporating key and additional information they must provide to a Custody Sergeant when booking in a detained person into custody, this will be supported by a yearly CPD package and delivered locally by Force Inspectors/Detective Inspectors again reminding officers around their role and responsibilities. Points 6 & 7 are covered in the above sections. I hope that this provides you with assurance that the Matters of Concern that were identified are being fully addressed by South Yorkshire Police. Legal Services South Yorkshire Police Headquarters Carbrook House 5 Carbrook Hall Road, Sheffield S9 2EH DX: 708870 Sheffield Tel: 0114 252 3588 For Sat. Navigation users S9 2EG Legal Services Humberside Police Headquarters Priory Road Hull HU5 5SF DX: 708885 Hull 18 Tel: 01482 578 266 E-Mail: LegalEnquiries@southyorks.pnn.police.uk Page 8 Yours sincerely PRIVATE Chief Constable of South Yorkshire Police Legal Services South Yorkshire Police Headquarters Carbrook House 5 Carbrook Hall Road, Sheffield S9 2EH DX: 708870 Sheffield Tel: 0114 252 3588 For Sat. Navigation users S9 2EG Legal Services Humberside Police Headquarters Priory Road Hull HU5 5SF DX: 708885 Hull 18 Tel: 01482 578 266 E-Mail: LegalEnquiries@southyorks.pnn.police.uk Page 9
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