Prevention of Future Deaths reports · 2024

Ashley Crews

Regulation 28 report to prevent future deaths, reference 2024-0216, written 23 Apr 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report23 Apr 2024
Reference2024-0216
DeceasedAshley Crews
CoronerZak Golombeck
Coroner areaManchester City
CategoryOther related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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 before an inquest. 

REGULATION 28 REPORT TO PREVENT DEATHS 

THIS REPORT IS BEING SENT TO: 
1  Greater Manchester Police 
2  Chief  Coroner 
3 
4  College of Policing 
5  IOPC -Independent Office for Police Conduct 

1  CORONER 

I am Zak GOLOMBECK, HM Area Coroner for the coroner area of Manchester City 

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 

INQUEST 

The Inquest was opened on 12th March 2024. The final hearing has not yet taken place. 
Following disclosure of evidence from Greater Manchester Police (“GMP”) and the 
Independent Office for Police Conduct (“IOPC”), there is concern that future deaths will 
occur, and I am of the opinion that action should be taken to reduce the risk of death. 

4  CIRCUMSTANCES OF THE DEATH 

Mr Ashley Crews died on 20th February 2024 from injuries sustained from a fall from 
height. On 20th February 2024, GMP officers attended Mr Crews’  address (a 9th floor flat) 
to execute an arrest warrant. The attending officers did not apply handcuffs. Mr Crews 
proceeded to walk to his bedroom in the flat, and whilst some officers followed him, Mr 
Crews was able to open a window and jump out. GMP have confirmed that they do not have 
a local policy dealing with the use and application of handcuffs when executing an arrest 
warrant. The IOPC have confirmed there is no national policy. 

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: 
(brief summary of matters of concern) 

1. There is no local policy for the use of handcuffs when executing an arrest warrant. 

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 – Before Inquest 
Document Template Updated 30/07/2020 

 
 You are under a duty to respond to this report within 56 days of the date of this report, 
namely by June 18, 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 Interested Persons. I have also 
sent it to organisations 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  Dated: 23/04/2024 

Zak GOLOMBECK 
HM Area Coroner for 
Manchester City 

Regulation 28 – Before Inquest 
Document Template Updated 30/07/2020

Responses

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.

Response from Greater Manchester Police (PDF)
Chief Constable 

Zak Golombeck 
HM  area Coroner for Manchester City 
Manchester City Coroner's Office and Court 
Exchange Floor,  The Royal  Exchange Building 
Cross Street 
Manchester 
M2 7EF 

10th  June 2024 

Dear Mr Golombeck 

Greater  Manchester  Police  acknowledge  the  matters  of  concern  raised  by  the  Regulation  28 
report,  issued  under  paragraph  7,  Schedule  5  of  the  Coroners  and  Justice  Act  2009  and 
regulations 28  and 29 of the  Coroners (Investigations)  Regulations 2013 on  23 rd  April  2024. 

We  acknowledge  that there  is  no  national  or local  policy  for policing  that specifically  deals with 
the application  of handcuffs during the execution of search warrants. 

The justification for the  use  of force  against an  individual  is  a matter for each  officer to  consider 
on  a case-by-case  basis.  Consideration  of how force  is  used  is  a common thread  through  many 
aspects  of police  guidance  and  Authorised  Professional  Practice  (APP),  with  a particular focus 
on  legislation and  use of the  National Decision Model. 

The  policing  scenarios  are  so  wide  ranging  that  it  is  impractical  to  offer  specific  instruction  or 
policy on when handcuffs should be  applied to  restrain  individuals whilst under arrest or detained 
under the  powers  of a search  warrant.  In  pre-planning  for the  execution  of search  warrants,  we 
consider the vulnerability of the known occupants including factors such as age,  mental  health or 
physical  issues.  That  would  not  necessarily  influence  an  individual  decision  to  use  force  and 
handcuff somebody during such  an  operation. 

Greater  Manchester  Police  do  have  a  Use  of  Force  policy  which  is  available  to  officers  as 
guidance for recording the  use  of force.  Officers are  also trained  in  the  legislation  relevant to the 
use of force and have access to  numerous nationally developed guidance documents to assist in 
their decision making. 

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

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