Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0585, written 25 Oct 2024. 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 2024 |
|---|---|
| Reference | 2024-0585 |
| Deceased | Chad Allford |
| Coroner | Susan Evans |
| Coroner area | Derby and Derbyshire |
| Category | Police related deaths · Alcohol, drug and medication related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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: 1 2 College of Policing Chief Constable Derbyshire Constabulary 1 CORONER I am Susan EVANS, Area Coroner for the coroner area of Derby and Derbyshire 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 01 December 2021 I commenced an investigation into the death of Chad George ALLFORD aged 23. The investigation concluded at the end of the inquest on 24 October 2024. The conclusion of the inquest was that: in Alfreton following a planned operation involving the On 27th October 2021 Chad Allford died at King's Mill Hospital. The cause of death is recorded as the effects of Cocaine. Police attended supply of class A drugs, in order to effect an arrest. After failed attempts to gain entry using keys and an enforcer, police officers gained access through an open door at the rear of the property. Following confrontation with a police officer Chad placed a package of Cocaine into his mouth. Police used various tactics in an attempt to retrieve the package and prevent injury or harm to Chad. A police officer called an ambulance, changing the incident from an arrest to a medical emergency as it was suspected that Chad had ingested a class A drug. Chad was assisted out of the property towards the drive where his health quickly declined. Chad started to convulse and was experiencing breathing difficulties. Chad was taken to King's Mill Hospital, where he later died at 18:21. 4 CIRCUMSTANCES OF THE DEATH See above 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) The evidence in this inquest focused, in part, on police officers’ response to concealment of drugs in the mouth. The officers were part of a team, acting on intelligence, to make a drug offence arrest. None of the officers concerned had received prior training in this regard. They employed various methods to try and control Mr Allford and although each instructed Mr Allford to spit the drugs out, none of them warned him of the risks to his life of not CONTROLLED Regulation 28 – After Inquest Document Template Updated 30/07/2021 doing so. It was not clear that officers understood the importance of communicating the dangers. Attempts were made by officers to open his mouth and sweep the drugs out of the mouth with their hands. A number of officers gave evidence that they were not aware of some of the risks inherent in placing their hands in someone’s mouth, including the risk of packages entering the airway and therefore choking, and they were not aware of the relevant passages in the NPCC Personal Safety Manual or importantly, the principles relating to this contained within. This was not only the position in 2021 but remained the position at the time of the inquest. I am concerned that there is no standard provision for guidance or training for police officers in units tasked to make arrests for drug offences, to equip them to make informed decisions when faced with this situation. In the Personal Safety Manual ( Module 12 pg 42), it is described as a 'common tactic used by some subjects during arrest to conceal controlled drugs in their mouths'. 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 You are under a duty to respond to this report within 56 days of the date of this report, namely by December 19, 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. COPIES and PUBLICATION 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Mr Allford’s family Derbyshire Police Legal Services I have also sent it to 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: 25/10/2024 CONTROLLED Regulation 28 – After Inquest Document Template Updated 30/07/2021 Susan EVANS Area Coroner for Derby and Derbyshire CONTROLLED Regulation 28 – After Inquest Document Template Updated 30/07/2021
2 responses 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.
Susan Evans HM Area Coroner Derby & Derbyshire 17th March 2025 Dear Ms Evans, Re: Regulation 28 Report into the death of Chad Allford I am writing in response to your Regulation 28 report following the investigation and inquest into the tragic circumstances of the death of Chad Allford on the 27th of October 2021. I hope to answer the concerns you raised within section 5 of your report, which are listed as follows: 1. The evidence in this inquest focused, in part, on police officers’ response to concealment of drugs in the mouth. The officers were part of a team, acting on intelligence, to make a drug offence arrest. None of the officers concerned had received prior training in this regard. They employed various methods to try and control Mr Allford and although each instructed Mr Allford to spit the drugs out, none of them warned him of the risks to his life of not doing so. It was not clear that officers understood the importance of communicating the dangers. Since the time of Mr Allfords death the College of Policing has instigated a review of the current version of the Personal Safety Manual, as a result of this review it is currently being revised, which is a detailed and lengthy process. Part of this process includes an examination on the guidance for dealing with articles in the mouth. The current manual does not feature guidance on informing a subject regarding the risk to their life as a result of swallowing drugs, future versions of the manual and curriculum will do so. In the interim period while the manual is completed communication will be sent out nationally via the NPCC Self Defence Arrrest & Restraint Panel to advise forces of this recommendation and implement appropriate changes. 2. Attempts were made by officers to open his mouth and sweep the drugs out of the mouth with their hands. A number of officers gave evidence that they were not aware of some of the risks inherent in placing their hands in someone’s mouth, including the risk of packages entering the airway and therefore choking, and they were not aware of the relevant passages in the NPCC Personal Safety Manual or importantly, the principles relating to this contained within. This was not only the position in 2021 but remained the position at the time of the inquest. As per the previous answer the revision of the Personal Safety Manual includes an examination on the guidance for dealing with articles in the mouth. The advice mentioned above in the current manual is given as “Officers should not attempt to put their fingers in the subject’s mouth to remove any objects, as this could pose a risk to the officer and could possibly push the object into the airway and causing an obstruction.” Words to this effect will remain in future versions of the manual and be reviewed against the latest medical guidance for this area. 3. I am concerned that there is no standard provision for guidance or training for police officers in units tasked to make arrests for drug offences, to equip them to make informed decisions when faced with this situation. In the Personal Safety Manual ( Module 12 pg 42), it is described as a 'common tactic used by some subjects during arrest to conceal controlled drugs in their mouths'. The issue of drugs being concealed in a subjects mouth may not be as widespread as the wording in the manual implies. Ancedotal evidence suggests it is ordinarily linked with a small number of subjects who practice the tactic frequently. In force areas where concealment of drugs in the mouth is an identified risk, training curriculums developed by the College of Policing allow for the provision of the relevant sections of the Personal Safety Manual to be delivered. This facility is available in both the historic Personal Safety Training and the latest Public & Personal Safety Training delivery methods. In forces where this is the case the staff that require the training, level it is delivered at, and the appropriate risk mitigation would be informed by a local needs analysis. I hope this helps to answer the points that were raised but if we can assist with anything further, please do not hesitate to contact me. Yours sincerely Policing Standards Manager – Specialist Operations College of Policing
Contact: Direct Telephone: Extension: Email: Our reference: Your reference: Date: 13th December 2024 Susan Evans Area Coroner for Derby and Derbyshire Dear Ms. Evans Regulation 28: Report to Prevent Future Deaths I write in relation to the above inquest which concluded on 24th October 2024, after which you issued a Prevention of Future Deaths (PFD) report under Regulation 28 of the Coroners (Investigations) Regulations 2013. I appreciate the opportunity to address the concerns raised and outline steps Derbyshire Constabulary are taking to mitigate the risks identified during the inquest. The concerns raised are that there is no standard provision of guidance or training for police officers in units tasked to make arrests for drugs offences, to equip them to make informed decisions when faced with this situation. You note that in the Personal Safety Manual (PSM) (Module 12, pg 42), that concealment of drugs in the mouth is described as a common tactic, used by some subjects during arrest. The College of Policing stipulate the curriculum required to be covered for Personal and Public Safety Training (PPST) which equips officers with the skills required to protect themselves and the public. It is for each force to determine how that is taught to ensure officers can apply the tactics in differing situations they deal with. Due to the nature of Policing, it is impossible to cover all potential situations, however numerous scenario based practical examples are used to teach the tactics required. All officers are required to undertake the training. Due to different situations being trained, dependant on questions asked by students and the direction the scenario goes in, some officers will have had training in relation to concealment of drugs in a subject’s mouth, others may not. We recognise this is not the ideal situation to provide standardisation of training. The training delivered by Derbyshire Constabulary already covers numerous situations which may arise when a subject tries to conceal something in their mouth, namely positional asphyxia, ground control and pressure points and we will continue to do this training. Since the incident leading to the death of Chad Allford, Derbyshire Constabulary have taken the following action: Derbyshire Constabulary, Headquarters, Butterley Hall, Ripley, Derbyshire, DE5 3RS Incoming telephone calls and communications may be monitored and recorded 2 1. A lesson plan has been designed and implemented to cover the necessary points pertaining to concealment of an item in a subject’s mouth for training within Derbyshire Constabulary. It has been mandated that during both initial and refresher safety training, at least one scenario covering the concealment of an item in the mouth must be delivered. who leads the training has made contact with the PPST lead from 3. Sergeant 2. the College of Policing and informed her of the concerns raised. The College of Policing have confirmed that the PSM is due to be reviewed in order to make it more concise. The swallowing of drugs is included within that under mouth searches so the content will be included as part of the review. As an organisation, Derbyshire Constabulary are committed to ensuring the training delivered to our staff is of excellent quality to ensure the safety of officers and the public and despite the tragic circumstances leading to the concerns raised, we appreciate the opportunity to improve on the service already delivered to ensure events like this are prevented in the future. Yours sincerely Chief Constable
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