Prevention of Future Deaths reports · 2024

Chad Allford

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 report25 Oct 2024
Reference2024-0585
DeceasedChad Allford
CoronerSusan Evans
Coroner areaDerby and Derbyshire
CategoryPolice related deaths · Alcohol, drug and medication related deaths
Sourcejudiciary.uk record · original PDF
Responses published2

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 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

Responses

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.

Response from College of Policing (PDF)
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
Response from Derbyshire Constabulary (PDF)
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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