Brian Ringrose

Executive Office 

24 September 2025 

Sean Cummings  
HM Assistant Coroner for Milton Keynes 
HM Coroner’s Office 
Civic Offices 
1 Saxon Gate East 
Central Milton Keynes 
MK9 3EJ 

Dear Mr Cummings, 

Re: Regulation 28: Report to prevent future deaths 

Thank you for your Regulation 28 report dated 1 August 2025 following the inquest 
into the death of Brian Thomas Ringrose on 2 February 2021. The inquest concluded 
on 24 April 2025. 

Central and North West London NHS Foundation Trust (CNWL) deeply regrets the 
death of Mr Ringrose and we would very much like to extend our condolences to his 
family. 

I am writing to provide the Trust’s response to the concerns that you raised in your 
report.    

Matters of Concern 

a)  Delay in Assessment: There was a significant delay in the mental health team 
attending to Brian in the Emergency Department (ED), despite the urgency of his 
condition. 

b)  Inadequate Assessment: When the mental health team did attend, they felt 
unable to assess Brian due to his unresponsiveness but did not escalate their 
concerns or communicate effectively with medical staff or police. They did not plan to 
return to follow up on Brian. 

c)  Failure to Escalate Concerns: A member of the mental health team believed 
Brian was not medically fit for discharge but failed to voice this to medical staff or 
police. 

Trust Headquarters, 350 Euston Road, London NW1 3AX 
Telephone: 020 3214 5700   
www.cnwl.nhs.uk 

 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 d)  Unsafe Communication Practices: Reliance on verbal communication and 
delayed written notes (within a maximum 24 hours) is inherently risky in emergency 
settings, as contemporaneous notes are essential for critical information to be 
promptly shared with other clinical and nursing staff dealing with patients. 

e) Inappropriate Discharge Recommendation: The mental health team suggested 
reassessment in police custody, despite Brian’s ongoing medical instability. In my 
view this represented a very high risk to Brian’s safety. 

I am responding to the concers in the order that you have raised them.   I would also 
like to make you aware that the Mental Health Liaison Team (HLT) Operational 
Policy has been updated and shared with Milton Keynes University Hospital (MKUH).  
The updates have been discussed at all staff meetings and interface meetings in 
June and July 2025 to ensure shared understanding. 

a.  Delay in Assessment 
We have revised our approach to ensure that referrals are accepted even when 
patients are not yet medically cleared. This enables earlier engagement, risk 
planning, and support. A key performance indicator for the HLT is timely response to 
referrals. In the past six months, over 95% of ED referrals have been responded to 
within one hour. This reflects not only operational improvements but a cultural shift 
towards proactive, parallel working with ED colleagues. 

b.  Inadequate Assessment 
Our revised protocol mandates that when a patient cannot engage due to 
intoxication (alcohol or drugs) or other factors rendering them unfit, the HLT must 
escalate concerns to the ED team, advise that the patient remains under ED care for 
ongoing medical management, and the HLT remain available for reassessment. This 
ensures continuity of care and avoids missed opportunities for intervention. This 
applies equally in cases where the patient is under police arrest within the ED. 

c.  Failure to Escalate Concerns 
We have strengthened our escalation pathways. A standing agenda item has been 
added to monthly cross-team meetings to review HLT practices. Our Operational 
Policy now explicitly requires immediate escalation of concerns to the treating medic 
or nurse in charge. 

We have also embedded trauma-informed care principles through RESPOND 
training and the dissemination of the Side-by-Side guidance for hospital settings, 
ensuring staff are equipped to act decisively and collaboratively. 

d.  Unsafe Communication Practices 
To enhance the robustness and integrity of our documentation process, we have 
implemented a joint entry protocol. Under this approach, both assessors will 
contribute directly: the second assessor will either formally approve the initial entry or 
provide a complementary entry to ensure a more comprehensive and balanced 
record. Verbal handovers to the treating medic, or to the Nurse in Charge if the 
medic is unavailable, are now mandatory immediately post-assessment, followed by 
contemporaneous entries in ECare summarising the handover with a more detailed 
entry to follow based on the SystmOne entry. These changes aim to improve the 

 
 
 
 
 
 
 
 
 
 accuracy, timeliness, and reliability of clinical communication. HLT entries are 
randomly audited for quality assurance. 

e.  Inappropriate Discharge Recommendation 
We have reinforced the principle that discharge from ED should never proceed 
where there are unresolved concerns about a patient’s safety, whether related to 
physical or mental health. This has been reiterated in team meetings and supervision 
sessions. Refresher training and Human Factors Training are taking place to support 
consistent application of this principle. 

All clinical matters are discussed in regular supervision with individual clinicians and 
in multidisciplinary team meetings. There is a monthly interface meeting with MKUK 
attended by senior management and Consultants from the Hospital Liaison Team for 
oversight. 

Thank you for bringing your concerns to our attention. I hope that the content of this 
letter provides sufficient assurance that CNWL takes the concerns raised seriously 
and has taken action following the death of Mr Ringrose.  CNWL has accepted the 
points raised and continues to work to improve the service we provide.  Should you 
have any questions or comments, please do not hesitate to contact me. 

Yours sincerely, 

Claire Murdoch 
Chief Executive

Dr Sean Cummings 
Assistant Coroner  
Milton Keynes Council 
Coroners.Office@milton-keynes.gov.uk  

24 September 2025 

Dear Dr Cummings, 

Regulation 28 Report following an inquest into the death of Mr Brian Ringrose 

I am writing following receipt of the Regulation 28 Report dated 1 August 2025, relating to 
the inquest into the death of Brian Ringrose which concluded on 24 April 2025.  

The circumstances of Brian’s death were harrowing, and I would like to express my profound 
regret that Brian did not receive the care he deserved while he was a patient in the 
Emergency Department, and to again extend my heartfelt apologies to Brian’s mother, Mary, 
and to his children and wider family. 

I would like to assure you that as a Trust we have learnt from Brian’s death and that Brian’s 
death has left an enduring legacy of improvement in how we care for patients in police 
custody, particularly in the Emergency Department.  

In your Regulation 28 Report to prevent future deaths, you set out a number of areas of 
concern and I would like to detail the changes and improvements made in each of those 
areas, appending evidence where I believe it is helpful. 

1.  Non-existent Documentation Referenced in Policy 

The hospital policy makes reference to a "discharge for police custody form" that 
does not actually exist. This suggests the policy was hastily created, possibly for the 
purposes of satisfying the inquest requirements, without appropriate consideration of 
its content or implementation 

This concern refers to a Standard Operating Procedure (Police Custody – Care in and 
Discharge from the ED) which was created using the Royal College of Emergency Medicine 
Guideline of the same name. I can assure you that it was not created in haste, but had not 
been updated to reflect work with Thames Valley Police which had continued to evolve and 
develop local processes and procedures after the guidelines had been published as a local 
SOP. 

The Emergency Department has subsequently amended the local SOP to ensure that the 
language now used reflects local practices between Emergency Department healthcare staff 
and Thames Valley police offices. Local guidance is appended as Appendix 1, including the 
Thames Valley Police transfer protocol and patients in police custody guideline. 

2.  Misleading Discharge Documentation 
The discharge form generated by hospital staff was interpreted by police officers as a 
formal discharge notice, as the jury found. The current system allows for the generation 
of forms that may be misinterpreted by third parties as official discharge documents 
when they may not be. 

Page 1 of 11 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The ED Discharge Summary is created in the ‘DEPART’ section of Firstnet the ED Module of 
Oracle Cerner Millenium our Electronic Patient Record known locally as eCare. If opened 
immediately after admission it looks like this: 

On the left are the various sections that need completing and on the right is a preview of how 
the discharge summary is developing. Sections highlighted in yellow are mandatory, those in 
grey are optional. At this stage there is no actual discharge summary as the final document 
is not created and stored in eCare until the patient is admitted or discharged. The Discharge 
Date time displayed in the template will be the time the depart tool was opened and it will 
move on each time the tool is opened as the patient passes through the ED pathway. 

As sections are completed the yellow sections turn grey and one can preview the discharge 
summary developing e.g. 

Page 2 of 11 

 
 
 
 
 
 
 
 
 The final section when opened appears like this: 

This allows staff to indicate the summary is completed and also whether a copy will be given 
to patient. Once complete when previewing the summary it shows as ‘Finalised’: 

Page 3 of 11 

 
 
 
 
 
 
 
 
 
 In the ‘DEPART’ tool there is a ‘Print’ button and an in-progress discharge summary could 
be printed from here if required prior to actual discharge but should not routinely be needed 
and would quite likely be incomplete and /or subject to change. The same tool can be used 
to generate a ‘Pharmacy Discharge Summary’ which ED nursing staff or pharmacy staff 
need if medication to take home is being prescribed – it can only be printed from here, hence 
the need for a print button. 

Once the patient is admitted or discharged the appropriate option is chosen from the 
DEPART tool: 

If ‘Discharge’ is selected the following window opens with various mandatory fields to enter 
with the remaining discharge details, on completion and signing the patient will be 
discharged from the system and disappear from ‘Launchpoint’ – essentially the dashboard 

Page 4 of 11 

 
 
 
 
 
 
 
 
 view of all the patients in ED. This is the ‘Discharge conversation’ window and staff 
completing shouldn’t be in any doubt they are discharging the patient. e.g.  

It is at this point that the document titled ‘Emergency Department GP Letters’ is created and 
stored in the record – it can be printed if required 
Looking in the ‘Documentation’ section following this the following are seen: 

The final document ‘Emergency Department GP Letters’ is the actual discharge summary, 
also sent to GP and to Patient portal. The earlier four documents are each of the text 
rendered forms completed as part of the ‘DEPART’ process. The forms themselves are 
stored in ‘Form Browser’ in eCare but these do not pull into the medical record when extracts 
are prepared for Subject Access requests, Coroners Reports etc, instead the information 
they contain is in these text-rendered documents.  

Page 5 of 11 

 
 
 
 
 
 
 
 
 
 
 Although the information they contain is repeated in the final overall discharge summary, in 
circumstances where that was never created (for whatever reason) then the information on 
any completed component forms would be missing from the record. 

The DEPART tool is one of the older sections of Oracle Cerner Millenium and is gradually 
being replaced by a Dynamic Documentation workflow. Similar workflows are currently in 
use for inpatients and outpatients and consist of workflow views from which users create a 
variety of notes. The first area in the Trust to use the newer discharge workflow is the Same 
Day Emergency Care (SDEC) department. Like ED they also use Firstnet so most other 
aspects of their workflow are very similar to ED; this went live in January 2025. 

If a similar patient were in SDEC this would be the working view: 

In the Discharge workflow page mandatory sections are indicated with a red star if 
incomplete or a green tick if completed; at the point of discharge when ready to complete the 
discharge summary one must ‘create’ SDEC Discharge summary, this then brings a preview 
which one can still edit and then sign, it then exists as a note and can be printed if required. 

Page 6 of 11 

 
 
 
 
 
 
 
 
 
 To discharge the encounter or admit the patient one can separately select options to ‘end 
visit, the resulting window that opens to collect final discharge details is the same as in ED. 
In SDEC each form still text renders for the same reasons, the naming of the resultant 
documents is perhaps clearer and there are slightly fewer than the current ED workflow. 

In both SDEC and ED, but ED especially, patients may be discharged without all details of 
the discharge summary being completed, in such cases a different workflow allows the 
patient to be discharged from ED but to go onto a ‘Missing Documentation’ list so the 
discharge summary can be completed when time allows. 

Discharge summaries are also created in eCare for inpatients (adult and paediatric), day-
cases and maternity cases. All currently use the older DEPART tool but the creation of the 
discharge summary and discharging of the patient from the system are carried out 
separately. Overtime we would expect all areas to migrate onto the newer Discharge 
Workflow mPage and associated Dynamic Documentation. 

With the exception of SDEC the discharge summary, processes have not changed materially 
since the Trust went live with eCare in 2018. 

The system workflows are somewhat challenging to set out in writing. Training and 
awareness on how the system must be used will continue – for the discharge process in ED, 

Page 7 of 11 

 
 
 
 
 
 
 
 
 
 
 
 aligned with the Discharge Standard Operating Procedure and the protocols for discharge 
with third party agency involvement (notably the police and mental health services, covered 
in the SOP and related operational protocols). Roll out of Dynamic Documentation to the ED 
will include training and awareness on discharge processes and will use this case as an 
illustrative learning tool.  

Whilst eCARE workflows gives structure to a process to ensure consistency in discharge, 
human override and miscommunication remain potential risks. In mitigation, having learnt 
from Brian’s death, staff in ED are acutely aware of the necessity of following our Trust 
processes, and our new suite of documentation supports and cements this. 

3.  Inadequate Discharge Review Process 
The decision on whether patients should have a final review by doctors before formal 
medical discharge is reportedly scheduled to be made by a committee by June 2025. 
Given that four years had already passed since Brian's death at the time of Inquest, this 
timeline for implementing such a critical safety measure is unreasonably prolonged and, 
in my view, cannot be supported. An immediate decision by the clinical director should 
have been made to institute final medical reviews before discharge. 

I would like to address the reference to the timeline for making a safety decision, as 
described above, relating to discharge. As you are aware, the Emergency Department 
discharges more than 100,000 patients annually, with regulated professionals working within 
their professional scope and competencies to provide care along the patient pathway to 
discharge. The Trust has an established Discharge Policy, which has been in place for many 
years.  

In the course of investigating Brian’s death and preparing for the inquest, the decision-
making, documentation and processes surrounding his discharge were an area of focus for 
the Trust in the context of the individual decision making and the actions and inactions of the 
healthcare professionals involved in his care. To be plain, the omissions were felt to be 
particular to this case and not a systemic issue requiring a change in wider policy and 
practice. The forensic level of examination of this issue at inquest enabled the Trust to reflect 
further on this and to consider whether wider change was in fact necessary to improve safety 
and make professional expectations explicit in a local context. To that end, the Emergency 
Department has developed and implemented a Standard Operating Procedure for the 
discharge of adult patients. This is appended at Appendix 2.  

Linked to point two, this SOP will be reviewed when Dynamic Documentation is rolled out in 
ED to ensure both are aligned. 

Particularly relevant extracts from the SOP are included below for ease of reference: 

1.0 Roles and Responsibilities: 

 1.1 ED Clinicians 
The responsibility for documenting that a patient is medically fit for discharge rests with the 
ED clinician who conducted the initial assessment and reviewed all relevant investigations. 
In cases involving suspected overdose, the clinician must document and adhere to the 
guidance provided by Toxbase. If the original assessing clinician is no longer available, the 
responsibility for confirming medical fitness for discharge passes to the clinician to whom the 

Page 8 of 11 

 
 
 
 
 
 
 
 
 
 
 
 case has been formally handed over, or to the Emergency Physician in Charge (EPIC).  

1.2 ED Nursing Staff  
Are responsible that a clear discharge plan is in place. They must ensure the patient 
receives any required take-home medications (TTOs), along with a discharge summary, as 
appropriate, that includes safety netting advice and details of any necessary follow-up. 

1.3 Mental Health Liaison Team 
Should respond within one hour of referral from the ED for urgent mental health 
assessments; conduct a full mental health and risk assessment; work collaboratively with ED 
clinicians in the decision to admit, refer, or discharge patients with mental health concerns; 
and document their findings in a timely manner.  

3.0   Discharge Processes and Procedures: 

3.1 Minimum Documentation Requirements 
All discharge summaries must include: 

•  Presenting complaint 
•  Summary of history and clinical findings 
Investigations performed and key results 
• 
•  Diagnosis (working or confirmed) 
•  Treatment provided in ED 
•  Follow-up arrangements (including who is responsible) 
•  Clear safety netting advice 
•  Mental Capacity assessment (if relevant) 
Interpreter involvement (if required) 
• 

3.2 Special Considerations 

•  Mental Health Patients: 

o  Must have a documented Mental Health Liaison Team (MHLT) assessment or 

clear reasoning why referral was not required. 

o  Risk assessment must be completed. 
o  Follow-up and safety netting should include mental health crisis contacts. 
o  The final discharge decision should be made jointly by the Emergency 

Department (ED) clinician and the Mental Health Liaison Team (MHLT). A 
clear rationale for the discharge must be documented in the patient’s notes 
and electronic record. The patient should be given the opportunity to ask 
questions, and all relevant documentation must be completed before 
discharge. 

•  Patients Under Police Custody: 

o  Refer to the MKUH SOP titled Patients in Police Custody (referenced below).  
o  Confirm mental capacity and document any assessment regarding fitness for 

custody. 

•  Patients Discharged Against Medical Advice (DAMA): 

o  Mental capacity must be clearly documented. 
o  Detail discussion of risks, advice given, and patient's decision. 

•  Vulnerable Adults (e.g. elderly, learning disability, substance misuse): 

Page 9 of 11 

 
 
 
 
 
 
 
 
 
 
 
 
 o  Consider safeguarding concerns. 
o  Liaise with community services or GP if necessary. 

3.3 Safety Netting 
All discharged patients must receive: 

•  Advice on when to return (e.g. red flag symptoms) 
•  Contact points (e.g. 111, GP, crisis line) 
•  Written discharge summary (or digital equivalent) 

3.4 Standardised Discharge Statements for Clinical Notes: 

For patients presenting with mental health needs who required medical assessment: 
“Patient medically assessed and deemed fit for discharge. Cleared by MHLT – Discharged 
home.” 

For patients presenting with mental health needs not requiring medical assessment: 
“Mental health assessment completed – no medical concerns identified. Cleared by MHLT – 
Discharged home.” 

For patients presenting with non-mental health conditions: 
“Medically fit for discharge – Discharged home.” 

4. Ambiguous discharge process 
The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase 
guidance, and not clearly documented and not clearly communicated. The ED doctor told 
the jury that he did not assess or intend that Brian was fit for discharge at the time he 
was removed from the ED. I note however that when Brian was being removed he did 
not intervene or seek to prevent it. 

This is addressed in the Emergency Department SOP for the discharge of adult patients 
described above and appended at Appendix 2. The individuals involved in this case have 
reflected at great length about their actions and inactions. Brian’s death was a seminal event 
for the Trust and learning from it has been widely shared within the Emergency Department. 
Further learning events using Brian’s case (anonymised) will continue in the Emergency 
Department, both to raise awareness of risk of unclear documentation and communication, 
and to ensure that there is an enduring legacy of improvement following Brian’s death. 

5. Unsafe supervision 
There were a number of senior clinicians and nursing staff present and seen to be 
watching the restraint of Brian. None of those senior individuals asserted their authority 
and made enquiry or intervened. 

As described above, Brian’s death has resulted in deep reflection by individuals, within the 
Emergency Department and across the Trust, with continued awareness-raising and 
learning.  

The Trust’s Restraint and Restrictive Practices policy has been re-drafted post the inquest 
(appended at Appendix 3) to incorporate Emergency Department specific guidelines (NICE 
NG10) and to make the roles and responsibilities of healthcare staff during any restraint 
unambiguously clear. The Trust’s training programme on restraint and restrictive practices 
for clinical staff is being reviewed under the new draft policy (Appendix 3). Breakaway and 

Page 10 of 11 

 
 
 
 
 
 
 
 
 
 
 
 
 
 conflict resolution training remains mandated for Emergency Department staff and security 
officers receive bespoke training to their roles.  

Every incident of restraint is reported on the Trust’s incident system, Radar. Incidents of 
restraint by the police have been reported, and include instances where healthcare staff in 
the Emergency Department have intervened to raise concerns about the safety and welfare 
of the patients, and have appropriately escalated through professional management 
structures to seek immediate support.  

6. Premature Discharge 
Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG 
not done as required, Toxbase recommendations not followed) 

Brian should not have been discharged. This is accepted and actions described above have 
been taken to mitigate the risk of a similar event occurring again. Toxbase guidelines have 
been reiterated to all Emergency Department clinicians, with a quick guide available on the 
Radar documentation system.  

A recent audit on discharge compliance is included at Appendix 4 for information and 
assurance. 

Thank you for the opportunity to demonstrate continuing improvements and learning from 
this case. I hope this response provides you with assurance of both what is already in place 
and our ongoing commitment to improvement. We will happily share further updates and 
information on any area explored in the Regulation 28 Report or meet with you to provide 
further detail or clarification if required. 

Yours sincerely, 

Chief Executive Officer 

Page 11 of 11

Jason Hogg
Chief Constable

THAMES VALLEY

Thames Valley Police HQ
Oxford Road

Kidlington
OX5 2NX
Sean CUMMINGS Tel: 01865 846002
Assistant Coroner chiefconstable@thamesvalley.police.uk
HM Coroner's Office www.thamesvalley.police.uk
Civic 1 Saxon Gate East
Milton Keynes 29 September 2025
MK9 3E]

Dear Mr Cummings

Inquest into the Death of Mr Brian Thomas Ringrose
Preventing Future Deaths response of the Chief Constable of Thames Valley Police

| am writing to outline the actions taken by Thames Valley Police in response to the
Regulation 28 Report following the inquest into the death of Mr Brian Ringrose. We have
carefully considered the concerns raised and implemented a series of measures to
prevent future deaths in similar circumstances.

Following the death of Mr Ringrose, a Gold Group was convened and chaired by
Assistant Chief Constable Christian Bunt. This group had a number of objectives
including responding to the investigation conducted by the Independent Office for
Police Conduct (IOPC) and the implementation of organisational learning. This group
brings together supervisory and specialist staff from relevant policing business areas
including Learning and Development, Professional Standards, Response Policing
Supervisors and Legal Services. This group also monitors and responds to the
investigation conducted by the IOPC.

The IOPC Investigation Report into death of Mr Brian Ringrose identified organisational
learning and in summary made the following recommendations;

1. The IOPC recommends that Thames Valley Police (TVP) review its training
material on handcuffing from prone (subject lying on their front) and the use of
ground pin.

TVP Response.

TVP utilise a series of resources to guide Public & Personal Safety Trainers through the
delivery of the training. The training content is provided by the College of Policing’s
Personal Safety Manual of Guidance. A Timetable provides guidance regarding the
order of training days for a particular course; a Session Plan provides the content to be

PROTECTING OUR COMMUNITIES

delivered on any training day; and trainer notes provide the detail of how a technique
is to be taught and the method of demonstration.

Scenario Based Training (SBT) allows officers to utilise appropriate skills to control
varying behaviours in an operational context. This delivery style is in line with the
College of Policing mandated programme for Public and Personal Safety Training (PPST).

Following review, TVP have made changes to their handcuffing from prone trainer notes
and their ground pin trainer notes. This will provide further clarity on how a subject's
arms are to be restrained during and after the application of handcuffs.

With specific reference to handcuffing from the prone position, TVP do not teach the
elevation or lowering of arms whilst handcuffed to achieve compliance or control.

TVP have also reviewed and published the following Snap Guides. These are summary
documents available to officers through their mobile devices and are designed to be
used whilst operationally deployed. They address identified matters such as ineffective
welfare monitoring; inadequate application of police restraint training and risks
associated with handcuffing to the rear and prone restraint.

e Safety Officer Snap Guide

e Safety Officer When Spit Guards Are Used Snap Guide
e ABD Snap Guide

e Alternative Ground Restraint Snap Guide

e Prone Restraint - Ground Pin Snap Guide

e Prone Restraint - Use of Force Snap Guide

2. The IOPC recommends that Thames Valley Police ensure that its training and
guidance on restraint and positional asphyxia clearly states the role and
responsibilities of the safety officer.

TVP Response

TVP have reviewed and expanded its operational guidance on the role of the safety
officer. This can found within Mental Health Operational Guidance and follows a section
on Acute Behavioural Disorder.

This guidance includes the circumstance in which a safety officer should be used; that
they should identify themselves to those present; the role of the safety officer and that
all officers regardless of role must speak up and speak out if they have any concerns
about the subject’s welfare.

TVP have introduced a PowerPoint presentation on positional asphyxia into our
Foundation Training for student officers. This presentation covers the definition of
positional asphyxia, the position it may occur in including the increased risk around
prone restraint, signs and symptoms and officer response. Officer response is centred
on situational awareness, communication and decision-making. These areas promote
the use of a safety officer where numbers permit.

PROTECTING OUR COMMUNITIES

TvP uses scenario based training (SBT), as mandated by the College of Policing. Within
this training, positional asphyxia is integrated into a series of scenarios to evoke
learning. These scenarios fall under the headings; vulnerable person, night time
economy, public order, custody, house disturbance and suspicious person. In varying
environments with differing impact factors known as layers, officers are expected to
demonstrate prone restraint and multi officer control, which includes the use of a safety
officer.

During this training and between the physical exposition and practice,TVP have
introduced online training known as Time on Tasks. Mandated topic areas include
managing a subject being restrained in the prone position.

Below is a summary of the issues specifically identified in the Regulation 28 report and
the corresponding actions taken by Thames Valley Police.

Response to the Regulation 28 concerns

Inadequate Application of Police Restraint Training

It is of note that there has been considerable National development of PPST by the
College of Policing and NPCC, with new Recertification and Foundation programmes,
introduced into TVP in November 2023 and April 2024 respectively. The introduction of
these training programmes has seen the PPST portfolio evolve significantly since the
time of the incident.

The annual 2-day Recertification programme requires Officers to complete two days of
Scenario Based Training (SBT) covering 6 topic areas 1) Vulnerable Person in a park 2)
Public Order, drunk and disorderly 3) Stop Search (Suspicious Person) 4) Fight in the
street (Night Time Economy 5) Domestic Incident (House Disturbance) and 6) Custody.

Officers are required to demonstrate competence against the assessment standard,
which includes all aspects of the PPST program, operational tactics and decision making
(based on the appropriate use of the National Decision Model to manage incidents in a
safe and effective manner - whilst dealing with a range of attitudes, behaviours and
resistance levels.

This training includes all aspects pertaining the matters of concern identified. Officers
are perceived to have a base level of understanding regarding Public and Personal
Safety, the session is designed to refresh knowledge and skills in order to bring Officers
back into licence. Scenario Based Training (SBT) is used to replicate an operational
environment and assess performance, whilst providing group or individual
development where required.

Scenarios have the opportunity to reflect organisational learning and can be directed
as such. Officers are required to demonstrate effective communication skills across
both training days, through performance in scenarios and knowledge during ‘time on

PROTECTING OUR COMMUNITIES

tasks’ which are implemented between SBT rounds. Officers are encouraged to use safe
restraint through prompts provided to role players whereby resistant behaviour
requires control. Appropriate Decision Making is reviewed by way of debrief following
each round and discussions on justification and alternative options ensure learning
needs are met. Subject welfare is the focus of all learning, once threat has been
eradicated and control achieved. Officers are encouraged to move on to aftercare at
the soonest most practical time during all scenarios. Where numbers permit, a Safety
Officer is to be used, replicating the operational environment. Instructors will pause
scenarios to direct Officers towards this best practice, and spotlight positive actions.

Should a Student Officer fall short of the expected standards around any of these topic
areas whilst learning, this is immediately addressed through the SBT methodology.
Actions may be paused and rewound, or zoomed in on to address any issues more
specifically. Good practice can be spotlighted for peer-to-peer learning, or breakouts
utilised (advanced teaching to ensure key components are covered). Time on Tasks
activities are used between SBT rounds to further compound learning. These Time on
Tasks can be tailored to meet organisational learning.

Trainer notes for handcuffing from prone and ground pin techniques have been
updated. Snap Guides were published for officers to access operational guidance on
mobile devices. Training now explicitly prohibits elevation or lowering of arms to
achieve compliance.

The new PPST Foundation Training (as with Recertification), is now also scenario based.
Officers are taken through a ten day programme with ad hoc development where
required. This programme is progressive in nature, introducing Learning Outcomes
throughout an initial five-day core, before a Summative Assessment is completed on
the sixth day. Failure to show competence during the Summative Assessment results in
further development on top of any outstanding Learning Outcomes.

Restraint Training is spiralled through the core and assessed at the summative stage,
with various control and restraint techniques introduced. This learning takes place
through SBT, a series of breakouts and supportive materials such as videos and
PowerPoint presentations. With Scenarios being the basis of all learning, Decision
Making utilizing the National Decision Model (NDM) is continually developed and
communication methods explored and reviewed. All scenarios are run from Contact to
Resolution, with decisions also made around prioritisation of tactics and when to
transport subjects.

The welfare of individuals is paramount to Public and Personal Safety. The Use of a
Safety Officer is encouraged in all training where numbers permit (replicating the
operational environment), but should someone be available or not, officers are taught
that focus is always on the welfare of the subject. Topics such as Acute Behavioural
Disturbance and Positional Asphyxia compound learning on monitoring subjects,
sharing information and challenging colleague's actions.

PROTECTING OUR COMMUNITIES

Should a Student Officer fall short of the required standards around these topic areas
during initial core delivery, this is immediately addressed through SBT methodology. An
inability to attain competence will result in additional development sessions being
timetabled. If an Officer falls short of any topics during Summative Assessment, further
development sessions are specifically orchestrated to address learning.

The number of Police Officers completing this training has increased for recertification,
with 4487 officers being licenced between November 2023 and November 2024 in a 2-
day programme. Depending on intake numbers, Foundation Training is delivered to
approximately 500 Officers a year.

Failure to Apply the National Decision Model

In addition to the above, Operational guidance has been expanded to define the role
and responsibilities of the Safety Officer in line with College of Policing Guidance.
Scenario-based training includes decision-making and reassessment protocols.

Ineffective Welfare Monitoring

In mid-March 2025, ACC Bunt delivered a force wide communication to all officers and
staff. This included changes to training and guidance as a consequence of the death of
Mr Ringrose. All police officers and police staff detention officers were mandated to
complete an online E-Learning package titled ‘Safer Restraint’. This training covers the
medical issues that can arise with prolonged restraint, welfare monitoring, situational
awareness and the importance of the role of Safety Officer. The completion of this
learning is being actively monitored and to date 4760 Officers and Detention Officers
have completed this training (95% of the target audience).

Failure to “Speak Up and Speak Out”

Guidance now mandates officers to speak up and speak out when concerns arise. Safety
officer role includes responsibility to challenge unsafe practices.

Training scenarios now include communication and handover protocols. Officers are
instructed to actively engage with medical staff during incidents.

In addition, in June 2025, TVP rolled out the College of Policing’s ‘Upstander’ E-Learning
to all officers and staff, designed to encourage people to ‘speak up and speak out’. A key
part of this training is the 4Ds model, which provides practical strategies for being an
effective upstander.

The 4Ds stand for:

e Direct - Confront the behaviour directly in the moment.

e Distract - Interrupt the situation without confrontation (e.g., change the subject).

e Delegate - Seek help from someone else who may be better placed to intervene.

e Delay - Check in with the person affected afterwards if immediate action isn't safe
or possible.

PROTECTING OUR COMMUNITIES

To date, 5861 people have completed this learning.

Inadequate Communication and Handover

Training scenarios now include communication and handover protocols as detailed
above. Officers are instructed to actively engage with medical staff during incidents.
Inappropriate Prioritisation of Transport Over Welfare

As outlined above, PPST emphasises welfare monitoring during transport and restraint.
Thames Valley Police remains committed to learning from this tragic incident and

ensuring the highest standards of safety and accountability. If | can be of further
assistance, please do not hesitate to contact me.

Yours Sincerely

Jason Hogg
Chief Constable

EEE, PROTECTING OUR COMMUNITIES