Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0502, written 7 Oct 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 7 Oct 2025 |
|---|---|
| Reference | 2025-0502 |
| Deceased | Ann Laskowsky |
| Coroner | Charlotte Keighley |
| Coroner area | West Yorkshire Western |
| Category | Alcohol, drug and medication related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
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 National College of Policing 3 National Police Chiefs' Council (NPCC) 1 CORONER I am Charlotte KEIGHLEY, Assistant Coroner for the coroner area of West Yorkshire Western Coroner Area 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 the 22nd October 2024 I commenced an investigation into the death of Ann Sabrina LASKOWSKY aged 65. The investigation concluded at the end of the Inquest on the 26th September 2025. The conclusion of the inquest was that Ann died as a consequence of naturally occurring disease contributed to by self-neglect and exacerbated by her long standing dependence on alcohol. 4 CIRCUMSTANCES OF THE DEATH Ann Sabrina Laskowski had a long history of significant mental health conditions associated with historic trauma and consequently, she struggled to form relationships of trust with professional and medical services. Ann also had a long history of alcohol dependency and was known to be an adult at risk. At 1200 hours on the 5th October 2024, the inactivity alarm in Ann’s home was triggered, because no movement had been detected inside the flat for over six hours. When Attempts were made to contact Ann, no response was received and so the emergency services were contacted due to the concern for her welfare. At that time, the Ambulance service were unable to attend due to an increased demand for services and so the police were asked to attend, to check that Ann was safe and well. At 1330 hours, two police officers attended at Ann’s home and when they entered, they found her slumped on the sofa. It was noted that Ann was breathing, with body worn camera footage confirming that neither of the Officers commented upon the normalcy of Ann's breathing, which is noted on the video as being both rapid and audible. Attempts were made to elicit a response from Ann, with Officers loudly calling to her and requesting that she open her eyes and wake up. The Officers also sought a response by tapping Ann’s legs at different times and squeezing her hand, however Ann did not open her eyes nor did she wake up. At no stage was Ann considered to be alert, however, both officers considered that she had responded to prompts via some movement of her head and arms and by making noises, Regulation 28 – After Inquest Document Template Updated 30/07/2021 with the officers considering that such movements and sounds were signs that she was responsive. Having decided that Ann was fast asleep and could not be woken, the Officers concluded that she did not require medical attention and therefore an ambulance was not required. Shortly after 1830 hours, an Ambulance attended Ann’s address where Paramedics found her slumped upright on the sofa, appearing very unwell, she was noted to be unresponsive with rapid breathing. Ann was subsequently taken to Bradford Royal Infirmary where imaging undertaken the following day, confirmed a diagnosis of ischaemic colitis with bilateral consolidation of Ann’s lungs and cirrhosis of the liver. Despite treatment, Ann's condition continued to deteriorate and she passed away at 1403 hours on the 6th October 2024. Expert evidence provided during the course of the investigation, confirmed that at the time the police officers attended at Ann's address, she was profoundly unwell and even if, medical attention had been sought for Ann at the time, it would not have prevented her death. 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. The adequacy of First Aid Training provided by West Yorkshire Police The body worn camera footage which was played during the course of the inquest, clearly shows that when the Officers arrived, they found Ann lying slumped on the sofa, appearing pale with an increased respiratory rate. Ann was profoundly unwell and required urgent medical attention. The attending Officers did not recognise the severity of Ann's condition and instead considered that Ann was asleep but could not be woken. This of itself, raises significant concerns in respect of the nature and adequacy of the training that had been provided to the officers at the time. Expert evidence received during the course of the Inquest concluded that even if the Officers had sought medical attention when they attended, given the severity of her condition, such treatment would not have prevented her death. During the course of the Inquest, evidence was received from a variety of sources, in respect of nature and quality of the First Aid Training provided to Officers, in both their initial training and their annual refresher training. This evidence demonstrated an overwhelming lack of clarity in terms of the way in which officers are trained to assess whether an individual is alive, breathing and conscious, something which it is expected that Officers can assess, in line with their authorised professional practice. The very nature of this evidence was such as to raise significant concerns as to the impact of this training upon the preservation of life. There were two main areas in which the lack of clarity and consequent inadequacy of training were of particular concern:- a. The assessment of whether a person is breathing normally and how this is to be assessed; and Regulation 28 – After Inquest Document Template Updated 30/07/2021 b. Whether an individual is responsive or unresponsive, particularly in cases where there may be some involuntary movements from the individuals concerned. 2. The knowledge, use and training in respect of available resources In the course of the Inquest, I heard evidence in respect of a resource or service, known as the ‘Partner Triage Line’. This is a service which has been provided for a number of years by the Yorkshire Ambulance Service which provides a direct line for police officers to speak to a medical practitioner at the emergency operations centre, to seek advice, with the facility for the Officer to send photographs to the practitioner to help inform their advice and an ability for the practitioner to conduct a live video assessment. Differing evidence was heard at inquest in terms of the knowledge of individual officers in respect of that service, with one officer being unaware that there was such a service or resource. In the course of my investigation, I received further evidence confirming that the telephone number for the ‘Partner Triage Line’ is visible and accessible in the contact environment and is then sent to officers on request, but that it is not known or promoted to those officers carrying out operational duties, who are those who are likely to need it the most. I have significant concerns in relation to the knowledge of this valuable resource and its overall lack of use and promotion amongst those Officer who might need it the most. In particular my concerns relate to the following:- The lack of knowledge and use of the service throughout West Yorkshire Police a. given the lack of dissemination and promotion amongst all of the officers to whom it would be of benefit, providing them with the tools to enable them to properly and effectively carry out their duties; and b. The lack of specific policy, guidance or training for Officers in respect of how the service can be used to support them in carrying out their duties, enabling them to keep members of the public safe. This is of particular concern, given that the service has now been available for a number of years. 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 02, 2025. 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 Yorkshire Ambulance Service (YAS) 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. Regulation 28 – After Inquest Document Template Updated 30/07/2021 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: 07/10/2025 Charlotte KEIGHLEY Assistant Coroner for West Yorkshire Western Coroner Area Regulation 28 – After Inquest Document Template Updated 30/07/2021
3 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.
Assistant Coroner Charlotte Keighley West Yorkshire Western Coroner Area 28 November 2025 Dear Charlotte Keighley Regulation 28 Ann Sabrina Laskowsky I am writing in my capacity as Chief Executive Officer of the College of Policing in response to the Regulation 28 report concerning the tragic death of Ann Sabrina Laskowsky. First and foremost, I wish to express my deepest condolences to Ms Laskowsky’s family and loved ones. The College of Policing serves as the professional body for policing in England and Wales, committed to supporting officers and staff in their mission to reduce crime and protect the public. We do this by setting standards, sharing knowledge and best practice, and supporting professional development across the service. The College licenses the First Aid Learning Programme (FALP), which is utilised by Home Office police forces, including West Yorkshire Police. This programme is endorsed by the National Police Chiefs’ Council (NPCC) and the Health and Safety Executive (HSE), and is subject to rigorous quality assurance processes to ensure alignment with HSE guidelines on the provision of first aid. Adequacy of First aid Training In 2023, the College undertook a comprehensive review of the FALP, which was subsequently endorsed by the NPCC. This review expanded both the learning content and the associated training time. The programme now includes high-level learning outcomes covering casualty assessment, primary survey techniques including responsiveness and breathing checks, and recognition of acute alcohol intoxication. These outcomes are embedded in both initial and annual refresher training for all public-facing officers. While the College sets the learning outcomes, individual forces retain discretion over delivery methods, in line with their local clinical governance arrangements. Forces licensed under the FALP are subject to compliance auditing via the Police Service Quality Assurance (PSQA) platform. West Yorkshire Police submitted a full audit in September/October 2022, followed by an interim submission in October 2024. The force has provided evidence demonstrating compliance with FALP requirements, and its next full audit is scheduled for October 2026. Use of Clinical Support Resources The operational deployment of local clinical support tools, such as the Partner Triage Line, is determined by individual forces in collaboration with local healthcare providers and falls outside the scope of the FALP licensing framework. Nonetheless, the College recognises the critical importance of ensuring that learning from incidents involving first aid provision is captured and shared across the policing community. To this end, all Regulation 28 reports and relevant inquest findings are reviewed as a standing agenda item by the NPCC First Aid Forum, for which the College provides the secretariat. The case of Ms Laskowsky will be formally raised at the Forum’s next meeting on 4 December 2025. To ensure that national learning identified through the Forum is effectively disseminated and embedded, the College works closely with NPCC strategic and clinical leads to: • • • - Produce and circulate national learning summaries and practice notes to all forces; - Update Authorised Professional Practice (APP) and training materials where appropriate; - Engage with force training leads and clinical governance advisors to support local implementation. This structured approach ensures that insights from coronial proceedings and operational experience inform continuous improvement in training, policy, and frontline practice. Thank you for bringing this important matter to our attention. We remain committed to supporting the police service in delivering safe, effective, and compassionate responses to those in need. Yours sincerely, Chief Executive Officer College of Policing
Charlotte Keighley
Assistant Coroner
West Yorkshire Western Coroner Area
H.M Coroner’s Court
Cater Street
Little Germany
Bradford
4th December 2025
Dear Charlotte Keighley,
I write on behalf of the National Police Chiefs Council (NPCC) in relation to paragraph 7, Schedule
5 of the Coroners and Justice Act 2009, and regulations 28 and 29 of the Coroners (Investigations)
Regulations 2013, in relation to the prevention of future deaths report sent via email to the NPCC
dated 7th October 2025.
The notice sets out concerns that arose from the information received during the inquest into the
death of Ann Sabrina Laskowsky. I am very sorry to read of the circumstances of Ann’s death. My
sympathies are with her family and friends.
Whilst the College of Policing are responsible for the Police First Aid Learning Programme, and the
quality assurance of the same through their licensing regime, the National Police Chiefs' Council
(NPCC) Health, Safety and Welfare portfolio work closely with the College to ensure that the
content of the FALP is fit for purpose. A full review of the content was conducted by a panel of
doctors and paramedics in 2023 which has been implemented this year, and I can confirm that an
assessment of whether a person is breathing and responsiveness levels are mandated in Learning
Outcome 1.3. Exactly how this is taught is not mandated nationally to allow for local variations in
practice which is determined by each forces' Clinical Governance group with the input of a
consultant-level doctor meeting criteria laid down in NPCC guidelines.
Since receipt of the Regulation 28 report NPCC have met with the College of Policing and West
Yorkshire Police to understand the failings. In the first instance we have recommended to West
Yorkshire Police that they implement clinical governance arrangements consistent with the NPCC
guidance, and have offered support to them in implementing this.
I hope the information provided will go some way to address your concerns. Please do not hesitate
to contact me if you require further action or information in relation to my response.
Yours sincerely,
Chair
National Police Chiefs’ Council
Assistant Chief Constable Force Headquarters Laburnum Road Wakefield WF1 3QP 1st December 2025 Dear Assistant Coroner Keighley, Regulation 28 report relating to the death of Ann Laskowsky Thank you for your report dated 27th May 2025 in respect of the death of Ann Laskowsky. I am aware that you will share my response with Miss Laskowsky’s family, and I firstly wish to express my sincere condolences to them. In providing this response I have consulted with our Learning and Organisational Development team (L&OD) who deliver First Aid Learning Programme for the force. I am aware L&OD have consulted with College of Policing directly in relation to this report. I am also aware the Partner Triage Line has been directly discussed with Yorkshire Ambulance Service (YAS) as part of our continued working partnership. This report and the case itself have been discussed at our Organisational Learning Board to ensure that wider stakeholders across the force understand the concerns, implications and jointly assess how West Yorkshire Police continuously improve our service to the public. Having carefully considered your report, I will respond to each area of concern raised. The adequacy of First Aid Training provided by West Yorkshire Police L&OD met with colleagues from the College of Policing and provided an outline of the training delivery for the First Aid Learning Programme including materials and lesson plans, with specific reference to the areas of concern raised. I understand that College of Policing have written to you personally in response to outline: • Forces licensed under the First Aid Learning Programme (FALP) are subject to compliance auditing via the Police Service Quality Assurance (PSQA) platform. • West Yorkshire Police submitted a full audit in September/October 2022, followed by an interim submission in October 2024. • The force has provided evidence demonstrating compliance with FALP requirements, and its next full audit is scheduled for October 2026. Whilst the training provided by WYP is fully compliant with College of Policing requirements, the force has taken the additional steps set out below to address the 2 concerns that you have raised. The First Aid Trainers now teach Officers that when they are looking for a response using AVPU (Alert, Voice, Pain, Unresponsive) that if they are unable to obtain a ‘suitable response’ from the casualty using Voice or to Pain then the casualty is unresponsive, and they should call for an ambulance. Trainers now invite Officers to question and discuss “what is a suitable response”. A scenario based on a person who appears to be asleep who the Officers are unable to wake up will be used to invite discussion between the Trainer and the Officers to support effective decision making. Officers will now be taught that if someone is asleep and they are unable to wake them using painful stimuli and they do not respond to their voice then this is not normal, and an ambulance should be called. Trainers now teach Officers to be aware of involuntary movements of limbs, head or face and that these are not to be mistaken for a suitable response. The Trainer now emphasises the need to call for an ambulance. Officers continue to be taught if the casualty is not responsive and the Officers have requested an ambulance; they need to check to see if the casualty is breathing and that they should do this by placing the casualty on their back and open the airway by tilting the head back and lifting the chin. Officers continue to be taught that to check for normal breathing they must look down at the chest to see if this is rising and falling and to check for normal/regular breathing by looking, listening, and feeling for a full ten seconds. Anything abnormal such as gasping, wheezing, agonal breathing (irregular, gasping or laboured), shallow breathing, then the casualty is not breathing normally. To assess your concerns about the assessment of whether a person is breathing normally, the Trainers will now include a discussion and clarification and confirmation of 12-20 breaths per minute (they should be taking a minimum of 2 breaths in 10 seconds). If it appears as though they are in distress or it is taking visible effort to breath, this is not normal breathing. The above will be put into practice by using acting casualties who are found in a variety of positions such as face up on the floor, face down on the floor and, also in a sitting position. Finally, Trainers will remind officers whilst on their First Aid Training Courses (including yearly refresher courses) that they can utilise the YAS Partner Triage Line if they need advice from a clinically trained practitioner. The knowledge, use and training in respect of available resources (specifically YAS Partner Triage Line) The YAS Partner Triage Line is one option that Officers can utilise to obtain advice to help to assess a situation or a person’s condition with a clinically include medical/healthcare advice, alongside other partnership professional phonelines including NHS 111, local authority and mental health services. It is important that Officers continue to use the National Decision- Making Model to assess the situation they are faced with to guide their decision making in taking the most appropriate action. trained practitioner. Other options The YAS Partner Triage Line was launched to WYP on 18th January 2021 and was communicated to all staff through force wide messages, briefings and an online learning package. Staff are reminded about the YAS Partner Triage Line by the Corporate Communications Team each year and I can confirm that demand data obtained from YAS demonstrates that WYP continue to use this service every month. Following the conclusion of the inquest into Ann’s death an intranet briefing has been posted to remind everyone of the facility and details of the facility have been included in operational briefings and training and guidance material has been updated to include reference to the Parter Triage Line, which all members have the force have access to via the force intranet. The Right Care Right Person team have been tasked with monitoring the usage of the facility as part of our partnership work with YAS. As set out above, the First Aid Trainers will also remind all officers when they attend their annual first aid training of the YAS Partner Triage Line. Thank you for bringing these important issues to my attention. I trust that this response provides assurance that action has been taken to address your concerns, but please do not hesitate to contact me should you need any further information. Yours sincerely, Assistant Chief Constable West Yorkshire Police
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