Scott Taylor

Association of Ambulance Chief Executives 
25 Farringdon Street 
London 
EC4A 4AB 

14 April 2026 

HM Area Coroner for Essex  
Sonia Hayes 

Dear Ms Hayes 

SCOTT DARREN TAYLOR (DECEASED) 

I am writing in response to the preventing future deaths report in my capacity as managing director of 
the Association of Ambulance Chief Executives (AACE). 

On behalf of AACE, I would like to extend our sincere condolences to the family of Mr Taylor. 

AACE is a private company owned by the English and Welsh Ambulance NHS trusts. It exists to 
provide ambulance services with a central organisation that supports, co-ordinates and assists with 
the implementation of nationally agreed policy. Our primary focus is the ongoing development of the 
English and Welsh ambulance services and the improvement of patient care. It is a company owned 
by NHS organisations and possess the intellectual property rights of the Joint Royal Colleges 
Ambulance Liaison Committee (JRCALC) UK ambulance service clinical practice guidelines (the 
“JRCALC guidelines”). AACE is not constituted to mandate or instruct ambulance services, however, it 
has national influence via the regular meetings of ambulance chief executives and chairs along with a 
network of national specialist groups.  

We respond in relation to your proposed matters of concern: 

It was agreed in evidence that the set of symptoms consistent with Acute 
Behavioural Disturbance amount to a medical emergency with a significant mortality 
risk.  The evidence was that the Association of Ambulance Chief Executives set the 
Categories nationally that dictate the required classification for ambulance response 
to emergencies, however in some ambulance localities the required response is 
allocated Category 2 and in others Category 1.   This means that there is not a 
national standard for response Acute Behavioural Disturbance with active restraint.    

We agree that acute behavioural disturbance (ABD) is a medical emergency. 

With regard to the required classification for ambulance response to emergencies, AACE do not set 
the categories nationally of ambulance response. Ambulance call codes are determined by NHS 
England by the Emergency Call Prioritisation Advisory Group (ECPAG). We are aware that cases of 
suspected ABD should be assigned a Category 2 response, which is the immediate dispatch of an 
emergency ambulance.   However, ambulance services are advised that a senior clinician within the 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 control room should be made aware of patients presenting with symptoms that are potentially ABD to 
assist with decision-making;  if necessary, this would, in certain situations, such as the use of 
restraint, include upgrading the incident to a Category 1 if the patient’s condition indicated that was 
appropriate. 

With regard to the ABD, over a number of years we have developed and further revised UK 
ambulance service clinical practice guidelines for clinicians. This has been based on learning from 
ABD cases we have been involved with, some of these via coroners’ inquests and preventing future 
death reports. We have published guidance for patients that are agitated, have delirium and have 
suspected ABD. This is to ensure that the recognition, assessment and management of these patient 
presentations are considered by ambulance clinicians. We emphasise in the ABD guidance that the 
condition is a clinical emergency and that the patient may suffer sudden cardiovascular collapse or 
cardiac arrest or both with little or no warning. We stress that the clinician must take all reasonable 
actions to clinically monitor the patient throughout restraint where possible, and that patient restraint 
time must be kept to an absolute minimum – the degree of restraint used must be justifiable, 
reasonable and applied for the minimum time necessary and proportional to the situation. The 
attending ambulance crews should undertake a time-critical transfer and provide a hospital pre-alert 
for suspected ABD cases. 

I hope this is helpful.  Please do not hesitate to contact me should you require any further information. 

Yours sincerely 

Managing Director

East of England Ambulance Service 
 NHS Trust 
Whiting Way 
Melbourn  
SG8 6NA 

HM Area Coroner Sonia Hayes 
Essex Coroners Service 
Seax House, Essex County Council 
Victoria Road South 
Chelmsford 
CM1 1LX 

19 March 2026  

Dear HM Coroner Sonia Hayes 

I am writing further to the inquest into the death of Scott Darren Taylor, which 
concluded on 31 July 2025. I understand that a number of Trust witnesses gave 
oral evidence in respect of the call handling and triaging aspects of the 999 
calls for Mr Taylor on 12 August 2022, who was exhibiting signs of Acute 
Behavioural Disturbance and sadly died on 13 August 2022.  

Ambulance call codings are set by NHS England via a group called ECPAG 
(Emergency Call Prioritisation Advisory Group). However, EEAST had previously 
determined that patients presenting with the symptoms exhibited by Mr 
Taylor should be classified as a Category 1 response (a higher response than 
that set by the Emergency Call Prioritisation Advisory Group), as this 
represented the most appropriate level of urgency. At the time, internal 
procedures required a Clinician to review Category 2 calls and, where 
indicated, upgrade them to Category 1. This happened with the call for Mr 
Taylor and the call was upgraded by a Clinical Co-ordinator to a Category 1 in 
line with the procedure in place at the time. 

I understand you raised the following concerns in the Regulation 28 report 
dated 2 February 2026: 

www.eastamb.nhs.uk 

 
 
 
 
 
 
 
 
 
 
 
 
 
 a.  The police, during the 999 call, were put on hold on three occasions 
by the ambulance service and became increasingly concerned about 
Mr Taylor’s deteriorating condition over an 18 minute period. The call 
remained a Category 2 call despite active police restraint with 
suspected Acute Behavioural Disturbance. Police decided to ‘scoop 
and run’ and urgently convey Mr Taylor to hospital due to the 
severity of their concerns. The EEAST Standard Operating Procedure 
required escalation to Category 1 where there is active restraint, but 
this is not linked to Acute Behavioural Disturbance and remains 
unclear and may continue to cause confusion during triage by contact 
call handlers.    

b.  The East of England Ambulance NHS Trust provide ambulance 

services across 6 counties and that also includes police/healthcare 
professionals reporting Acute Behavioural Disturbance and active 
police restraint. There is concern that there is a different response 
applied and that this discrepancy between Category 1 and Category 2 
responses is significant and could affect the survival of patients.  

c.  The EEAST updated training on Acute Behavioural Disturbance, active 
restraint and reports received from police and correct coding remains 
confusing with the policy and training handouts in December 2023 
with discrepancies between those who are sectioned and those who 
are not.  

d.  The EEAST documents continue to use the term ‘Excited Delerium’ 
interchangeable in some of the training materials and this may lead 
to confusion with contact handlers triaging calls.  

Following the inquest a working group was set up with the intention of revising 
the guidance for patients exhibiting signs of Acute Behavioural Disturbance 
and establishing the most appropriate way to respond to these patients within 
the Emergency Operations Centre.  

The conclusion of this group was the implementation of Emergency Operations 
Centre Standard Operating Procedure 145 in January 2026, which is a 
standalone procedure for cases were Acute Behavioural Disturbance is 
suspected or confirmed by either members of the public or Police. 

 
 
 
 
 
 
 
 
 
 Specifically, the term “excited delirium” has been removed from the 
documentation and the signs and symptoms that could be associated with 
Acute Behavioural Disturbance are outlined and made much clearer.  

The procedure has also been updated to reflect that a Category 1 coding is 
now applied to all calls where the police are actively restraining a patient; or 
reporting agitation/behaviour changes; or the police use the term Acute 
Behavioural Disturbance. The call handler will immediately escalate this to a 
Call Handler Team Leader who will upgrade the call to a Category 1 and the 
response will be dispatched on this basis. If, at this point, the Call Handler 
Team Leader or Dispatcher believe this may not be a Category 1 call, the call 
will be highlighted to a Clinical Navigator who will complete a clinical review 
and triage to establish if a downgrade is required.  

The same process is applied where the caller is a member of the public and 
they state that the patient has taken illicit drugs and is being restrained; or 
reporting agitation/significant behaviour change.  

In addition, both Emergency Operations Centre Standard Operating Procedure 
044 (Patients Detained under the Mental Health Act) and the Guidance on 
Escalation for Emergency Operations Centre staff have been changed to reflect 
Emergency Operations Centre Standard Operating Procedure 145. These have 
also been approved and disseminated to the relevant staff.  

During the inquest you requested further information in respect of the 
progress of introducing protected time for Emergency Operations Centre staff 
for 1:1 supervision and time to review procedure/policy updates.  

From 3 November 2025, all call handling staff have been given 1 hour 
protected time each month for the purpose of reviewing emails and newly 
released policies/procedures; completion of mandatory training; undertaking 
any additional training from the International Academy of Emergency Dispatch 
(the organisation that provide the call handling system); and participating in 
1:1s. There are plans to increase this to 2 hours protected time per month over 
the coming year.  

Providing the same level of protected time for dispatchers has proved more 
challenging although we do acknowledge that the dispatch role has more 
flexibility in their working day and ‘downtime’ to review procedures/complete 

 
 
 
 
 
 
 
 
 
 training etc than the call handling role. It is anticipated this will be fully rolled 
out by 30 June 2026.  

All clinical staff based in the Emergency Operations Centre are also receiving 
monthly 1:1s with their Clinical Workforce Manager for supervision and 
updates to be shared. In addition, any procedural updates are being graded to 
assess whether they are high priority or not. If an update is identified as high 
priority, the member of staff may not start shift until they have read and 
acknowledged this update.  

Please do not hesitate to contact me should you require any further 
information.  

Yours Sincerely, 

Chief Executive

HM Area Coroner Sonia Hayes 
HM Coroner's Office 
County Hall, A Block 
Victoria Road South, Chelmsford 
Essex 
Essex 
CM1 1QH 

Essex Police Headquarters 
PO Box 2 
Chelmsford 
Essex 

27/03/2026   

Dear Ms Hayes, 

Re: Regulation 28 Report to Prevent Future Deaths – Scott Taylor (Ref: 2026-0092) 

I write in my capacity as the senior officer responsible for overseeing the matters arising from your 
Regulation 28 Report dated 2 February 2026, issued following the inquest into the tragic death of Mr 
Scott Darren Taylor, which concluded on 31 July 2025. I would like to take this opportunity to express 
my sincere condolences to Mr Taylor’s family. Essex Police remain committed to learning from this 
inquest and taking appropriate steps to prevent future deaths. 

Your  report  identified  concerns  regarding  potential  disparities  in  the  training  provided  to  police 
officers and Special Constables in recognising and responding to Acute Behavioural Disturbance (ABD). 
The report also raises concerns in relation to the clarity and operational suitability of police policy to 
remove all methods of restraint when an individual appears unconscious. These matters have been 
examined  closely  within  Essex  Police,  informed  by  the  evidence  heard  during  the  inquest  and 
subsequent internal review. 

In relation to ABD, you noted that Special Constables may not have received the same depth of training 
as regular officers. Essex Police acknowledges the importance of ensuring that all officers, regardless 
of role, are equipped to identify life-threatening medical emergencies and respond consistently. As a 
result,  all  officers—regular  and  Special  Constabulary—now  receive  the  same  level  of  training  in 
relation to ABD.  

This change addresses the previous differences created by reduced refresher training time provided 
for  Special  Constables.  Furthermore,  ABD  training  has  been  moved  from  the  First  Aid  Learning 
Programme  refresher  sessions  into  the  College  of  Policing’s  Scenario-Based  Training  programme, 
which ensures that ABD is taught in the context of practical, decision-making scenarios involving the 
National Decision Model, tactical considerations, personal safety, and use-of-force decision-making. 
This training is now fully standardised across both initial and refresher inputs, guaranteeing that all 
officers  receive  consistent  information  irrespective  of  role.  These  changes  ensure  a  more  robust 

Protecting and serving Essex 
 
 
 
 
           
 
 
 understanding  of  ABD  across  the  workforce  and  improve  the  identification  and  management  of 
high-risk presentations. 

You also expressed concern that police officers did not remove handcuffs or leg restraints when Mr 
Taylor appeared unconscious, and that officers did not appear clear that the relevant policy required 
them  to  do  so.  The  policy  in  place  at  the  time  contained  an  absolute  instruction  to  “remove  all 
methods of restraint,” in the case of unconsciousness which, when considered against the operational 
realities of ABD and the unpredictable nature of such presentations, was not sufficiently aligned with 
safe decision-making or with the principles of the National Decision Model.  

Following review at the inquest and subsequent policy analysis, Essex Police has updated this guidance 
to provide officers with clearer, more realistic direction. The revised policy now states that officers 
must remove restraints where it is considered safe and appropriate to do so, and that this decision 
must be informed by the prevailing circumstances and assessed through the National Decision Model. 
This  updated  wording  removes  the  absolute  instruction  that  did  not  reflect  the  operational 
complexities faced by officers, and instead reinforces the requirement for a considered, risk-assessed 
approach that is consistent with officer training and the realities of managing individuals experiencing 
ABD. The updated policy has now been incorporated into both initial and regular refresher training so 
that all officers fully understand their responsibilities and the rationale underpinning these changes. 

Essex Police recognises the seriousness of the issues highlighted in your Regulation 28 Report and is 
grateful for the opportunity to reflect, improve, and strengthen its practices. The actions already taken 
will  improve  the  recognition  and  management  of  ABD,  ensure  consistency  in  officer  training,  and 
provide clearer, more operationally realistic guidance to support officers in making safe and effective 
decisions in highly dynamic circumstances. 

If you require any further information, clarification, or supporting documentation, I would be happy 
to provide it. 

Yours sincerely, 

Chief Superintendent 
Local Policing Commander – South Essex