Source · Prevention of Future Deaths

Carl Butler and Sean Brett

Ref: 2025-0035 Date: 21 Jan 2025 Coroner: John Gittins Area: North Wales (East and Central) Responses identified: 1 / 1 View PDF

Cheshire Police had confused report management with no officer acknowledgement system and significant delays in delivering critical ANPR/Vehicle Finder system training to control room staff.

Date 21 Jan 2025
56-day deadline 18 Mar 2025 est.
Responses identified 1 of 1
Road (Highways Safety) related deaths Wales prevention of future deaths reports (2019 onwards)

Coroner's concerns

AI summary
Cheshire Police had confused report management with no officer acknowledgement system and significant delays in delivering critical ANPR/Vehicle Finder system training to control room staff.
View full coroner's concerns
The MATTER OF CONCERN is as follows. –

1. There was a confused picture of the management of the reports and information being handled by Cheshire Police insofar as a request for observations would be put out to officers by a communications operator, however there was no requirement for any officer to acknowledge that they had received such a request and therefore no means by which it could be confirmed that any actions were being undertaken as a result of the reports which had been received.
2. There was also confusion within the control room as to the methodology by which a vehicle could be added to an ANPR/Vehicle Finder System, and although an IOPC investigation was finalised in February 2023 which identified potential learning for the force in respect of ensuring control room staff understand the appropriate processes, evidence was heard at the inquest that a witness had not received this training until December 2024 due to a lack of time being made available to her to undertake the same. (Where learning identifies required training/actions, any delays in delivering this, can only serve to perpetuate the risks which such training/actions is aimed at mitigating.)

Responses

1 respondent
Cheshire Constabulary Police / Law Enforcement
PDF
Action Taken

Cheshire Constabulary has reviewed the way in which reports of dangerous driving / drivers are processed and all communications operators and operational officers will receive new guidance requiring clear and sustained attempts to confirm patrol acknowledgement of radio transmissions. All communications operators have attended a specific course which includes ANPR, Hotlist and Vehicle Finder. (AI summary)

View full response
1 S28 Response to John Adrian Gittins, Senior Coroner for North Wales (East and Central) Matters of concern raised within the S28 Response Point 1 There was a confused picture of the management of the reports and information being handled by Cheshire Police insofar as a request for observations would be put out to officers by a communications operator, however there was no requirement for any officer to acknowledge that they had received such a request and therefore no means by which it could be confirmed that any actions were being undertaken as a result of the reports which had been received. Response Cheshire Constabulary has reviewed the way in which reports of dangerous driving / drivers are processed. As part of that change, all communications operators who work within the resource deployment centre (RDC) and all operational officers will receive new guidance as a direct result of the learning from investigation into the deaths of Mr Butler and Mr Brett on 26th February 2022:  Part of the that guidance is the requirement for communications operators to make clear and sustained attempts to confirm that an appropriate patrol acknowledges their radio transmissions regarding observations for drivers or vehicles that pose a risk to the public.  These attempts must continue until it is established that there is either such a patrol available to be assigned, or that there are no patrols available immediately in the relevant location.  Once these facts are established, the call sign of the patrol assigned must be recorded in line with current practices, with the addition of the patrol’s location and their direction of travel. OR  The incident log will be updated to reflect the fact that there are no available patrols and where appropriate, this will be escalated to the Force Incident Sergeant for them to consider deploying a patrol from another geographic location or force.  The practice of operators stating or recording the words ‘nothing heard’ (or similar) in response to any request for an available patrol that is unanswered will cease, and officers will be required to respond over the air. Point 2 There was also confusion within the control room as to the methodology by which a vehicle could be added to an ANPR/Vehicle Finder System, and although an IOPC investigation was finalised in February 2023 which identified potential learning for the force in respect of ensuring control room staff understand the appropriate processes, evidence was heard at the inquest that a

OFFICIAL 2 witness had not received this training until December 2024 due to a lack of time being made available to her to undertake the same. (Where learning identifies required training/actions, any delays in delivering this, can only serve to perpetuate the risks which such training/actions is aimed at mitigating.) Response In court, communications operator Natalia Komorowska stated that she had not received her training until December 2024. Natalia has clarified that she was referring to refresher training and Constabulary training records show that she had received her initial training in March 2021, and she was confirmed as being a competent deployment operator in October 2021. In December 2024 Natalia received a refresher of the foundation and dispatcher NCALTS training. All communications operators who currently work within the resource deployment centre have attended a specific course which includes ANPR, Hotlist (Cleartone) and Vehicle Finder. There is also ongoing continued professional development plan in which all operators (including call taking function) will be required to repeat refresher training. Additional support will be provided by the ANPR coordinator.

Report sections

Investigation and inquest
On the 28th of February 2022 I commenced investigations into the deaths of Carl Anthony Butler (DOB 19.10.67 DOD 26.02,22) and Sean Brett (DOB 03.01.72 DOD 26.02.22) . The investigations concluded at the end of the inquest on the 17th of January 2025. In relation to both deaths, I returned narrative conclusions as follows:

For Mr Butler – On the 26th of February 2022 whilst intoxicated, the deceased drove his vehicle in the wrong direction along the A55 at Broughton and into collision with an oncoming vehicle, sustaining unsurvivable injuries, and as a result he was verified dead at the scene.

For Mr Brett - On the 26th of February 2022 on the A55 at Broughton, the deceased was the driver of a motor vehicle which was struck by another vehicle which was being driven in the wrong direction on the carriageway by a person who was over the prescribed drink driving limit. As a result of the collision Sean Brett sustained injuries which were incompatible with life and was declared deceased at the scene.
Circumstances of the death
On the 12th of February 2022, Carl Butler had been arrested, charged and bailed by Cheshire Constabulary in relation to a drink-drive offence.

At approximately 05.15 on the 26th of February 2022, Cheshire Constabulary received report of an intoxicated driver leaving a petrol station in Chester. (This was Mr Carl Butler driving a vehicle registered to him).

A report was put out requesting observations for this vehicle but the car and driver were not located.

At approximately 11.45 the same day, Cheshire Constabulary received a further report in relation to this vehicle and to the erratic manner in which it was being driven.

Around 30 mins later, Mr Butler drove his car the wrong way along the A55 dual carriageway, colliding with Mr Brett’s’ vehicle coming in the opposite direction, resulting in both their deaths.

Subsequent tests established that Mr Butler was more than four and a half times the prescribed drink drive limit at the time of the collision.

Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN Tel 01824 708047 |
Inquest conclusion
For Mr Butler – On the 26th of February 2022 whilst intoxicated, the deceased drove his vehicle in the wrong direction along the A55 at Broughton and into collision with an oncoming vehicle, sustaining unsurvivable injuries, and as a result he was verified dead at the scene.

For Mr Brett - On the 26th of February 2022 on the A55 at Broughton, the deceased was the driver of a motor vehicle which was struck by another vehicle which was being driven in the wrong direction on the carriageway by a person who was over the prescribed drink driving limit. As a result of the collision Sean Brett sustained injuries which were incompatible with life and was declared deceased at the scene.

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Report details

Reference
2025-0035
Date of report
21 January 2025
Coroner
John Gittins
Coroner area
North Wales (East and Central)

Responses identified

Responses identified 1 of 1
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 18 Mar 2025 (estimated).

Sent to

Cheshire Constabulary

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