Source · Prevention of Future Deaths

George Dillon

Ref: 2024-0488 Date: 16 Jul 2024 Coroner: Henry Charles Area: Hampshire, Portsmouth and Southampton Responses identified: 2 / 2 View PDF

Police lacked adequate understanding, training, and procedures for responding to automated car crash alerts from electronic devices, leading to delayed response and potential risk to life.

Date 16 Jul 2024
56-day deadline 8 Nov 2024 est.
Responses identified 2 of 2
Road (Highways Safety) related deaths

Coroner's concerns

AI summary
Police lacked adequate understanding, training, and procedures for responding to automated car crash alerts from electronic devices, leading to delayed response and potential risk to life.
View full coroner's concerns
A) At 22.26pm Hampshire Constabulary’s control room received an automated telephone call from the deceased’s iPhone indicating that the deceased had been in a serious car crash and was not responding to their iPhone.  The operator logged “no direct request made and cannot hear anything distinctive in the background – no sounds of distress/disturbance”.  An accurate location was provided by the iPhone.  B) The iPhone was called back, but the call went straight to voicemail. C) The control room supervisor forwarded the message to the intelligence team to establish who the iPhone belonged to and whether there was any serious harm or risk to life at that time. D) By 22.43 the intelligence team had drawn a blank.  But for a separate telephone call from a member of the public at 22.45, further steps may have been made to make contact (one of which, an “Icetrak” message which was sent to the iPhone at 22.59 asking whether there was an emergency and requesting  a 999 call if so)  or a Police vehicle may have been assigned to attend the GPS co-ordinates provided by the iPhone or no further action taken. E) The evidence indicated that false alarms from electronic devices such as telephones and watches are commonplace, and that locations received from such devices was often inaccurate and liable to involve substantial Police time in tracking the device down.  F) The Apple serious car crash detection automatic calls were a recent development at the time of the index accident.  Other manufacturers have launched a similar feature. The investigating officer stated during the inquest that “not enough is known (by the police) about this technology within people’s personal phones.”  G) I am concerned that the understanding, training and procedures need review to assist with appropriately prompt response in situations where there is an indication of a collision where a risk to life may exist.

Responses

2 respondents
Hampshire and Isle of Wight Constabulary Police / Law Enforcement
29 Aug 2024 PDF
Action Taken

Hampshire and Isle of Wight Constabulary has updated guidance to operators regarding automated crash detection calls, requiring deployment of officers unless contact is quickly re-established and police are confirmed to be unnecessary. (AI summary)

View full response
Dear Sir Response to Coroner Concerning the Death of George Dillon This is the Constabulary's response to the Regulation 28 Report to prevent further deaths issued by Henry Charles, Assistant Coroner in the matter of George Robert Dillon deceased. In that notice dated 16th July 2024 the coroner outlined his concerns, in respect of an automated telephone call from the decease's iPhone received in Hampshire and the Isle of Wight Constabulary's control room at 22.26pm on 18th
2023. On 22.26pm the Constabulary's control room were notified by BT of a 999 automated call from the deceased's iPhone indicating that had been involved in a collision and were not responding to their iPhone_ 2 The iPhone was called back but went straight to voicemail
3. The control room supervisor forwarded the message to the Intelligence desk to establish who the iPhone belonged to and whether there were any previous markers associated to the number which would indicate the owner of the number could be at risk 4 By 22.43 the Intelligence desk identified that there was no supporting markers
5. The Constabulary's guidance to operators on automated notifications at the time of the incident aligned to its response for abandoned 999 calls: Having failed to receive an answer on call back and with no supporting information to inform deployment the incident would be closed_ In this case had it not been for separate call from member of the public at 22.45 hours police would not have dispatched an officer to the location of the notification where the collision had occurred_ Hampshire & IOW

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6. Evidence at the time identified that false activations from telephones and watches was common place and the locations received often inaccurate and unreliable, to the extent the routine deployment of police resources without supporting evidence was not appropriate. 7 , Apple Crash detection and onward notification was a recent development at the time_ Other manufacturers have since introduced similar automated notifications_ The investigating officer stated during the inquest that "not enough is known (by the Police) about this technology within people's personal phones' 8 . The coroner was concerned that the understanding, training and procedures needed to be reviewed to assist with appropriately prompt responses in situations where there is a notification of a collision or where a right to life may exist. Action Taken At the time of the incident there was no national guidance available as to how police forces should be responding to crash notifications. Following the Inquest Hampshire and the Isle of Wight Constabulary accepted the need to clear guidance in place. As a result immediate action was taken by the Head of Contact Management who; A_ Included in a video message an update and clear direction to all staff as to the expected course of action upon receipt of a crash notification B Arranged for the video message to be followed up with written guidance from the Operations Manager across both Hampshire and Thames Valley Forces (Ex1), with the expectation that operators will deploy to all crash technology notifications if we are not able to get a human response or other information to support it being a false notification. In addition the Constabulary has now developed a toolkit to be made available to all operators and control room staff which is due to go live in September: Once it does copy will be released to the coroner. The toolkit provides guidance for both abandoned and automated notification calls across what are now, range of sources, including Apple Crash detections_ The toolkit directs the call taker to confirm the eastings and northings, to record what was heard in playback; to check whether any incidents have been reported nearby and to search the callers history and undertake precautionary background checks In the case of Apple Crash detection and Ford Notifications if there is no response on call back and no further information the operator is directed to create Grade 1 incident for immediate deployment: Changes have been made in part, because; as recognised at the inquest; the technology has advanced to the extent that the Constabulary's previous approach left room for error, notwithstanding the development of these technologies has taken place with little or . no interaction between the private companies providing these notifications and UK Policing: The Head of Contact Management has since engaged with the Chair of the National Contact Management Support Group, who has confirmed receipt of the coroners PFDNA A copy of the Constabulary s Toolkit has been shared and it is now being used to further national discussion on the subject: Hampshire & IOW

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Finally, am enclosing a copy of the email referred to above (Ex1) Whilst the toolkit itself is not suitable to be shared publically, slide which deals specifically with Apple Crash notifications can be published and is included here as of the email at Exhibit 1.
National Police Chiefs' Council Police / Law Enforcement
6 Sep 2024 PDF
Action Planned

The National Police Chiefs Council (NPCC) will direct a task and finish group on 13th September 2024 to create an agreed national position in relation to automated calls. The 999/112 Liaison Committee will also update its Memorandum of Understanding (MOU) in relation to SOS-Alerts using UK GSM Networks. (AI summary)

View full response
Dear Mr. Charles,

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 regarding the death of George Robert DILLON on 20/05/2023, in my role as NPCC lead for Contact Management.

The notice sets out concerns that arose from the information received during the inquest into the death of Mr Dillon. I am very sorry to read of the circumstances of Mr Dillon’s death. My sympathies are with his family and friends.

Within the Regulation 28 you stated that you have concerns that the understanding, training and procedures in relation to automated crash detection calls into force control rooms needs reviewing to assist with ensuring an appropriately prompt response in situations where there is an indication of a collision where a risk to life may exist.

In my role as NPCC lead for Contact Management I chair the National Contact Management Steering Group (NCMSG), which is made up of representatives from all police forces in England and Wales, plus Police Scotland and the Police Service of Northern Ireland. Attendees also include representatives from government departments, HMICFRS, College of Policing and BT. I will be directing a task and finish group from the NCMSG on 13th September 2024 to work in fast time to create an agreed national position in relation to automated calls, including e-call, mobile phone crash detection and wearables notifications.

I also chair the 999/112 Liaison Committee, which is a cross emergency service and governmental board, with attendees from BT, Vodafone and Ofcom supported by the Department for Science, Innovation and Technology. This committee have ownership of the Code of Practice for the Public Emergency Call Service (PECS) which is the definitive document which deals with the method of handling 999/112 public emergency telephone calls between call handling agents and the emergency authorities. This is currently under review and includes in Memorandum of

Understanding (MOU) in relation to SOS-Alerts using UK GSM Networks. At the next meeting on 11th September 2024, as part of the work already ongoing to review and refresh the PECS, I will task work to update this MOU so that it is fit for purpose in line with the direction of your Regulation 28 document.

I hope the information provided will go some way to address your concerns and I believe these actions fulfil the NPCC’s duties under the Regulation 28 notice. Please do not hesitate to contact me if you require further action or information in relation to my response.

Report sections

Investigation and inquest
On 01 June 2023 an investigation was commenced into the death of George Robert DILLON aged 19.  The investigation concluded at the end of the inquest on 24 April 2024.  The conclusion of the inquest was that:

On the evening of Thursday 18th May 2023 the Deceased was driving a VW Golf south along a country road, namely Lee Lane, Romsey, in the vicinity of its junction with Spaniard Lane when at around 22.16 to 22.26 he lost control of the car by reason of his speed on a crest in the road, and hit a large tree.  He was the sole occupant of the car.  There is no evidence that any other vehicle was involved.  He suffered catastrophic and unsurvivable injuries.  He was taken to the Neurosurgical Unit at Southampton General Hospital where he died from his injuries on 20th May 2023.
Circumstances of the death
On the evening of Thursday 18th May 2023 the Deceased was driving a VW Golf south along a country road, namely Lee Lane, Romsey, in the vicinity of its junction with Spaniard Lane when at around 22.16 to 22.26 he lost control of the car by reason of his speed on a crest in the road, and hit a large tree.  He was the sole occupant of the car.  There is no evidence that any other vehicle was involved.  He suffered catastrophic and unsurvivable injuries.  He was taken to the Neurosurgical Unit at Southampton General Hospital where he died from his injuries on 20th May 2023.
Copies sent to
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Report details

Reference
2024-0488
Date of report
16 July 2024
Coroner
Henry Charles
Coroner area
Hampshire, Portsmouth and Southampton

Responses identified

Responses identified 2 of 2
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 8 Nov 2024 (estimated).

Sent to

Hampshire Constabulary
National Police Chiefs’ Council

Part of a series

2 reports
2024-0489 All responses identified

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