Andre Moura

Dear Ms Mutch Re: Regulation 28 Report into the death of Andre Moura I am writing in response to your Regulation 28 report following the investigation and inquest into the tragic circumstances of the death of Andre Moura on 7th July 2018. I hope to answer the concerns you raised that are listed within section 5 of your report, which are listed as follows:

1. During the course of the Inquest, evidence was heard about the understanding and training in relation to Acute Behaviour Disturbance (ABD). All of the officers who had received their College of Policing Personal Safety Training had been trained on the ABD module within that package. However it was clear that the training package had not achieved the objective i.e. to recognise ABD in a real life setting. The Inquest heard that ABD is an umbrella term and not all of the symptoms need to be present for someone to be suffering from ABD. It was clear from the officers’ evidence that the videos played in the training particularly of extreme examples of ABD had led them to not consider or recognise ABD in this situation. The Inquest heard that it could be difficult to recognise ABD in a dynamic situation but the training was there to ensure officers considered it in situations where it was a possible explanation for behaviour seen by officers. An emphasis on the nuances and less on extreme examples may assist in improving the recognition of ABD;

In 2020, the College of Policing commenced a national working group to update the First Aid Learning Programme (FALP). The review that took place considered recommendations made by Coroners and the IOPC, including the detail of learning outcomes on Acute Behavioural Disturbance and treatment of head injuries.

The FALP has now been published and includes a revised learning outcome “recognise the signs and symptoms of acute behavioural disturbance”

The new Public and Personal Safety Training (PPST) for all police officers has recently been developed with the emphasis on de-escalation. It is a scenario-based method of delivering training and is focused on learning, decision making, understanding decisions and de-briefing decisions. The updated training will include identification of the signs and symptoms of ABD and management of the incident with the focus now being on de- escalation and ‘contain rather than restrain’, where officers suspect a person to be experiencing ABD. There will also be an emphasis on treating ABD as a medical emergency and seeking immediate medical assistance.

2. The Inquest heard that the ABD training did not have any formal way of measuring/testing knowledge but was reliant of the perception of the trainer. A more formalised approach may have increased the ability of officers to recognise ABD;

The new PPST is designed to be an interventionailist style of training delivery. The trainers observe the students managing the scenarios. The training is stopped at regular intervals when the trainers will test the knowledge of the students and get the students to explain the rationale for their decisions. PPST is a pass or fail course.

3. The role for a safety officer which is part of the College of Policing training in a situation such as this was not recognised. The Inquest heard evidence from an expert witness that a safety officer plays a key role in an incident such as the one involving Mr Moura and ensures key information is not lost/shared. This lack of an officer at his head taking on such a role emphasised the fact that although officers had attended the PST training key points had not been retained. Greater emphasis on this role in training would be beneficial in reducing the risk to prisoners being restrained;

Assessment criteria for the new PPST includes a requirement that officers must be able to demonstrate to trainers the correct response to a person experiencing ABD. This includes the appropriate use of a Safety Officer. The requirement for the use of a Safety Officer is also a learning outcome for all multi-officer restraints within the PPST programme. From April 2024, the College of Policing will be conducting a quality assurance process and will undertake licence moderation visits to ensure that forces comply with the new national standards.

4. Many of the officers who gave evidence indicated that they believed that Mr Moura was feigning his lack of responsiveness. This was despite the fact that there was very limited evidence of officers carrying out the recognised AVPU checks. Officers relied on their own perceptions rather than AVPU. An officer who did carry out AVPU did not clearly share his lack of responsiveness with other officers. The Inquest heard that there is no formal training on what officers should do if they believe a prisoner under arrest is feigning unresponsiveness. Clarification and enforcement of the need for objective use of AVPU may well prevent subjective assessments leading to erroneous and potentially fatal conclusions that a prisoner is feigning lack of responsiveness;

The College guidance does not support any change in approach where officers may believe that someone is feigning a lack of responsiveness. All ABD guidance is focused on how to treat the displayed symptoms and should be followed regardless of any suspicions that symptoms are feigned.

The new PPST training implementation went live in 2023 and forces are required to have implemented or be in the process of implementation by April 2024. The revised ABD training package will be published mid-September 2023. I hope this helps to answer the points that were raised but if we can assist with anything further, please do not hesitate to contact me.

Dear Ms Mutch,

Regulation 28 Report – Mr Andre Moura

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 10th July 2023.

The notice sets out concerns that arose from the information received during the inquest into the death of Mr Moura which occurred in July 2018. I am very sorry to read of the circumstances of Andre’s death. My sympathies are with his family and friends, and I share your commitment to addressing the issues you have highlighted.

I note you set out five areas of concern, four of which focus on College of Policing Personal Safety Training, with particular focus on Acute Behaviour Disturbance (ABD). I am aware the College of Policing have written to you separately to address these points and have shared the timeframes for implementation of new Public and Personal Safety Training and revised ABD training.

In relation to point 5, we are in the process of re-writing and revising the NPCC Body Worn Video (BWV) guidance and it has been agreed that we would include that BWV should be left running during periods of prisoner transport, due to the vulnerability of officers and subjects during that process, and to provide a documented account of that journey. This guidance will be published in October, and I share the relevant draft wording below: “Recent national events and feedback from HM Coroner have identified vulnerability when transporting prisoners/subjects to custody centres or places of safety. All transporting and escorting officers should have their BWV activated during this journey as a record of that journey and any

incidents that occurred within. Any decision made not to record a journey should be strongly justified on their camera prior to stopping recording. This is to include any transport within vehicles that may have a separate camera system within them, such as caged vans, as there may be limitations to some of these systems, such as no audio and a short retention period that means footage may be auto deleted before its requirement is known. Forces should check who manages the data from these camera systems and how long footage is stored for, and ensure that between the use of BWV and in-vehicle solutions, that a journey is covered by both/either, and data can be accessed and processed efficiently.” I hope that the information that has been provided goes some way to reassure you that the matters of concern you have raised have been addressed and will be subject to continual review.

For any further information please contact my Staff Officer

who will be happy to address any concerns and answer any questions.