Neal Saunders

Dear Mrs Connor, Thank you for your report sent by letter dated 15th December 2022 under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 in respect of circumstances surrounding the untimely death of Mr Neil Saunders. Your report contains the following matters of concern: The key concerns around training can be summarised as follows:-
1. How long is “prolonged” restraint?
2. One of the witnesses questioned whether the guidelines applied at all if somebody is under arrest, particularly regarding “contain rather than restrain”. Given that these are police guidelines, it seems to me likely that they would apply, whether a person is arrested for public order offences or other matters (but that should be clarified).
3. The College of Policing slides regarding ABD state that a “Cat 1 call” should be made to the ambulance service. The slides go on to say that the ambulance service should respond to ABD as a “category 1” [response]. It is clear that categorisation would be a matter for the ambulance service rather than the police, and this training may result it inappropriate expectations on behalf of officers at scene, who are expecting an ambulance to arrive more quickly that it in fact does. This in turn could affect their decision-making.
4. The guidelines also refer to providing “chemical sedation”. This appears to me to indicate an incorrect understanding of what is likely to be done medically by a first responding paramedic or emergency care assistant.

Chief Constable Thames Valley Police Thames Valley Police Headquarters Oxford Road Kidlington OX5 2NX Date : 09/02/2023

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5. It was interesting to note that the parts of the training the officers did seem to remember were around when the training was provided in a very physical way (around positions for restraint etc.) and the final slide “ABD = A&E”. It appears that the more “classroom based” training is less well received. I understand that the College of Policing is changing its methods, and it may be that an educational consultant with policing background could assist with this in trying to achieve training that will stick with those being trained more effectively.

6. Is there a better way for the College of Policing to ensure that the training has worked and is embedded?

Training generally

I raise 2 points here:

1. Checking of guidance which is infrequently used

2. Joint training with ambulance services

Response to the Regulation 28 concerns

On receipt of your letter, Thames Valley Police (“TVP”) convened a group, chaired by Chief Superintendent , to address your concerns. This group comprised of senior representatives from the College of Policing (CoP); South Central Ambulance Service NHS Foundation Trust (SCAS); Association of Ambulance Chief Executives (AACE)/ National Ambulance Services Medical Directors (NASMeD)/JRCALC); and TVP’s Medical Director

, Consultant in Emergency Medicine and Pre-Hospital Care.

Our response to the specific matters of concern set out in your notice are detailed below.

1. How long is “prolonged” restraint?

• The College of Policing have advised that there is no set definition for ‘prolonged restraint’. As a result, and on the advice of , the teaching outlined below will be based on the assumption that within individuals, the physiological changes that can take place during restraint are dynamic, in that they are different for each person and in each situation. The teaching will reinforce Officer’s staying alert to the needs of the subject at all times.

2. Clarification of ‘contain rather than restrain’

• At any incident, Officers will have a range of tactical options available to them in terms of the subject management. Using the National Decision Model (NDM), Officers will decide on what tactic(s) may be necessary, justified, proportionate and legitimate. The decision to contain rather than restrain is for the Officer to consider, and applies whether the subject is under arrest or not. The Training

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material on this issue has been updated to ensure that Officers understand this point.

3. Police expectation of a ‘Category 1’ response by Ambulance Service

• Guidance received from SCAS and the AACE has clarified the nationally mandated list of Category 1 call ‘types’ and the descriptions. The AACE have confirmed that ABD would be classified as a Category 2 incident. This will only be upgraded to a Category 1 if the clinical picture dictates it. As a result, TVP’s teaching materials have been changed to place greater emphasis on the signs and symptoms of ABD and the physical effects of restraint.
• On contacting Ambulance Services, Police Officers, Special Constables, Police Community Support Officers, and Detention Officers will be taught to be as accurate as possible in describing a subject’s history (appropriate for the level of an Emergency First Aider), signs and symptoms, and the importance of providing updates to any changes in condition.

• The original references to ABD being classified as a ‘Cat 1’ Ambulance Response and the use of ‘chemical sedation’ which was included in the CoP’s ABD E-Learning package, have been removed by TVP and training materials updated in accordance with the guidance from SCAS and the AACE. As such, it will still be taught that ABD is considered a medical emergency.

4. Guidance referring to ‘chemical sedation’

• Please see response above.

5. Classroom based verses physical training scenarios

• TVP’s response includes new learning materials and programmes for all frontline Officers and Staff who have direct contact with the public. This learning will be blended learning which will include classroom-based inputs, supported by written material and subject to practical assessments, which will include a physical scenario to consolidate learning as set out below.

• Police Officers, PCSOs, Special Constables and Detention Officers (as defined above), are required to achieve re-accreditation in Public and Personal Safety Training (PPST) and First Aid Training annually, as mandated by the College of Policing.

Public and Personal Safety Training:

• In April 2023, the College of Policing are introducing a new PPST 2-day training and assessment re-accreditation programme for all Forces nationally. The new programme will be based around six scenarios to aid officer’s learning and the retention of knowledge and skills. Forces have until the end of March 2024 to introduce the new programme, which is due to go live in TVP on 14th November
2023.

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• Before the introduction of the new CoP PPST programme, TVP will be re- accrediting Officers and Staff who require re-accreditation prior to November with an updated training package. Delivery of the new 1-day package (called PST Mod 1) will start on 2nd March 2023 through to November 2023.

• PST Mod 1 training will start with an operational update presentation, designed to cover the organisation learning from the Neal Saunder’s Inquest, ABD and issues related to Prone Restraint. Officer’s will receive refresher training on what ABD is; it’s physical signs and physiological symptoms; how it should be treated as a medical emergency; and how Officer’s should call for an Ambulance and update the Police Control Room. Officer’s will also be refreshed in the application of Prone Restraint and the safety considerations around signs and symptoms of positional asphyxiation, and the use of the National Decision Model (NDM) and the principles behind the use of a Safety Officer to act as an advocate for the subject.

• Learning related to the Operational Update Presentation will then be reinforced and assessed within the practical elements of the training day, this includes a 4- stage layered scenario. The scenario is designed to escalate through from a compliant subject (at Stage 1), to a non-compliant subject who becomes unresponsive during control, requiring the officers to recognise this and take the appropriate action (at Stage 4). Training will include an assessment of Officer’s understanding of the impact of physical restraint; medical implications; consideration of ‘contain rather than restrain (if safe to do so)’; communication processes, de-escalation, and the escalation of the medical emergency.

• Following the scenario, each Officer will complete the Mod 1 2023 written test which consists of 10 questions covering the knowledge areas of ABD and Prone Restraint. Those officers that do not achieve 100% will be notified, along with their Supervisor and the appropriate development learning will be sent in an e- mail with the appropriate presentation for the Officer to review.

• The Training Resources relating to the training described above can be provided at your request, should you wish to view them. These include:- PST Mod 1 Lesson Plan 2023 – This document summarises the content that sets out the aims, objectives and timetable for the training PST Mod 1 Op Update Presentation 2023 – PowerPoint presentation that addresses Service Improvement Requirement (Reg. 28), What is ABD, How it presents, What do we do, Prone restraint, National Decision making Model (NDM) and NDM Subject perspective. PST Mod 1 Operational Update Trainer Notes 2023 – Trainer notes are documents that trainers use as reference and provide the detail of the content to be delivered by the training team to ensure consistency. PST Mod 1 Layered Scenario 2023 – Trainer Notes PST Mod 1 Positional asphyxia Drill 2023 – Trainer Notes PST Mod 1 2 Officer Control PST Mod 1 Written Test

• The relevant sections of TVP’s PST MOD 1 training material have been reviewed by the CoP and feedback incorporated.

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First Aid Training:

• To reinforce the organisational learning further, TVP will also ensure that additional training material is included within all First Aid and Medics training programmes from the 1st May 2023. This will ensure that Officers and Staff who have direct contact with the public will receive key aspects of this learning within both their mandatory training inputs (PPST and First Aid re-accreditation, i.e. twice in any year).

• The material added into First Aid training will include an expansion of the CoP material on Acute Behavioural Disorder (ABD), written in conjunction with the guidance received from SCAS and AACE to ensure consistency. This will include signs and symptoms related to ABD, and the physiological effects of restraint; guidance on information to Ambulance Control and why ABD is a medical emergency.

• New material added to the E-Learning element of First Aid / Medics Training packages is assessed within the practical skills assessment phase of courses. This blended learning approach ensures Officers and Staff have and retain access to the knowledge components of their training, whilst the practical skills assessments test that retention and application.

• The Training Resources relating to the training described above can be provided at your request, should you wish to view them. These include:- First Aid Training – additions to E-Learning 2023 HSD1C First Aid Trainer Notes 2023 – reference notes and content detail for the training team to ensure consistency.

Initial Training (Police Officer, Police Community Support Officer, Special Constable, Detention Officer):

• Initial training programmes for all Police Officers and Staff in Public and Personal Safety Training and First Aid, are being updated to include new material on ABD and restraint, and a written test included to check knowledge. As with reaccreditation training, practical skills assessments will further check that the knowledge components have been retained, and skills applied correctly.

• The training resources relating to the training described above can be provided at your request, should you wish to view them. These include:- Foundation ABD PowerPoint– Amended and will be delivered until the new the CoP ABD guidelines and package is available. Foundation ABD Trainer notes – Updated to include learning and good practice identified. Foundation written Test - updated to include questions on ABD.

Contact Management Training

• Training specifically focused on Control Room and Contact Centre staff will begin in May 2023. This will raise awareness around Acute Behavioural Disorder, its

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signs and symptoms; what to do if officers are at scene with a suspected ABD patient and why this is a medical emergency. The training will also raise awareness that when dealing with ABD, the importance of using the full name of the medical condition and not using acronyms, especially when passing details to SCAS. In the interim, all staff will be briefed on this specific point. The briefings will be conducted by an Inspector/Operational Duty Manager at their place of work and all staff receiving this briefing will sign to say they have understood what is expected of them.

• It is worth noting that last year, 2022, the Contact Management PCR, Contact Management Centre and Front Counter Staff all received bespoke NDM THOR (Threat Harm Opportunity and Risk) training delivered by the departments’ key decision makers, Force Incident Inspectors and Operational Duty Managers. This training was designed to support and equip our staff making better-informed decisions when managing open incidents and receiving calls from the public.

• There is no written protocol around how a medical emergency is relayed to the Ambulance Service from Police. It is decision, based on circumstance as to who is best to pass the most accurate and timely information. The training will include the following - if the officer at the scene suspects ABD, then the Control Room Operator will state to the ambulance call taker that ‘acute behavioural disorder’ is suspected, and fully document this in the incident log. The Control Room Operator will inform the officer on scene that the Ambulance Service will be ringing their mobile phone, for greater detail of the patient’s symptoms and situational awareness. If circumstances allow, best practice will be that the officer on scene rings 999 and speaks directly to the Ambulance Service. This will be an auditable interaction via the Ambulance Control Rooms recorded lines and the officer will have initiated their Body Worn Video.

• Due to the dynamic nature of ABD and associated medical conditions, it is extremely difficult for Control Room Operators to assess if, or when to proactively remind officers of guidance in this area. The College of Policing does not provide a definition of prolonged restraint and several factors such as age, health, substance misuse and fitness may not be apparent to Control Room staff. Planned training will address this issue. By using the National Decision Making Model and inputs on THOR, Control Room staff will be encouraged to use their professional curiosity and proactively interject reminders to officers on scene relating to ABD and Prone Restraint ‘SNAP Guidance’ products. In a similar way, Control Room staff sometimes remind officers around Body Worn Video use, Personal Protective Equipment and Stay Safe advice.

6. Assessing and embedding training

• Measures taken to assess knowledge and skills and reinforce learning and retention are set out in the answers above.

• However, because any annual recertification programme will take time to reach all front line Officers and staff, TVP will issue an operational briefing by the end of February 2023, to highlight the key organisational learning and draw attention to the new SNAP Guides on ABD and Prone Restraint.

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7. Checking of guidance which is infrequently used

• In response to the Reg. 28 section which states ‘I consider that police officers should be mandated to review guidance (whether APP guidance or otherwise) in any scenario that they have not (or not recently) dealt with’, we have considered whether it would be practicable to mandate officers to periodically review what amounts to 282 SNAP Guides, 222 Operational Guidance notes, and APP covering a 24 areas. Given the high volume of this guidance, this has not been deemed practicable.

• TVP have mechanisms to communicate guidance e.g. through LPA operational briefings, and where risk is identified we already mandate completion of training or viewing of operational guidance.

• The Governance and Service Improvement Unit have designed a number of condensed versions of operational guides, known as ‘SNAP Guides’ to act as Aid Memoirs or Field Guides for operational Officers and Staff. These are available on operational mobile phones, and a number of communication initiatives to publicise the SNAP Guides, including visits to LPAs have taken place.

• Two new SNAP Guides to cover ABD and Prone Restraint are being designed (to be compliant with feedback received from the CoP) and will be available and disseminated by the end of February 2023.

• In addition, within PPST training, which includes the National Decision Making Model (NDM), specific guidance on how to apply the NDM to manage vulnerability, has been included.

8. Joint training with ambulance services

• TVP has been in contact with SCAS regarding the feasibility of joint training. It has been jointly agreed that logistically this would be difficult to achieve with the current recruitment and operational demand volumes. However, the benefits of greater sharing of guidance documents was evident and there is a clear appetite from TVP and SCAS for this to continue. The mechanism for this will be via the Clinical Governance Board chaired by the Assistant Chief Constable for Joint Operations and Contact Management.

I hope the actions taken by TVP go towards satisfying the concerns you have raised with regard to the sad circumstances around Mr Saunders death, but please do not hesitate to contact if you have anything further for us to consider in this regard.

Dear Mrs Connor

We are writing to you in response to the concerns that you highlighted following the inquest hearing into the sad death of Neal Saunders that concluded on 2nd December 2022. Thank you for allowing us the time to review and respond to your concerns.

To confirm, your Regulation 28 report was predominantly aimed at the national bodies responsible for providing training and guidance to police and ambulance service emergency personnel. Within that report, you asked the South Central Ambulance Service to consider working jointly with Thames Valley Police (TVP) to review our policies and training as suggested by our Medical Director during the evidence he provided to you.

I am pleased to inform you that in addition to meeting with representatives from TVP, we have also participated in discussions with representatives from the College of Policing and the Association of Ambulance Chief Executives in relation to the written Joint Royal Colleges Ambulance Liaison Committee (JRCALC) UK ambulance service clinical practice guidelines provided to ambulance staff and the training slides delivered to police officers.

Accessing JRCALC guidelines.

As you will be aware from previous correspondence and engagement with the Trust, we provide our staff access to the JRCALC guidelines via the mobile APP. This ensures that they are able to access the most up to date version of the guidance for any condition or set of circumstances they may be presented with when they are with the patient they are treating. Whilst it was apparent during the evidence that you heard that the paramedic involved in this specific case, who worked for a private provider rather than the Trust, was not aware of some of the specific wording of the guidelines, he was aware that placing someone in a prone position should be avoided generally. From our review, there is no evidence that staff employed by the Trust have experienced any difficulties in accessing the guidance whether due to them being unaware of how to or because of technical difficulties in doing so. We are therefore confident that staff will always be able to review the guidelines when necessary.

Guidance regarding restraint.

We are aware that nationally, there is not a definition of what would constitute prolonged restraint. Evidence was provided to you regarding this during the inquest hearing. The guidance currently provided to ambulance staff confirms that any form of patient restraint should be kept to a minimum and the form of restraint must be justifiable based on the circumstances. Currently ambulance personnel do not receive any specific training regarding physical restraint. We are aware that The Association of Ambulance Chief

Executives (AACE) has recently appointed a national lead in relation to this with the intention that a national training standard specific to ambulance personnel will be produced. We have liaised with them regarding this as well as exploring the options that could be available for the design of a training package for our staff. This project of work is ongoing and we will of course ensure that any training that is delivered in the future is compliant with any national standard that is set by AACE.

In the interim, it is our intention to strengthen the direction we provide to our staff to ensure there is a clear understanding of the role they must play when attending to a patient who is subject to restraint by police officers or has been restrained prior to our attendance. The guidance will confirm that once in attendance ambulance personnel are clinically responsible for the wellbeing of the patient and they must work with police officers to ensure that any restraint is subject to continuous review and adjusted where appropriate to ensure the wellbeing of the patient whilst they are conveyed to a definitive point of care. This will include making enquiries regarding the length of time the patient has been subject to restraint prior to the arrival of the ambulance crew. The guidance will also reiterate the risks of placing the patient in a prone position whether during conveyance or whilst being treated on scene to ensure as far as possible there is a clear understanding of these risks and how to avoid them.

If required, we would be happy to share these guidance documents with you once they have been finalised and signed off by our relevant internal review groups.

Joint working with TVP

In relation to the steps that we are taking to enhance our joint working with TVP, the following steps have been taken:

1. Call centre management
a. Our Head of Education and Quality Assurance (Clinical Co-ordination Centres) has met with their equivalent at TVP and shared NHS Digital’s guidance document called ‘Spotlight On: Acute Behavioural Disturbance (ABD)’. We understand that TVP intend to use this to update the training and guidance they deliver to their staff.
b. In addition we have drafted a directive regarding using the phonetic alphabet to pass over and receive information from other emergency services. As you know, in this specific case, the incorrect information was provided to the Trust by TVP which affected the category of ambulance response initially reached. Going forward, whilst the full name of the medical condition will always be confirmed, any acronyms will be handed over phonetically as well to minimise the risk of information being lost in translation.
c. We are also working with TVP to ensure that their officers are aware that our call takers will attempt to contact them at the scene so that a more accurate triage can be undertaken. Whilst it is recognised it may not always be possible for a police officers to answer their telephone, it is important that police officers understand the process that will be followed so that the appropriate category of ambulance response can be arranged for the patient.
2. Operational staff
a. It has been agreed and accepted by both TVP and SCAS that regrettably due to operational demands, joint face to face training is not currently feasible. This will however be kept under review.
b. The intention moving forward is for each organisation to regularly share guidance and policy documents to promote joint understanding and cohesive working.

I hope that this letter has adequately addressed the concerns that you have raised. Should you wish to discuss these matters further, please contact , Head of Legal Services at SCAS who will be able to facilitate this.

Dear Mrs Connor Regulation 28 report, Neal Terence Saunders Thank you for providing the College of Policing with your Regulation 28 report in respect of the tragic death of Neal Terence Saunders. I would like to assure you that we take the recommendations in your report extremely seriously and will ensure that the learning from this incident is incorporated into our training and guidance. The College is currently implementing a new mandatory training package for Public and Personal Safety Training (PPST) along with an updated national curriculum and Authorised Professional Practice (APP). The nationwide roll out of this programme will commence in April 2023 and all forces must achieve implementation by April 2024. This will result in police forces delivering PPST to a common national standard which will be subject to an ongoing quality assurance process by the College. The training is a two-day annual package which is delivered in person and is focused on supporting learners with information retention. The new PPST has a strong focus on de-escalation and communication skills. The training is based around scenarios which incorporate identifying and managing vulnerability, dealing with signs of medical emergency and requesting appropriate medical emergency responses. This will include important content to equip officers and staff to recognise and respond appropriately when faced with ABD. In respect of the six points in your report, our response is as follows:
1. ‘Prolonged restraint’ is not currently defined. This issue has been tabled for discussion at the national Clinical Governance Panel and we will look at ways to use clinical expertise to inform work in conjunction with College PPST leads.

2. The new PPST content will be clear that the guidance applies to those who are restrained in any circumstances, including people who are under arrest.

3. We will ensure that the revised training and guidance makes it clear that the response from the ambulance service is a matter for them, and the important point for policing is to ensure that relevant information is communicated so that ambulance despatchers can make appropriate decisions on prioritisation.

4. References to ‘chemical sedation’ will be removed from training.

5. & 6. The new PPST delivery has been carefully developed and refined following a 12- month pilot. We are confident that this will be an improvement on previous training and will deliver a nationally consistent approach.

The aforementioned new scenario based training is designed in order to ‘embed’ learning and make the training true to life.