College of Policing
Police / Law Enforcement
Action Planned
The NPCC First Aid Forum will formally raise the issue of establishing a first aid (CPR) coordinator at its next meeting. The College of Policing will send out a national circular to raise awareness of the Coroner's concerns so that forces can consider a coordinator role in appropriate circumstances while the associated national guidance and training is considered. (AI summary)
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Dear Mrs Louise Hunt (HM Senior Coroner), Regulation 28 Report – Mr Trevor Smith I write on behalf of the College of Policing (the College) 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, prevention of future death report to the College dated the 17th November
2021. The report sets out two primary concerns that arose from the information received during the inquest into the death of Mr Trevor Smith. I was very sorry to read of the circumstances of Mr Smith’s death. My sympathies are with his family and friends and I share your commitment to addressing the concerns that you raise. The College is the independent professional body supporting everyone working in policing to reduce crime and keep people safe. The College has three complimentary functions;
• Sharing knowledge and good practice: creating and maintaining easy access to knowledge, disseminating good practice, and facilitating the sharing of what works
• Setting standards: setting standards for key areas of policing which help forces and individuals provide consistency and better service for the public
• Supporting professional development: setting requirements, accrediting, quality assuring and delivering learning and professional development, promoting diversity and wellbeing, and helping to nurture and select leaders at all levels.
The first concern raised in the report relates to the MARAC process undertaken by West Midlands police, and specifically that potentially significant information disclosed at a meeting to discuss Mr Smith was not effectively cascaded to the SIO or firearms team prior to the policing operation to arrest him. I understand that West Midlands police has provided a response to your concern. Police forces implement localised policies and practice in terms of the recording and dissemination of information and intelligence. The College Authorised Professional Practice for Armed Policing (APP-AP) Armed policing (college.police.uk) provides guidance to firearms commanders in respect of information and intelligence gathering, and the importance of considering the potential that the subject of an operation may be emotionally or mentally distressed. I consider the relevant APP-AP content to be appropriate. My Armed Policing Team has, however, agreed with the National Police Chiefs’ Council (NPCC) portfolio lead for armed policing (Chief Constable Simon Chesterman), to publish a national circular for dissemination to chief officers. The intention is that the circular, which will be sent out imminently, will raise awareness of both of your concerns and will recommend that forces consider local policy and practice in respect of recording and sharing information disclosed during the MARAC process.
Your second concern relates to the provision of CPR to Mr Smith and your report states: The evidence at the inquest confirmed that officers appeared confused about the need for rescue breaths to be given to Mr Smith during resuscitation. The inquest also heard how appointing one person to coordinate the resuscitation (if there are sufficient personnel) would have been of benefit. Consideration should be given to amending policies, procedures and training to ensure one person is allocated to coordinate CPR if it is required. The College licences the First Aid Learning Programme (FALP) used by Home Office Forces, including West Midlands Police. The programme is endorsed by the NPCC and the Health and Safety Executive (HSE). The College is responsible for ensuring appropriate quality assurance processes are in place to guide forces in the implementation of the HSE guidelines relating to the provision of first aid. The requirement in respect of first aid training provided to armed officers is included in the National Police Firearms Training Curriculum (NPFTC). Armed officers receive an enhanced level of training to deal with ballistic injuries and other first aid interventions that may be required during an armed deployment, or indeed any other incident.
While the College sets the required learning standards to be achieved by armed officers, the training to support these outcomes is developed and delivered under local ‘clinical governance’ arrangements. This ensures the appropriate clinical expertise, and the currency and credibility of the first aid interventions that are included. The first aid training delivered to armed officers also has to be delivered within the context of armed operations to ensure its relevance to operational situations. Armed officers must receive first aid refresher training every year, during which they are assessed for their continued competence. The national training and policy do not currently include or mandate the appointment of a CPR or first aid coordinator. Depending on their role and deployment profile, armed officers may deploy in pairs or relatively small numbers. During any incident that involves the use of force, and particularly the discharge of a police firearm, there may be a variety of tasks required of officers (e.g. to mitigate continued threat to the public or the preserve evidence at the scene). First aid provision will always be a primary consideration, however the number of officers, and/or other responsibilities, may impact the ability for a dedicated first aid or CPR coordinator to be identified. That said, I accept that it would be good practice, and there will be instances when it would be either necessary or achievable for a coordinator to be appointed. The APP-AP is regularly reviewed often in response to recommendation and investigation findings, and includes a requirement to prioritise medical assistance and some of the associated considerations for commanders. It was revised in May 2021, and the revised version contains additional guidance in respect of ensuring the prompt attendance of ambulance service staff in the event of police firearms discharge. This amendment was made in response to findings identified by the Independent Office for Police Conduct (IOPC) in their investigation into the fatal shooting of Mr Smith. I consider that the APP-AP already provides appropriate operational guidance. However I do feel that amendments to training could be considered. As a matter of course all coroner reports and inquests related to the provision of first aid by police officers is reviewed by the NPCC First Aid Forum as a standing agenda item. At the NPCC First Aid Forum meeting on the 9th December 2021 the chair raised the issue of establishing a ‘safety officer’ where, if possible, an officer at the scene might provide oversight for colleagues administering first aid. These discussions were not related to the inquest in question but in reflection of possible organisational learning from a similar role being considered for officer personal safety training, specifically when conducting restraint. There was broad support for the idea, and further discussions will take place at the next meeting on 25th March. As a result of your report, the issue of establishing a first aid (CPR) coordinator will also be raised formally as a substantive issue at this meeting. The concept of a coordinator for first aid provision has potentially wider application than armed policing and that wider application, and the policy and training considerations will be progressed by the NPCC First Aid Forum to ensure that national standards and consistency are achieved.
The introduction of a new role will require clear guidance on the responsibilities to be discharged by an officer performing the role and consideration of any additional training requirements. As I have previously indicated the national circular will however raise awareness of your concerns so that forces can consider a coordinator role in appropriate circumstances while the associated national guidance and training is considered. The College works proactively with forces, the NPCC and other agencies to raise standards of practice in the care of people who come to police attention. We would like to thank you for bringing the circumstances of Mr Smith’s death to our attention so that we can ensure that our immediate and future work is informed by the events that culminated in his death.
2021. The report sets out two primary concerns that arose from the information received during the inquest into the death of Mr Trevor Smith. I was very sorry to read of the circumstances of Mr Smith’s death. My sympathies are with his family and friends and I share your commitment to addressing the concerns that you raise. The College is the independent professional body supporting everyone working in policing to reduce crime and keep people safe. The College has three complimentary functions;
• Sharing knowledge and good practice: creating and maintaining easy access to knowledge, disseminating good practice, and facilitating the sharing of what works
• Setting standards: setting standards for key areas of policing which help forces and individuals provide consistency and better service for the public
• Supporting professional development: setting requirements, accrediting, quality assuring and delivering learning and professional development, promoting diversity and wellbeing, and helping to nurture and select leaders at all levels.
The first concern raised in the report relates to the MARAC process undertaken by West Midlands police, and specifically that potentially significant information disclosed at a meeting to discuss Mr Smith was not effectively cascaded to the SIO or firearms team prior to the policing operation to arrest him. I understand that West Midlands police has provided a response to your concern. Police forces implement localised policies and practice in terms of the recording and dissemination of information and intelligence. The College Authorised Professional Practice for Armed Policing (APP-AP) Armed policing (college.police.uk) provides guidance to firearms commanders in respect of information and intelligence gathering, and the importance of considering the potential that the subject of an operation may be emotionally or mentally distressed. I consider the relevant APP-AP content to be appropriate. My Armed Policing Team has, however, agreed with the National Police Chiefs’ Council (NPCC) portfolio lead for armed policing (Chief Constable Simon Chesterman), to publish a national circular for dissemination to chief officers. The intention is that the circular, which will be sent out imminently, will raise awareness of both of your concerns and will recommend that forces consider local policy and practice in respect of recording and sharing information disclosed during the MARAC process.
Your second concern relates to the provision of CPR to Mr Smith and your report states: The evidence at the inquest confirmed that officers appeared confused about the need for rescue breaths to be given to Mr Smith during resuscitation. The inquest also heard how appointing one person to coordinate the resuscitation (if there are sufficient personnel) would have been of benefit. Consideration should be given to amending policies, procedures and training to ensure one person is allocated to coordinate CPR if it is required. The College licences the First Aid Learning Programme (FALP) used by Home Office Forces, including West Midlands Police. The programme is endorsed by the NPCC and the Health and Safety Executive (HSE). The College is responsible for ensuring appropriate quality assurance processes are in place to guide forces in the implementation of the HSE guidelines relating to the provision of first aid. The requirement in respect of first aid training provided to armed officers is included in the National Police Firearms Training Curriculum (NPFTC). Armed officers receive an enhanced level of training to deal with ballistic injuries and other first aid interventions that may be required during an armed deployment, or indeed any other incident.
While the College sets the required learning standards to be achieved by armed officers, the training to support these outcomes is developed and delivered under local ‘clinical governance’ arrangements. This ensures the appropriate clinical expertise, and the currency and credibility of the first aid interventions that are included. The first aid training delivered to armed officers also has to be delivered within the context of armed operations to ensure its relevance to operational situations. Armed officers must receive first aid refresher training every year, during which they are assessed for their continued competence. The national training and policy do not currently include or mandate the appointment of a CPR or first aid coordinator. Depending on their role and deployment profile, armed officers may deploy in pairs or relatively small numbers. During any incident that involves the use of force, and particularly the discharge of a police firearm, there may be a variety of tasks required of officers (e.g. to mitigate continued threat to the public or the preserve evidence at the scene). First aid provision will always be a primary consideration, however the number of officers, and/or other responsibilities, may impact the ability for a dedicated first aid or CPR coordinator to be identified. That said, I accept that it would be good practice, and there will be instances when it would be either necessary or achievable for a coordinator to be appointed. The APP-AP is regularly reviewed often in response to recommendation and investigation findings, and includes a requirement to prioritise medical assistance and some of the associated considerations for commanders. It was revised in May 2021, and the revised version contains additional guidance in respect of ensuring the prompt attendance of ambulance service staff in the event of police firearms discharge. This amendment was made in response to findings identified by the Independent Office for Police Conduct (IOPC) in their investigation into the fatal shooting of Mr Smith. I consider that the APP-AP already provides appropriate operational guidance. However I do feel that amendments to training could be considered. As a matter of course all coroner reports and inquests related to the provision of first aid by police officers is reviewed by the NPCC First Aid Forum as a standing agenda item. At the NPCC First Aid Forum meeting on the 9th December 2021 the chair raised the issue of establishing a ‘safety officer’ where, if possible, an officer at the scene might provide oversight for colleagues administering first aid. These discussions were not related to the inquest in question but in reflection of possible organisational learning from a similar role being considered for officer personal safety training, specifically when conducting restraint. There was broad support for the idea, and further discussions will take place at the next meeting on 25th March. As a result of your report, the issue of establishing a first aid (CPR) coordinator will also be raised formally as a substantive issue at this meeting. The concept of a coordinator for first aid provision has potentially wider application than armed policing and that wider application, and the policy and training considerations will be progressed by the NPCC First Aid Forum to ensure that national standards and consistency are achieved.
The introduction of a new role will require clear guidance on the responsibilities to be discharged by an officer performing the role and consideration of any additional training requirements. As I have previously indicated the national circular will however raise awareness of your concerns so that forces can consider a coordinator role in appropriate circumstances while the associated national guidance and training is considered. The College works proactively with forces, the NPCC and other agencies to raise standards of practice in the care of people who come to police attention. We would like to thank you for bringing the circumstances of Mr Smith’s death to our attention so that we can ensure that our immediate and future work is informed by the events that culminated in his death.