Source · Prevention of Future Deaths

Paul Reynolds

Ref: 2021-0151 Coroner: Jacqueline Devonish Area: Suffolk Responses identified: 2 / 2 View PDF

Pontins' physical intervention policy was inadequate, lacking proper staff training, allowing unbadged personnel in restraints, and failing to ensure proper monitoring for positional asphyxia.

Responses identified 2 of 2
Other related deaths Police related deaths

Coroner's concerns

AI summary
Pontins' physical intervention policy was inadequate, lacking proper staff training, allowing unbadged personnel in restraints, and failing to ensure proper monitoring for positional asphyxia.
View full coroner's concerns
(1) The Physical Intervention Policy August 2016 places the onus on staff to seek additional training.

(2) Pontins does not undertake any internal training or employ external trainers for security staff.

(3) Unbadged staff are allowed to participate in restraint (4) Ground restraint remains in the PI policy as an appropriate method to contain an incident even though this is not taught in SIA accredited courses.

(5) At no point during the prone restraint was Mr Reynolds placed in the recovery position. Neither did any member of staff appear to seriously consider the potential for positional asphyxia by closely or effectively monitoring Mr Reynolds breathing.

(6) There appeared to be no clarity in the Policy about who should take charge of an incident or what the responsibilities are for security staff and Managers.

(7) There appeared to be a lack accurate information and clarity around what information should be shared with the police about the incident.

(8) There was no documented evidence of the induction or any other training for staff.

Responses

2 respondents
Britannia Jinky Jersey Ltd
PDF
Action Planned

The company is planning to remove ground restraint references from its Physical Intervention Policy and re-emphasise that non-badged staff are not permitted to participate in restraint. It is also investigating engaging external providers for annual refresher security training. (AI summary)

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Dear Sirs: Re: Regulation 28 Report As you will be aware there was a delay in the report being received by me. Having considered your report, I respond on behalfof Britannia Jinky Jersey Ltd as follows: The Company's policy regarding SIA badged training at the time of the incident was that those being recruited were required to produce their current SIA licence confirming that they had complied with the requirements of the SIA. We take on board your observations regarding external service providers and we are looking into the prospect of engaging external training providers to deliver annual refresher trainingto all security badged staff. The ground restraint references in the Physical Intervention Policy will be removed. As per the documentation which was provided to prior to and during the inquest the Company emphasise in their training that employees should avoid confrontations and to defuse situations. The incident involving Mr Gladwell was unprecedented as I believe you heard in evidence during the Inquest. Your concern regarding the information given by staff to the police is unclear as I believe you heard in evidence that the employees in question responded to all questions asked of the Police and described the circumstances leading to his restraint and police attendance. I would like to make it clear that it is not the case that non badged staff are allowed to participate in restraint. As part of our revisions to the Physical Intervention Po licywe will however re-emphasise this instruction. Registered Office: 15 Esplanade, St Heller, Jersey. JEl lRB Company No.107325

BRITANNIA JINKY JERSEY LIMITED Contact address: Ainsdale House Shore Road Ainsdale Southport PR8 2PZ Regarding staff inductions, all staff receive inductions and I understand that prior to or during in the course ofthe Inquest copies for each of the employees were provided to you via the Company's Barrister. eeJones Director of Operations Britannia Jinky Jersey Ltd Registered Office: 15 Esplanade, St Heller, Jersey. JEl lRB Company No.107325
Suffolk Constabulary Police / Law Enforcement
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Action Taken

Suffolk Constabulary has enhanced its training delivery and supporting guidance on officer assessments and use of force, and invested in a new skills management system to track training records. It is also reviewing training schedules and designing new scenarios for scene management. (AI summary)

View full response
Dear Judge Devonish, Inquest into the death of Mr Paul Reynolds – ** May 2021 Regulation 28 Report to Prevent Future Deaths I am writing in response to the matters of concern raised in your Regulation 28 Report to Prevent Future Deaths report following the Inquest in to the death of Mr Paul Reynolds. Your report and the Constabulary’s response have been carefully considered by the Constabulary and I have shared this response via the Suffolk Police and Crime Commissioner to ensure openness and onward accountability. With respect to the matters of concern, the Constabulary has reviewed the circumstances of its involvement and responds as follows:
1. Officers appeared to be under the impression that pain/pressure testing to determine whether a person was unconscious or simply asleep was an assault rather than being justifiable in certain circumstances. The Constabulary’s involvement with Mr Reynolds stemmed from a reported incident of assault by Pontins Security Officers. Upon finding Mr Reynolds being restrained, the Constabulary training would have directed officers to assess the person being detained and review the evidence being presented. It was clear from the Inquest that the officers involved did not fulfil this assessment robustly and we acknowledge that their evidence identified confusion surrounding their police powers. The Constabulary has enhanced its training delivery and supporting guidance to clarify the importance of the initial assessment and the differences between proportionate and necessary checks of health and the application of force. It will reinforce this learning through practical based assessed scenarios, as part of the nationally revised curriculum design (see paragraph 3), that will specifically test officer’s ability to assess a person being detained and determine whether the circumstances warrant a medical intervention or the reinforcement of restraint.
2. The time allowed for training had been reduced from 12 to 4.25 hours. Positional asphyxia training had been ringfenced, but there were questions about the impact of the reduction upon officers. Suffolk Constabulary’s delivery of Emergency First Aid at Work Training and Personal Safety Training are compliant with the requirements of the College of Policing specification. This has been reinforced by external and independent inspections as part of national and local governance arrangements. However, we recognise that nationally there have been changes to the programme that may have created a perception of a reduction in the time assigned to positional asphyxia. The time allocated to individual areas of the curriculum are subject to change and nationally the focus of positional asphyxia has shifted towards the signals and signs of acute behaviour disorder. This is a precursor behaviour but is part of the same continuum. Material surrounding both acute behaviour disorder and positional asphyxia is delivered in accordance with national guidance and time allocations, but the Constabulary will do more to embed this learning within the wider aspects of its Personal Safety Training through supplementary videos and guidance on its Learning Management System.
3. The College of Policing and NPCC Officer and Staff safety Review made two recommendations to include revising the curriculum to ensure greater consistency, and to implement guidelines to ensure officers are sufficiently skilled in non-physical aspects of conflict management. The time scales for implementation were not stated.

The College of Policing is leading the redesign of the personal safety training programme and we will support the College through this period and implement the new programme upon its adoption. We understand that this new programme will come into fruition during 2022 and will be more scenario orientated. From our understanding of the programme design there will be opportunity for us to re-enact scenarios of concern and, as identified in paragraph 1, we will adopt scenario-based assessments that recreates the events of this incident. This will allow Trainers to assess officer understanding of their medical responsibilities and use of force powers.
4. Officers did not control the scene by clearing the ballroom and switching off the music which would have improved their ability to assess Mr Reynolds’ condition. We accept the concerns raised surrounding the control of the scene. We also recognise that while the first officer attending may have had difficulty in coordinating the various aspects presented, the arrival of other officers gave sufficient opportunity for scene to be controlled. As stated in paragraph 3, we will take this learning into the design of a scenario that will replicate and therefore enable the Constabulary to assess officer’s scene management approaches. Additional Learning

As reflected within our evidence, the Learning and Development department did undertake a comprehensive review of its practices and procedures following this incident. We acknowledge our responsibilities as a professional organisation to learn lessons and our review identified weaknesses within our records management. This resulted in the lapses surrounding the frequency of refresher training for some of the officers involved, as shared during the inquest. Our review also identified that training material constantly evolves around new information and best practice but that it was equally important to be able to identify officers learning to each iteration of a training package. These two factors, would have enabled the Constabulary to present greater confidence in the completeness of the officer refresher programmes as well as the rationale surrounding any changes to the time allocations, including when these were introduced. In response to this learning, we have invested in a new skills management system that will make it easier for our learning and development department to track and identify officer training records as well as link these records to the training the officer received. We trust that this combination shows the seriousness in which we have reflected upon the circumstances of this incident and the changes in our practices that we will implement to prevent its reoccurrence.

Report sections

Investigation and inquest
On 19 April 2021 I commenced an investigation into the death of Paul Steven Reynolds, aged 38. The investigation concluded at the end of the inquest on 10 May 2021 . The conclusion of the inquest was that Mr Reynolds died following an unlawful restraint by the neck and further in prone position at Pontins Pakefield in Lowestoft, Suffolk on 14 February 2017.

The inquest concluded that Pontins security had unlawfully restrained Mr Reynolds by the neck and then placed him in an unlawful prone restraint without conducting effective monitoring of his breathing.

The medical cause of death was concluded to be ‘Complications Arising from Restraint of an Intoxicated Obese Individual in a Prone Position, with Compression of the Neck and Potential Obstruction of the Upper Airways’.
Circumstances of the death
On 11 February 2017 Paul Reynolds attended the Pontins holiday leisure park in Lowestoft. During the evening of the 14th there was an incident between guests in the communal area of the leisure park. As a result of this incident Mr Reynolds was restrained by security and other staff until police arrived. He was grabbed from behind in a bear hug, taken to his knees in a neck hold and placed on the ground in a prone restraint. During the 11 minute prone restraint, captured on CCTV, Mr Reynolds did not appear to make any movement, although the Pontins staff involved in the restraint gave evidence that he had be wriggling, resisting the restraint, talking and later murmuring. He had also apologised and asked to be let up. This information had not been shared with the police. The police arrived just after Mr Reynolds was heard snoring, and presumed to be asleep. The effectiveness of the monitoring by Pontins staff was deemed to be unsatisfactory as Mr Reynolds was in fact unconscious and no member of staff had recognised this. A guest had identified to Pontins restraint staff that Mr Reynolds was at risk of breathing difficulties, but this was ignored. The police arrived and arrested Mr Reynolds by applying handcuffs and eventually placing him in the police van. On route to the Police Investigation Centre the police stopped the vehicle when they noticed Mr Reynolds appearing unwell. They took Mr Reynolds out of the van and performed CPR until the paramedics arrived. Mr Reynolds was conveyed to James Paget University Hospital where he died with hypoxic brain injury due to a lack of oxygen to the brain, on 16 February 2017. Experts attending the inquest gave evidence that Mr Reynolds may have fallen unconscious within seconds of the neck hold. This was exacerbated by moving him into a prone restraint with his legs tucked up to his buttocks and failing to relax the constraint and get him back to his feet or into recovery position.

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Report details

Reference
2021-0151
Coroner
Jacqueline Devonish
Coroner area
Suffolk

Responses identified

Responses identified 2 of 2
All listed responses identified

Sent to

Brittania Jinky Jersey Limited
Brittania Hotels Group Limited

Part of a series

2 reports
2020-0178 All responses identified

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