Source · Prevention of Future Deaths

Joseph Agnew

Ref: 2021-0055 Date: 26 Feb 2021 Coroner: Andrew Harris Area: London Inner South Responses identified: 3 / 1 View PDF

Police training was inadequate for assessing intoxicated individuals, monitoring breathing, and there is no suitable facility for acutely intoxicated homeless people found on buses.

Date 26 Feb 2021

56-day deadline 23 Apr 2021 est.

Responses identified 3 of 1

Alcohol, drug and medication related deaths Police related deaths

Coroner's concerns

AI summary

Police training was inadequate for assessing intoxicated individuals, monitoring breathing, and there is no suitable facility for acutely intoxicated homeless people found on buses.

View full coroner's concerns

The MATTERS OF CONCERN: The attention of different organizations is drawn to each according the evidence and the opportunity to mitigate the risks.
1. For the attention of CoLP and College of Policing: CoLP officers were not taught how to assess people to meet the agreed criteria for finding someone “drunk and incapable”. A senior officer was not content that the officers involved had given a satisfactory level of questioning nor welfare checks. The risk to life continues since there appears to be no clarity for officers from their training as to when to refer an intoxicated person for medical attention.

2. For the attention of CoLP, MPS and College of Policing: No police officers who gave evidence understood the significance of snoring in a person with a reduced level of consciousness, nor how to monitor breathing. My independent expert in A&E gave evidence that snoring indicates partial airway obstruction. He dismissed perceptions of officers that there was such a thing as good or bad snoring. He opined that in a person with reduced consciousness officers should assume that snoring needs medical attention. The person needs assessment to exclude when it is not a concern. Whilst he acknowledged the difficulty of assessing breathing, he stressed its importance as an indication of medical emergency, gave little weight to the value of chest movements which officers used, and highlighted the danger signs of very slow or very fast breathing. He also stressed that concern for medical attention should be triggered by unrousability. The evidence suggested that officers were unaware of all these matters and had not learnt how to effectively monitor breathing.
3. For the attention of the MPS: Two MPS officers who attended the scene gave evidence that they would do nothing different even in hindsight. No evidence was presented as to the post incident performance reviews and individual learning, and there is uncertainty about the adequacy of the corporate process of learning from incidents. There is a lack of assurance to the public that the risks related to the decisions of these officers or other incidents have been mitigated for the future.
4. For the attention of the Mayor of London: Evidence was heard that whilst the police can refer chronic rough sleepers to charities, there is no facility to which police can refer acutely intoxicated homeless people found on buses. It was reported that such facilities do exist elsewhere and that they create a place of safe refuge where monitoring can be effectively conducted. The potential of such a facility to save lives is drawn to the attention of the Mayor.

Responses

3 respondents

City of London Police Police / Law Enforcement

12 Apr 2021 PDF

Action Taken

Since Mr. Agnew's death, City of London Police officers receive further training on assessing intoxicated persons. First aid training of City of London Police officers now includes training to recognise that snoring in a person with a reduced level of consciousness is a sign of airway obstruction and to perform the "jaw thrust" manoeuvre. (AI summary)

View full response

Dear from being the they they fully they

We believe that your point in relation to there appearing to be a lack of clarity, was that one of the City of London Police officers (PC commented during his evidence that "unable to fully understand what is said to them if the word "fully" is to be taken literally would include many people who have had a lot to drunk but who are plainly not in need of conveyed to hospital by an ambulance The officer explained that he would use his common sense in relation to this and we would respectfully submit that that is the correct approach to take in order to avoid ambulance services to be overwhelmed by calls to attend those who are not in need of emergency treatment Concern (2) relates to the failure to appreciate the significance of snoring in a person with a reduced level of consciousness_ We believe that this concern was primarily one that related to the Metropolitan Police officers who attended upon Mr. Agnew after the City of London Police officers had left. It is who explained to the jury that they had been reassured by hearing Mr. Agnew snoring_ He was not; of course, snoring when being dealt with by the City of London Police officers shortly beforehand: Furthermore_the reference to "good or bad snoring" originally came in questions from our counsel, to the Metropolitan Police officers_ He put to them that there is no such thing as 'good' snoring in a person who requires an emergency ambulance because of their reduced level of consciousness and it should not have been reassuring to them would, however, confirm that my instructions are that the first aid training of City of London Police officers will henceforth fall in line with that given to Metropolitan Police officers, who you heard are now trained specifically to recognise that snoring in a person with a reduced level of consciousness is a sign f airway obstruction which must be rectified and are taught to perform the "jaw thrust" that was described to you by the Metropolitan Police Service's Senior Adviser , First Aid, Policy , Assurance and Training, in her evidence before you_ DCI has confirmed that this will be thoroughly covered in the first aid training provided to City 0f London Police officers Officers will be taught how to monitor breathing and will be taught not to seek to rely on being able to see the casualty's chest rise and fall

College of Policing Police / Law Enforcement

19 Apr 2021 PDF

Action Planned

The College of Policing will use the coroner's concerns to inform a review of the learning outcomes for the FALP (roads policing) programme, which will take place this year. The College has developed a vulnerability learning programme which supports the PCDA programme. (AI summary)

View full response

Dear Dr Harris Re: Joseph Agnew (Deceased) 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 26th February 2021 _ The report sets out concern that arose from the information received during the inquest in to the death of Mr Joseph Agnew. was sorry to read of the circumstances of Joseph's death_ My sympathies are with his family and friends and share your commitment to addressing the issues that contributed to his untimely loss. The report sets out your principle concerns in respect of the training that is available for officers_ Your concerns were; firstly in respect of the ability of officers to assess a person as being "drunk and incapable" and when to refer an intoxicated person for medical attention, and secondly in respect of whether officers had learnt how to effectively monitor breathing and other symptoms that might be linked to the need for medical assessment or attention. More specifically your letter provides the following information.
1. For the attention of CoLP and College of Policing: CoLP officers were not taught how to assess people to meet the agreed criteria for someone "drunk and incapable"_ A senior officer was not content that the officers involved had given a satisfactory level of questioning nor welfare checks_ The risk to life continues since there appears to be no clarity for officers from their training as to when to refer an intoxicated person for medical attention. (ollesye? < ['oslicine Louterl is fcf;sI6Y |ssuciel mEnplu"l zuul WVak' ; = bithmn-unipie: |mulni{Vsspy VAI IJ:~Tehumiei 15.812744") Jm me Alme"'J (dJ'o Flic " mleul FFm Rth K.-(0m,i ~ri VN keep very finding 70i

2. For the attention of CoLP, MPS and College of Policing: No police officers who gave evidence understood the significance of snoring in a person with a reduced level of consciousness, nor how to monitor breathing: My independent expert in A&E gave evidence that snoring indicates partial ainway obstruction. He dismissed perceptions of officers that there was such thing as good or bad snoring: He opined that in a person with reduced consciousness officers should assume that snoring needs medical attention The person needs assessment to exclude when it is not a concern Whilst he acknowledged the difficulty of assessing breathing, he stressed its importance as an indication of medical emergency, gave little weight to the value of chest movements which officers used, and highlighted the danger signs of slow or very fast breathing: He also stressed that concern for medical attention should be triggered by unrousability_ The evidence suggested that officers were unaware of all these matters and had not learnt how to effectively monitor breathing: 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 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 College licences the First Aid Learning Programme (FALP) used by Home Office Forces_ including the Metropolitan Police Service and the City of London Police The programme is endorsed by the National Police Chiefs Council (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. very key

The FALP has five modules and the national recommendation is that police officers receive a minimum of Module 2 training (the equivalent to the qualification of a HSE Emergency First Aider): While Module 2 does not seek to provide detailed coverage of all specific medical conditions it does allow officers and staff to make an assessment of the casualty, including the known factors that may present a risk to their health: Officers and staff are called on to provide first aid in a wide range of incidents during their work: The range of incidents officers attend means it is not possible or viable for all officers to be trained for all types of medical emergencies, or for the FALP to explicitly outline the appropriate medical response in every context. It is recognised that some areas of policing, such as working in custody environments, firearms operations or public order teams, require additional skills and knowledge The relevant staff have additional FALP training modules available to ensure are prepared for situations they are likely to encounter in their specialist roles. Additionaly, where local force risk assessments identify critical need, Chief Officers are able to add additional medical training provisions under the advice of local clinical governance_ The FALP modules are monitored via the College's own governance and a national NPCC coordination committee_ The NPCC portfolio includes the HSE representation, and is supported by a dedicated subject matter expert group of force first aid leads, and national clinical governance structure, which includes a broad range of independent clinical expertise _ The NPCC governance structure considers all relevant recommendations as a standing agenda item. In addition, a wider review of the high level learning outcomes for the FALP has already been initiated to ensure that remain fit for purpose_ We will ensure that your causes for concern will form part of this review It is anticipated that this work will be completed towards the end of 2021 following the publication of updates expected from the UK Resuscitation Council this year The College also sets the education and training requirements for all new recruits. Historically, all officers have been trained in accordance with the requirements of the Initial Policing Development Programme (IPLDP) but increasingly forces are putting their recruits through the Police Constable Degree Apprenticeship (PCDA): The IPLDP had content in respect of; the 'signs and symptoms of drunkenness' , the potential for symptoms of drunkenness to be caused they they

by medical conditions , and where there is any doubt; that it should be assumed the person has an illness or injury and medical assistance should be requested: The PCDA places a high level of emphasis on the potential vulnerability of a person who, because of their situation or circumstances, is unable to take care or protect them self from harm or exploitation. This includes the importance of considering the possibility of hidden medical conditions or non-visible signs that may lead to a person being vulnerable. The College has developed a vulnerability learning programme which supports the PCDA programme and can also be used for officers who have not been trained through the PCDA to ensure consistency in learning: In summary, through initial training, the vulnerability programme and the FALP the focus is on providing officers with the skills and information to look for signs and symptoms that indicate the need for medical intervention and to request it when found. For the FALP in particular; we will use these causes for concern to inform review of the learning outcomes that will be taking place this The College is committed to continuing our work 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 Agnews 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_

Greater London Authority on behalf of Mayor of London Other

29 Apr 2021 PDF

Action Taken

Since 2016, the Mayor of London has established a night transport outreach team that assists rough sleepers on the transport network, helping over 1,020 clients. The team enables drivers and others to refer those of concern to this service. (AI summary)

View full response

Dear Sir

Inquest arising from the death of Joseph Agnew

I write on behalf of the Mayor of London (the Mayor) with regard to the Senior Coroner’s Regulation 28 Report to Prevent Future Deaths (PFD) dated 26 February 2020 following the inquest arising from the death of Joseph Agnew.

Mr Agnew’s inquest and the Prevention of Future Deaths (PFD) report

The Senior Coroner’s PFD report raises the following matter of concern for the attention of the Mayor:

‘Evidence was heard that whilst the police can refer chronic rough sleepers to charities, there is no facility to which police can refer acutely intoxicated homeless people found on buses. It was reported that such facilities do exist elsewhere and that they create a place of safe refuge where monitoring can be effectively conducted. The potential of such a facility to save lives is drawn to the attention of the Mayor’.

Mr Agnew died on 15 December 2016 and the inquest into his death concluded on 17 November 2020. The Mayor was not an Interested Person in the inquest and was first made aware of this inquest upon receipt of the Senior Coroner’s PFD report. The Senior Coroner has kindly provided a copy of the IOPC’s report into the investigation into police contact with Mr Agnew prior to his death and the following extracts of evidence from the City of London Police officers at the inquest:

PC
– ‘It was a common practice in 2016 to have to leave intoxicated people in bus shelters or at a station. He never received any guidance or instruction otherwise’.

PC
– ‘To avoid instances of vulnerable people being left on the street, we need a way to deal with folk on buses – outreach services tend not to count these people. No solution has been found yet. They don’t attend – they may fall outside their LA. What would be helpful is a place to take drunk people. There is an SOS bus in the City. The

time slot is critical – there is a narrow window. Such a facility needs to be more widely available. He has been involved in trying to secure facility for Christmas period’.

I am the Executive Director for Housing and Land at the Greater London Authority (GLA) and one of the teams within my department is the rough sleeping team, so I am responding to the Senior Coroner’s report on the Mayor’s behalf.

I would like to take this opportunity to offer our sincere condolences to the family and friends of Mr Agnew and outlined below is a response to the area of concern raised by the Senior Coroner.

The Mayor’s responsibilities for rough sleeping

The Mayor’s Life Off the Streets programme provides a range of services and initiatives to help people sleeping rough to leave the streets and rebuild their lives. These complement those provided by London’s boroughs.

The Mayor does not have a statutory duty to provide these services but works alongside London’s boroughs who also provide services to those who sleep rough. The Mayor commissions services that are pan-London or multi-borough in their remit. Local Authorities have a duty under the Housing Act 1996 to secure accommodation for unintentionally homeless households who fall into a ‘priority need’ category. There is no duty to secure accommodation for all homeless people.

Services available for rough sleeping

The Mayor provides a range of services to assist people to rebuild their lives. These include street outreach which involves teams of outreach workers locating people sleeping rough and supporting them to leave the streets. There are also services to provide immediate options for someone to leave the streets or prevent them from sleeping rough. This includes emergency accommodation services and assessment centres which provide safe shelter and support for people to find longer term accommodation.

Services also include longer term accommodation solutions and access to appropriate support including mental and physical health, training and employment to enable people to move on with their lives.

The priorities underpinning all the Life Off the Streets rough sleeping services, projects and initiatives funded by the Mayor are set out in the pan-London Rough Sleeping Commissioning Framework.

The overarching priorities of the Commissioning Framework are to work with boroughs and partners to: (i) minimise the flow of new rough sleepers onto the streets, (ii) ensure that no-one new to the streets sleeps rough for a second night, (iii) ensure that no-one lives on the streets of London; and (iv) ensure that no-one returns to sleep on the streets of London.

There are also various cross-cutting priorities that are critical to tackling rough sleeping and will underpin the nature and shape of the GLA’s commissioned services over the coming period. This includes working with boroughs and partners to: (v) tackle rough sleeping by non-UK nationals, (vi) improve partnership working around enforcement, (vii) tackle hidden or mobile rough sleeping, (viii) meet the physical and mental health needs of rough sleepers, (ix) help ensure the availability of appropriate accommodation, including emergency accommodation, (x) enhance the service offer from smaller organisations, including faith and community based organisations, (xi) maintain and improve the collection and use of data about sleeping rough; and (xii) promote employment, training and volunteering among rough sleepers.

All services for rough sleepers commissioned by the GLA are tested against the four overarching priorities and the relevant cross-cutting aims to ensure that they are making an appropriate and demonstrable contribution to tackling rough sleeping in the capital.

More information on all of these services, including funding and the provider organisations, can be found in the Mayor's Life Off the Streets rough sleeping services briefing. I enclose a copy with this letter.

Policies on rough sleepers sleeping on buses

In August 2017, the Mayor announced the creation of a new team dedicated to helping the rising number of homeless people who use Night Buses and Tubes as a place to sleep. I enclose a copy of the Mayoral Decision (MD2166) which approved this policy.

As set out in MD2166, the Mayor wanted to ensure there was an offer for every rough sleeper in London and that services were in place to help them access available support. One gap in provision was the coverage of outreach on London’s night buses and the tube network. The ongoing extensions of the night tube, in particular, created additional ‘spaces’ where people who were homeless may sleep to stay warm and safe.

It was therefore proposed that the GLA-commissioned London Street Rescue (LSR) service be enhanced to provide a new ‘night transport outreach team’ to run for 18 months (starting in October 2017) to work on the night bus and tube network in London. The team would work closely with Transport for London (‘TfL’), with whom LSR already had good links. This would enable intelligence-led shifts based on TfL staff reports which would feed into shift delivery patterns. The service would also develop the skills of TfL staff to improve the quality of referrals.

The team help find accommodation, provide access to support services and reconnect people with family and friends to prevent them from ending up sleeping on the streets.

This announcement followed data from TfL which revealed that the number of homeless people sleeping on night buses in winter 2015/16 was 121% greater than the same period

in 2012/13. This reflected a trend of rising homelessness seen more widely across the capital in recent years. The Mayor’s aim for the night outreach team was to help prevent people using transport as a bed for the night and to ensure they receive immediate help to access he accommodation and range of services they need.

The night-time transport team focuses on transport routes which homeless people are known to frequent or that bus and Tube drivers have referred the team to. The emergency services and members of the public can alert the outreach team to anyone needing their help by using the online Streetlink London service (www.streetlink.london).

Prior to the establishment of the team, support for individuals rough sleeping on buses was, in the main, the responsibility of borough commissioned outreach teams. With the introduction of this team, bus drivers, tube workers and the emergency services were able to refer individuals to the service regardless of borough boundaries so that support can be given. The Mayor has recently agreed funding for this service to continue within the London Street Rescue service for 2021/22. I enclose a copy of the relevant Mayoral Decision (MD2789).

However, this team is not a blue light service and whilst it will aim to respond to all referrals in a timely manner, this service aims to get help those who regularly rough sleep on buses in order to help the most vulnerable.

Therefore, since Mr Agnew’s tragic death in December 2016, a dedicated outreach service to assist individuals who are rough sleeping on buses has been established by the Mayor.

Facilities for intoxicated persons

There are several alcohol intoxication management services (AIMS) that have been commissioned by local borough public health teams, the London Ambulance Service (LAS) and the NHS, such as the SOS bus in the City of London and Alcohol Recovery Centres that run in several London boroughs. These services are not run by the Mayor. These services are designed to receive, treat and monitor intoxicated patients who would normally attend Emergency Departments and to lessen the burden that alcohol-misuse places on A&E services. These mainly operate at Christmas and other busy times of the year when demand for the London Ambulance and A&E services is high.

These services are not generally designed to assist and support rough sleepers, as they are generally set up to help people sober up and reduce the strain on A&E departments rather than provide interventions and ongoing support for vulnerable clients.

Conclusion

As detailed above, the main development since Mr Agnew’s death in December 2016 has been the establishment of the night transport outreach team to assist anyone rough sleeping on the transport network at night, enabling drivers and others to refer those of

concern to this service. Since the creation of this service, the team has helped over 1,020 clients.

The National Institute for Health Research has recently published an evaluation into alcohol intoxication management services and made several recommendations around future work on the management of alcohol intoxication in night-time environments which I hope will be taken forward at national and borough level to provide a more comprehensive safety net for those intoxicated and vulnerable.

I trust this response is helpful. Please contact us if we can be of any further assistance.

Report sections

Investigation and inquest

This report arises from the death of Mr Joseph Agnew, who died on 15th December 2016 aged 63 at Kings College Hospital ( ). I opened an inquest into the death on 13th January 2017, which was concluded on 17th November 2020. The delay in hearing the inquest was due to a police homicide investigation, which the CPS decided should not be prosecuted. The delay in writing this report is occasioned by the Covid-19 pandemic which created unprecedented pressures on the coroner’s service.

The jury recorded the medical cause of death as 1a Bronchopneumonia 1b Hypoxic Cardiac Arrest 1c Alcohol and Diazepam intoxication It was drug and alcohol related death

Circumstances of the death

This death was an out of hospital cardiac arrest, resuscitated and admitted, but found to have a devastating brain injury, dying five days later. On the evening of 8 December 2016, he refused to get off a bus at its terminus at Peckham bus garage. The bus company called the Metropolitan Police (MPS) to assist with his removal from the bus. Whilst awaiting members of the MPS, a bus driver flagged down a passing police car from City of London Police (CoLP). Two members of the CoLP force attended the incident and removed Mr Agnew from the top deck of the bus, by this time it was 00.40 hours on 9 December 2016. After removal from the bus, they propped Mr Agnew in a nearby bus shelter, and left the scene. Within 30 minutes members of the MPS attended the scene in response to the initial call and found Mr Agnew lying face down in the bus shelter. Their attempts to rouse him were unsuccessful and an ambulance was called. The jury recorded these matters in the circumstances, but they were not found to be causative of his death:
• Training provided to officers around managing intoxicated individuals with reduced responsiveness was inadequate
• Inadequate checks were carried out in assessing his breathing, airway and primary survey.
• There was a serious failure not to carry out an assessment of his respiratory rate and pulse
• Training was insufficient with regard to action to take when he was intermittently snoring.

Action should be taken

In my opinion action should be taken to prevent future deaths. I believe that the listed organizations would wish to learn of the evidence given in the inquest about the circumstances of this death and are in a position to mitigate or prevent future deaths.

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2021-0055
Date of report: 26 February 2021
Coroner: Andrew Harris
Coroner area: London Inner South

Responses identified

Responses identified 3 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 23 Apr 2021 (estimated).

Sent to

City of London Police, Metropolitan Police Service, College of Policing Units and Mayor of London

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.