Douglas Oak

Dear Ms Griffin Re: Douglas Paul Oak (Deceased) We write on behalf of the College of Policing (the College) and 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, prevention of future deaths reports to the College and to the NPCC , both dated 24th October 2019. Whilst the College and the NPCC have separate and distinct responsibilities, the two organisations frequently work together on national approaches to policing policy_ As such, this response is provided jointly in respect of both organisations' separate prevention of future deaths reports. The notice sets out concern that arose from the information received during the inquest in to the death of Mr Oak: are very sorry to read of the circumstances of Doug's death_ Our sympathies are with his family and friends and we share your commitment to addressing the issues that contributed to his untimely loss_ The notice sets out your principle concerns which were in respect of the recognition of ABD as a matter requiring an immediate medical response and the communication and coordination between the police and ambulance service who responded to Mr Oak. You specifically asked for a response in relation to a number of areas for concern in which the College of Policing and NPCC would have involvement The College is the independent professional body supporting everyone working in policing to reduce crime and keep people safe_ The College has three complementary 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, helping to nurture and select leaders at all levels: The NPCC brings police forces in the UK together to help policing coordinate operations, reform, improve and provide value for money It does this in fulfilment of its six primary functions, those The co-ordination of national operations including defining, monitoring and testing force contributions to the Strategic Policing Requirement; and working with the National Crime Agency where appropriate The command of counter terrorism operations and delivery of counter terrorist policing through the national network as set out in the Counter Terrorism Collaboration Agreement The co-ordination of the national police response to national emergencies and the co-ordination of mobilisation of resources across force borders and internationally Colleje Policing !imitec|% Loian" (egjistered in Englaricl ard Walos. #illi rerjistered nurber 8235- 99 rind VAT reristeredl purnbet 5202 3*49 Our registererl office at College ot Policing Limited, |eairucyton) Fcacd; Rytan-Un Dursmre; Coventry CVR JEN the We key and being: the

The national operational implementation of standards and policy as set by the College of Policing and Government To work with the College of Policing, to develop joint national approaches on criminal justice, value for money, service transformation; information management; performance management and technology Where appropriate, to work with the College of Policing in order to develop joint national approaches to staff and human resource issues, including misconduct and discipline, in line with Chief Officers' responsibilities as employers The College works closely with the NPCC to ensure that the guidance and standards that it sets are to be effective in supporting police officers and staff in their principle roles of keeping public safe and reducing crime Where the work of the police overlaps with other agencies or bodies the College and NPCC also seek to ensure that we work together to jointly address areas of risk and concern_ The College and NPCC are particularly concerned to learn lessons from circumstances such as those that were involved in Mr Oak's death: We have processes in place to formally consider Prevention of Future Death (PFD) notices and the concerns they contain. In this letter we have set out the responses of the College and the NPCC to each of the concerns that you have raised in your letter. There is a lack of awareness generally regarding ABD and would request consideration is given to the inclusion of the signs; symptoms and management of ABD within the First Manual so that all those trained in first aid are able to deal with a patient presenting with ABD: The College First Aid Learning Programme (FALP) already includes a learning outcome for recognising Acute Behavioural Disorder (ABD) as part of Module 3 (relating to first aid in a custody setting). In light of the above cause for concern the College will work with police stakeholders through the NPCC First Aid Forum and the national clinical governance panel to reflect this learning outcome in Module 2, the refresher training module for front line staff. This will ensure that this training is given to all front line officers. This amendment will be made as part of the wider scheduled review of the FALP following the release of updated guidance by the UK Resuscitation Council in 2020. Officers undergo personal safety training (PST) every year with the content varying in line with national priorities and local need. The PST is informed by the content of the National Personal Safety Manual (NPSM) which is developed jointly by the College and NPCC and published to policing by the College: ABD training also sits within NPSM contained in Module 4: Medical Implications. This part of the Manual is currently undergoing a full review by Dr Meng Aw-Yong: This is in response to a number of changes that have been included over the past 12 months due to PFD notices_ An interim update to the information has been agreed with Dr Meng and will be instigated in the near future Each change to Module 4 is communicated to forces so that and their PST trainers are aware The College and NPCC have developed a PowerPoint presentation on ABD which describes the behavioural and physical signs of ABD and makes very clear the need for rapid clinical assessmentlintervention. The ABD PowerPoint was developed with the benefit of clinical input and was last updated in July 2019. The ABD PowerPoint covers the bullet points raised above by HM Coroner; containing the latest information on recognising ABD, the management which includes containment;, de-escalation, implementation of a MOU the likely the Aid they

with ambulance trusts to respond as a category call, sedation where necessary and transfer options for a person suffering from ABD_ Each update is communicated to forces by the NPCC Self Defence and Restraint (SDAR) Lead, Deputy Assistant Commissioner Matt Twist; NPCC Custody Portfolio Lead;, Deputy Chief Constable Neville Kemp and the College posts the changes on POLKA (a site that enables the college to share learning) and the Managed Learning Environment (MLE) which hosts on line learning materials for the police service We welcome the feedback that officers involved in responding to Mr Oak were able to identify ABD as a medical emergency shortly after attending: Recognising that concern about awareness of ABD extends beyond the police and ambulance services the College and NPCC will share the PowerPoint presentation on ABD with the Tripartite Committee who publish the First Aid Manual The College and NPCC hope that this collaboration will increase knowledge of ABD amongst the first aid societies (St John Ambulance, The British Red Cross and St Andrews First Aid) ultimately the public_ The ABD PowerPoint has already been shared with NHS Trusts and Ambulance partners. The PowerPoint is aimed at frontline police officers and the College and NPCC have made it clear that ambulance partners are at liberty to utilise and amend the PowerPoint; as appropriate, to meet the needs of their staff There is no joint national guidance on the management of ABD by those who work for Police and Ambulance Services; both on the front-line and in the control rooms are the people most likely to encounter those suffering with ABD and in most cases work together in the management of these patients Accordingly, request consideration is given to providing joint national guidance on the management of ABD patients by the Police and Ambulance Services to include_ the provision of chemical sedation in pre-hospital care the training of all paramedics in administering chemical sedation the categorisation of Emergency Service calls relating to ABD the transfer of an ABD patient to hospital The College has recently joined the NHS Clinical Commissioners National Mental Health forum at which the ambulance service are represented. At the last meeting on 18 November 2019, this PFD notice was discussed to help formulate a joint response to some of the concerns you raise that cover both emergency services_ The police and ambulance services are committed to raising awareness of ABD and have an ongoing programme of work to achieve this. The ABD PowerPoint has been made available to ambulance trusts as described above. As well as the content already mentioned, it also addresses the importance of appropriate conveyance for these patients which would be in an ambulance unless a dynamic risk assessment identified the need to use police transport The other matters within this area for concern (chemical sedation and categorisation of calls) are clinical matters in which police officers would not be directly involved other than to ensure that the ambulance service has access to the information that it needs. Police officers would defer to ambulance colleagues in these matters_ The College and NPCC are aware of the current good practice that exist in London where the London Ambulance Service would respond to calls of suspected ABD by Metropolitan Police Service officers and where appropriate paramedics would sedate cases of suspected ABD and that Surrey Police and SECAMBE will have a similar process (MOU) in place. The ABD PowerPoint reinforces the necessity of such an MOU between all police forces and ambulance trusts_ and the They

The College and NPCC are aware of a pilot across the Yorkshire forces where police and ambulance services in this region are trialling new ways of prioritising and responding to cases of ABD. The pilot will review patient care from start to finish and as part of this trial the Yorkshire Ambulance Service have agreed to respond to all ABD calls as a category response. The College is linked in with the local team in relation to this and when this pilot concludes in early 2020 the outcomes will be assessed with a view to sharing this knowledge across policing and health:
iii. believe it is likely there persons working within Ambulance Service Trusts and Police Forces; whether it be on the front line or in the control room who are not aware of ABD and the serious risk to life it presents: therefore request that consideration is to ensuring all those working on the front line, or in control rooms in Ambulance Service Trusts and Police Forces in England and Wales are trained in ABD. The College is in the process of refreshing the National Contact Management Learning Programme (NCMLP)_ This is a detailed set of learning standards that forces use to develop their local training for all contact management staff including those taking calls from the public and tasking and informing resources who respond: In this refresh we will include the importance of call handlers and dispatches understanding the medical emergency that is ABD. This will complement the ABD presentation referred to below: The NPCC is working with and Subject Matter Experts in police and ambulance (SECAMBE and LAS) Control Rooms to produce a PowerPoint on ABD specifically for police and ambulance control room staff. This PowerPoint will form the basis of a template for both police force or ambulance trusts to train their staff with the aim of teaching recognition of ABD and the risk to life, thereby standardising the language and response to ABD (point 2.v). For the first time this PowerPoint is also endorsed by the Independent Ambulance Association and Heath Practice Associates (Council) increasing the reach of the material. will also share this with the Association of Ambulance Chief Executives or the National Ambulance Service Medical Directors_
iv. also have concerns in relation to the frequency of the delivery of the training referred to in (iii) and therefore request consideration be given to that training delivered regularly, at least on an annual basis and with a variety of training techniques, including simulation and role play scenarios. The learning outcomes relating to ABD will in future be contained within Module 2 of the FALP. Consequently this will feature as part of the structured refresher training, which is completed annually, on a rolling three year of content Those officers and staff who attend PST have refresher training on a yearly basis. This training varies depending on national and force priorities The College and NPCC have a current programme of work to develop a national PST curriculum to improve national consistency: The potential impact of restraint on a person with ABD is well recognised, highlighted and communicated in both the NPSM and the PST through the use of the ABD PowerPoint: The presentation has video content which illustrates ABD to assist officers in recognising the signs The College has produced Conflict Management Guidelines which contain information to assist in the development of de-escalation training and skills for front line staff. The College and NPCC will shortly be piloting conflict managementlde-escalation training as part of its work to develop the national PST curriculum: The approach involves the use of role play as well as presentations and didactic learning: The College Guidelines recommend that role plays include resolution through de-escalation and of the medical impacts of any physical intervention used by learners. Through first aid and PST officers will receive training focusing on ABD at least every three years and probably more frequently in practice_ The first aid and PST training represent a minimum requirement;, balanced against the other significant training police officers require for their role_ It would not be are given We being cycle

proportionate to mandate more frequent training given the tens of thousands of staff involved and the relative infrequency of incidents where ABD is suspected to be a factor. Chief Officers do retain the ability to direct additional training in both PST and first aid provision where specific local needs are identified. Given that the Police and Ambulance Services work very closely in treating and managing a patient with ABD; and other patients who present with life threatening conditions, it is important that they understand each other: It was clear from this Inquest that there is different terminology used by different services; the meaning of which is not understood by the other Emergency Services An example of this was use of the phrase 'on the hurry up'. Although the confusion regarding this terminology was not found to be causative Or contributory to Doug's death, it could be in respect of a future death. therefore request that consideration is given to the joint national training packages for all Emergency Services; namely the Police Service, Ambulance Service and the Fire Service on the workings within each control room and around the language used in the control rooms: The ABD PowerPoint and NPSM content make it clear that cases suspected to be ABD are to be treated as a medical emergency and that immediate medical attention is sought: In addition the control room version of the ABD PowerPoint will assist in standardising the terminology used with regard to ABD We accept that clarity in language is important when communicating across emergency services Contact Management officers and staff are trained to enquire and probe for additional details when receiving calls and our experience leads us to believe that there are seldom misunderstandings in relation to the importance of response required. It is however recognised that the ambulance service triage each call based on the description of the medical presentation of the patient not on the type of illness being stated. The College and the NPCC will continue to work at a national level to secure greater consistency in the recognition and prioritisation of ABD_ It is also our position that forces should discuss communication issues with their local emergency service providers_ vi Extending this point further; evidence was given that there would be benefit in cross working within the emergency services, So for example an Ambulance Clinician working within the Police control room to provide advice. would therefore request that consideration is given on a national level to cross working within the emergency services. The College is aware of a number of schemes involving police forces across England & Wales having direct access to clinical advice that looks to support people in mental health crisis_ We are working with Nottinghamshire University to evaluate these schemes following a recommendation from HMICFRS to give greater clarity on any system wide benefits from adopting such schemes This is due to report in early 2020 and will be shared across policing and ambulance service commissionersltrusts_ The College and NPCC are aware that Surrey Police, in conjunction with SECAMBE ambulance trust; will be working on a joint training exercise involving control room and officers responding to ABD
vii. In relation to the training package that has been provided by the College of Policing regarding ABD, although recommended this could be rolled out to control room staff; the package is tailored for front-Iine staff: would therefore request consideration is given to a specific training package on ABD being designed and rolled out to those working in the control room environment by the College of Policing together with the Association of Ambulance Chief Executives or the National Ambulance Service Medical Directors: As stated above_ The refreshed NCMLP will feature ABD to raise awareness among control room staff. In the the Ihas

the meantime the College will ask the NPCC national lead for Contact Management; ACC (Police Service of Northern Ireland) to circulate the ABD PowerPoint presentation to force leads, with advice on how this could be delivered locally to brief staff working in control rooms. viii: Evidence was given that Dorset Police have established a Clinical Governance Board which helps to create an awareness of, and improvement in, medical care provided by those working in the Police Service. This is not something adopted by all Police Forces in England and Wales and therefore request that consideration is given to setting up a Clinical Governance Board in Police Force in England and Wales; The need for forces to establish local clinical governance is already a condition of the use of the College of Policing's licence for the FALP. Additionally, the NPCC , through the National Clinical governance Group, has issued guidance reiterating this requirement and articulating the specific requirements of good clinical governance. Joint work through the College of Policing and the NPCC First Aid Forum has already commenced to ensure that forces have developed suitable clinical governance structures_ With the support of the NPCC lead we have written to all force first aid and governance leads to remind of this requirement: It may assist HM Senior Coroner to know that there is also currently a Clinical Advice Panel in the Metropolitan Police Service which operates on a similar (voluntary) basis as the Clinical Governance Board in Dorset: The NPCC recognises the importance of Clinical Governance and multiagency working in developing safe working systems. The NPCC together with the College will be developing Medical and Police Advisory Committee (MAPAC) with medical representation from each of the 9 police regions_ These doctors will come from Emergency Medicine where the bulk of medicallpolice interactions take place_ The MAPAC will form local liaisons with hospital and individual police forces local ambulance trusts_ As HM Coroner may be aware many police forces have commissioned their healthcare provision to external providers NHS England has a group of advisors as part of the National Liaison & Diversion & Police Healthcare team_ This operates on a strategic level developing national policy and the national service specification for commissioning of these providers. The next re-iteration of this service specification will include awareness of medical conditions including ABD and its management: IX. It was clear from the evidence that there appears to be confusion of when Dorset Police Officers should call 999 directly and when they should request assistance through the Police control room. would request that there is consideration of the redrafting of the current "Police Requesting Ambulance Support" policy within Dorset Police and specifically when Police Officers should dial 999. In addition, would request consideration of training be provided by Dorset Police to all Police Officers regarding the use of dialling 999 when contacting other Emergency Services. In this would ask that consideration is given to liaising with the other local emergency services regarding their expectations, especially SWAST. The College and NPCC position is that forces should discuss communication issues with their local emergency service providers_ Given the number of relatively recent deaths associated with ABD that have resulted in reports such as this being issued by my fellow Coroners, and the fact that all of the above points have raised still create a risk of future deaths due to the lack of national guidance and policy, would request that the concerns have raised in this report are given immediate attention. further request urgency is taken in responding to this report and taking any action deemed appropriate. This is a sentiment very much echoed by Doug's every and doing

family, who are very keen to assist the authorities following their tragic loss to prevent any future deaths occurring in similar circumstances to Doug's death: As already covered in this response the College and NPCC are working with forces and medical service partners to address the concerns raised in this report: We are undertaking both immediate and longer term steps to raise awareness and consistency in the recognition and response to ABD which we recognise continues to present a significant risk to those who experience it: xi In addition, would request that those in receipt of this report make the individual Police Forces and Ambulance Services within England and Wales aware of the risks surrounding ABD as a matter of urgency and consider forwarding this report to all Chief Constables and Chief Executives of the Ambulance Services in England and Wales: The Chair of the NPCC will be to all Chief Constables to bring the content of this PFD and the proposed response to their attention. The College and NPCC are committed to continuing their work with forces, the NPCC and other agencies to raise standards of practice in the care of suspects who come to police attention: This includes their safe restraint and care if they are subject to police detention: would like to thank you for bringing the circumstances of Mr Oak'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_

Dear Ms Griffin REGULATION 28 REPORT ACTION TO PREVENT FUTURE DEATHS: DOUGLAS PAUL OAK We are writing in response to the Regulation 28 report to prevent future deaths following the inquest into the death of Douglas Oak which you issued on 24th October 2019 to Martin Flaherty on behalf of the National Ambulance Service Medical Directors (NASMeD) and Anthony Marsh Chair of the Association of Ambulance Chief Executives (AACE): We would Iike to clarify that is the Managing Director of AACE and in relation to this report we have liaised with who is the Chair of NASMeD: AACE is a formally constituted private company wholly owned by the English Ambulance NHS Trusts who are all full voting members_ Its primary focus is the ongoing development of the English ambulance services and the improvement of patient care_ It is a company owned by NHS organisations and it wholly owns the intellectual property rights of the JRCALC UK ambulance service clinical practice guidelines NASMeD is a subgroup of AACE You requested that the NASMeD and AACE consider matters of concern and suggested that action is taken to prevent future deaths We will address each of your concerns, insofar as we are able. NASMeD, and the Association of Ambulance Chief Executives (AACE) as its parent body, have no involvement in the development of the content of First Aid manuals and are therefore unable to assist with this matter. ii) Joint guidance between the statutory ambulance services and the Police Forces is in development overseen by a joint committee of AACE and the National Ambulance Commissioning Network, and supported by the ambulance and mental health group in NHS England. NASMeD has requested development of ambulance guidelines by the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) and these are due to be ratified shortly: The guidelines have been developed following consultation with the Faculty of Forensic and Legal Medicine (FFLM) and the Faculty of Pre-Hospital Care (FPHC): The provision of chemical sedation by all paramedics is a matter of contentionand one which we have previously discussed on more than one occasion with lincluding in national conference with the Police in December 2018. Chemical sedation for any indication and, perhaps more importantly, the skills to manage a chemically sedated patient falls outside the scope of practice of frontline ambulance paramedics In addition, the infrequency with which would need to practise these skills would lead to skill fade and poses a risk to patient safety. Dr Mark does not agree with position that "chemical sedation or tranquillisation is often the best way to calm a person suffering with ABD" A two-year audit by London Ambulance Service NHS Trust, the results of which are known to Dr Yong, demonstrated Chairman: Professor Anthony C Marsh QAM SBStJ DSci (Hon) MBA MSc MA FASI Managing Director: Martin Flaherty OBE they

that 62% of patients with suspected ABD, attended by Advanced Paramedics who were trained in chemical sedation, were successfully managed using only verbal de-escalation techniques_ Work is ongoing, between Yorkshire Ambulance Service NHS Trust and the four Yorkshire and Humber Police Forces on behalf of the national groups described above, to establish the most appropriate response categorisation for patients with suspected ABD. The first component of this study is due to conclude in March 2020 and will report shortly afterwards. The framework for the study was devised following consultation with all English Police Forces The primary goal in the prehospital management of patients with suspected ABD is transfer to an Emergency Department for further assessment and intervention as indicated therefrom. may be that on an individual case by case basis, in consultation with Police and Ambulance control rooms the most appropriate management for a patient with ABD is transfer by the Police to an Emergency Department. The study described above is exploring this and other options_ iii) Following the publication of the JRCALC guideline on ABD there will be an expectation that all statutory ambulance services will ensure that their frontline staff are aware of, and cognisant with, its contents and ambulance control staff are also made aware of the new guidance. Following the outcome of the study described above recommendations will be made to the NHS England lead group which oversees emergency call prioritisation to incorporate specific response categorisation for patients with suspected ABD iv) Annual refresher training in ABD is disproportionate given the incidence of these cases and the need to maintain and develop the broad range of competencies required of a frontline paramedic in a statutory ambulance service We believe each of the English ambulance services receives two or three calls each week for patients with suspected ABD, amongst two to four thousand 999 calls per day: Whilst NASMeD or AACE is not in a position to mandate training requirements, we would not support a recommendation for annual refresher training on this subject We do believe that the absence of common terminology or the use of the term 'on the up' was the issue. The ambulance response to all incidents are prioritised on information based on the patients presenting condition. Therefore it is essential to obtain appropriate information about the patient's condition, and that this is passed from police to ambulance services in order to correctly prioritise the response and this will be our principal focus of ongoing work with the police Once the new guidance on ABD has been ratified and issued and the trial in Yorkshire as described in point above has been completed, we will continue to discuss this in our work with the police to improve communications between ambulance and police control rooms_ vi) On the subject of cross working with emergency services, whilst we understand the motivation behind the evidence given, in practice; where ambulance trusts have placed clinicians in Police control rooms, it has not proven to be an efficient operating model. Improving communications and operating practices appears to be at the heart of this recommendation and we feel this would be best addressed through the arrangements to improve the joint working between police and ambulance services_ As described in point v) above we would propose to develop this in close partnership with the police_ vii) The provision of training for control room staff in ambulance services will be considered following recommendations that arise from the response categorisation study described in point ii above. viii) We welcome the development of clinical governance partnerships between Emergency Services_ rather than Police Clinical Governance Boards that operate independently of the ambulance service. The development of partnerships would assist in addressing the interoperability issues you have highlighted in your report. Chairman: Professor Anthony C Marsh QAM SBStJ DSci (Hon) MBA MSc MA FASI Managing Director: Martin Flaherty OBE rapid hurry not

ix) AACE agree with the evidence offered by Jthat a direct call from the Police Officer on scene to the ambulance control room (either through dialling 999 or use of Airwave radio) is likely to result in more accurate triage of the patient's condition and better assessment of the appropriate response priority. AACE have previously shared this view with the National Police Chiefs Council (NPCC) and with the multi-agency Emergency Services Demand Management Group (ESDMG) chaired by the Home Office_ AACE understand the cultural and practical barriers raised by the NPCC and accept that direct communication from the Police Officer on scene may not always be practicable. Ambulance trusts have locally agreed arrangements for the passage of information between Police and Ambulance control rooms. This is best determined at a local level due to differing technologies and working practices_ For example, in London the Police and Ambulance Computer Aided Dispatch (CAD) technologies are linked enabling direct passage of information with no voice contact by phone. In some ambulance services; requests from Police control rooms are directed through the 999 system and in others there is a dedicated phone number for contact between Police and Ambulance control rooms_ Where an ambulance trust has agreed arrangements with the Police for a dedicated phone line for the passage of emergency requests for ambulance attendance it would seem important to ensure that the speed with which the phone is answered is in line with 999 call answering: AACE will share this, and the other operational considerations outlined in this report; with the National Directors of Operations Group (NDOG) for ambulance services Prior to your report; the subject of the recognition and management of ABD in the prehospital environment had already received considerable attention and work has been progressing to address this complex topic, as described above. South West Ambulance Service NHS Foundation Trust have been appraised of this work through NASMeD. Our work nationally will continue to progress in this important area as soon as practicable, as described in the other points within this report_ xi) This report and our ongoing work will be discussed and shared at future meetings of NASMeD NDOG and with the Ambulance Chief Executives Group that you will agree that we have responded to the concerns that you have raised and explained our reasoning: We can assure you that we are absolutely committed to learning from all such adverse events and doing everything within our power to prevent them happening again in the future If we may be of further assistance, please do not hesitate to contact us ._ We would Iike to extend our sincere condolences to the family of Mr Oak.