Source · Prevention of Future Deaths

Matthew Lewis

Ref: 2019-0048 Date: 13 Feb 2019 Coroner: Graeme Hughes Area: South Wales Central Responses identified: 2 / 2 View PDF

Confusing and inconsistent call handler instructions to police officers during a hanging incident created ambiguity between scene preservation and life preservation, risking unsuccessful rescue attempts.

Date 13 Feb 2019
56-day deadline 19 Jul 2019 est.
Responses identified 2 of 2
Emergency services related deaths (2019 onwards) Suicide (from 2015) Wales prevention of future deaths reports (2019 onwards)

Coroner's concerns

AI summary
Confusing and inconsistent call handler instructions to police officers during a hanging incident created ambiguity between scene preservation and life preservation, risking unsuccessful rescue attempts.
View full coroner's concerns
Bothi in their evidence expressed confusion as to the instre Jassed to them by the cali handler: In particular, whether they should approach Mr Lewis and attempt to cut him down or refrain from any

SO in the interests Of scene preservation (2) The subsequent evidence of the Officer in Charge, was to the effect that his primary role as a police officer was the preservalion onlife The initial instructions of the Call handler here appeared inconsistent with that expressed overriding (3) In any hanging episode; time is very much of the essence following suspension: Whilst it could not be determined on the evidence the exact time that that occurred on 27.2.18, medical evidence received at the Inquest indicated that deathlirreversible brain injury would likely occur, no later than 5 minutes post suspension With such a narrow "rescue window" , the clarity of instructions to rescuers appears paramount Whilst it was found on the evidence that the actions of the call handler were neither directly , nor indirectly causative of Mr Lewis' death, there is a risk that in the future a repeat of confusinglinconsistent call handler instructions may lead to & potentially contribute t0 the prospects of an unsuccessful rescue (4) Guidance toltraining for call handlers as to how to deal with such scenarios wouid seem desirablelmandated

Responses

2 respondents
South Wales Police Police / Law Enforcement
13 Feb 2019 PDF
Action Taken

South Wales Police have developed a procedure for call handlers that incorporates guidance highlighting the presumption that 'life is not extinct' in hanging scenarios. This procedure is now part of call handler training. (AI summary)

View full response
Dear Mr Hughes, Re: Mr Matthew William Lewis (Deceased) refer to your letter dated 14h February 2019 addressed to the Chief Constable of South Wales Police as it has been passed to me: This letter is the Regulation 29 Response on behalf of the Chief Constable. have had the opportunity to consider wholly the contents of the Regulation 28 Report to Prevent Future Deaths dated 13 February 2019 enclosed with your letter. The matters raised therein have been fully considered by the senior officers responsible for the South Wales Police Public Service Centre in an effort to ensure that we have addressed the concerns raised. This arises out of the Inquest into the death of the late Mr. Mathew William Lewis The matters of concern you have identified are contained in section 5 of the Regulation 28 Report: have set this out below, for ease for reference: (1) Botl in their evidence expressed confusion as to the instructions that were passed to them by the call handler: In particular; whether should approach Mr Lewis and attempt to cut him down or refrain from SO in the interests of scene preservation. (2) The subsequent evidence of the Officer in Charge, was to the effect that his primary role as a police officer was the preservation of life. The initial instructions of the call handler here appeared inconsistent with that expressed overriding duty: (3) In any hanging episode, time is very much of the essence following suspension. Whilst it could not be determined on the evidence the exact time that that occurred on
27.02.18, medical evidence received at the Inquest indicated that death/rreversible brain injury would likely occur, no later than 5 minutes post suspension. With such a naiow "rescue window", the clarity of instructions to rescuers appears paramount HEDDLU DE CYMRU SOUTH WALES POLICE Pencadlys Heddlu De Cxmru, Heoly Bont-faen, Penybont CF3I 3SU South Wales Pollce Headquarters, Cowbridge Road, Bridgend CF3 | 3SU Mewn argyfwng ffoniwch 999, fal arall, ffontwch I0/ In an emergengy always dial 999, for non-emergencles dial IOl Gwelan: wwwheddlu-de-cymru-policeuk Website: wwwsouth-wales police:uk Mae Hodlu De Cymrum coestwu derbyn gohebhathyn Gymnez Sacrncg: South Wks Folica wekomes receing conEspondence h Wekhund Endih: Byddwn yn nteb gohebisath dderbynnkry Gyrrgyn Gymnegec nl fdd cenespondence recclved In Webh wdl be answered h Webh and conponding gohcbuyn Gmracgyn arwln %t oedi: In Wckh will not kead to responding: Prlf Gwnstabl Matt Jukes QPM, MA(Oxon)MSc Chlef Constable they doing willing AMm delzy

Whilst it was found on the neither evidence that the actions of the call handler were directly, nor indirectly causative of Mr Lewis' death, there is a risk that in the future repeat of confusinglnconsistent call handler instructions may lead to delay potentially contribute to the prospects of an unsuccessful rescue_ (4) Guidance to/training for call handlers as to to deal with such scenarios would seem desirablelmandated: South Wales Police invest considerably in training call handlers to deal with a multitude of situations; however, training scenario can never replicate the experience gained from with real incidents. In respect of can confirm that South Wales Police have a procedure in place for new and inexperienced call handlers , where a trainer or more experienced operator monitors and is able to step in quickly when the new operator is unsure of the advice they should be giving: In addition, whilst there is no national guidance for this type of circumstance issued by the College of Policing to Call Handlers in Police Forces, South Wales Police has taken steps to develop a procedure for call handlers, which incorporates appropriate guidance into its force procedures. This new procedure is incorporated into the training that call handlers receive and in particular; the paragraph below that highlights the presumption that 'life is not extinct' "It is important to note that in any hanging scenario the emphasis is that the presumption must always be that that life is not extinct It is recognised that no two incidents be the same and there will be other factors that need to be taken into consideration. For example, the ability of the member of the public reporting the incident to assist; or to offer assistance without placing himself or herself in any jeopardy or danger; and the accessibility to the location in which the person is found hanging". The guidance is designed for the call handler to engage with the caller in a constructive and meaningful way to determine the appropriate level of support and assistance , which may be provided until the arrival of the emergency services hope that these actions address the points raise within your Regulation 29 notice, but if there are any further concerns, please let me know:
College of Policing Police / Law Enforcement
8 Apr 2019 PDF
Action Planned

The College of Policing will amend learning standards for contact management staff within the next month to reflect the importance of preserving life. They have also asked for a summary of the issue to be circulated to heads of contact management across England and Wales. (AI summary)

View full response
Dear Mr Hughes Re:13270 , Matthew William Lewis (deceased) write on behalf of the College of Policing in response to the Prevention of Future Deaths report of the 13 February 2019 in relation to Matthew William Lewis (deceased) who sadly lost his life through suicide in 2018 In the report you refer to instructions given by the police call handler which, whilst not judged to be directly or indirectly linked to the death of Matthew Lewis, may have implications for similar future events You express your concern that there is a risk that a repeat of inconsistent or confusing call handler instructions may lead to and potentially contribute to the prospects of an unsuccessful rescue_ You also observe that training for call handlers on how to deal with such scenarios would be desirable and mandatory The College of Policing produces the National Policing Curriculum which sets the learning standards for a number of areas of policing including contact management which informs the training of police call handlers and dispatchers. In SO we work closely with the National Police Chiefs Council lead for this area, currently Assistant Chief Constable (ACC)E from the Police Service of Northern Ireland: In response to this report we will, within the next month, amend the learning standards for contact management staff to reflect that the preservation of life is paramount when considering the impact on scene preservation and that suitable instructions should be given t0 willing members of the public who are able to assist in preserving life and providing rescue where possible_ have also asked that a summary of this issue is circulated, via Ito all heads of contact management across England and Wales so that can take any necessary urgent action in respect of clarifying locally delivered training hope that this addresses the concerns that you set out in your report and am grateful for you bringing them t0 my attention:

Report sections

Investigation and inquest
commenced an investigation on the 6th March 2018 into the death of Matthew William Lewis The investigation concluded at the end of the inquest on 1th February 2019. The conclusion was "Suicide" and the medical cause of death was Ia. Hanging
Circumstances of the death
attach a copy of the record of Inquest: The Inquest focused upon - The events of 27.2.18 leading to, & of Mr Lewis's hanging, the South Wales Police response to the incident; & the emergency medical treatment he received; The clarity, appropriateness & causative impact of the instruuctions @ivem the South Wales Police call handier to the willing rescuers Iwho reported the finding of Mr Lewis hanging): attach a copy of the transcription of the call which was played during the Inquest
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you and your organisation has the power to take such action.

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Report details

Reference
2019-0048
Date of report
13 February 2019
Coroner
Graeme Hughes
Coroner area
South Wales Central

Responses identified

Responses identified 2 of 2
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 19 Jul 2019 (estimated).

Sent to

College of Policing
South Wales Police

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