Avon and Somerset Police
Police / Law Enforcement
Action Planned
Avon and Somerset Constabulary outlines changes to their communication services, including a new call scripting system with dynamic assessment capabilities to be adopted in April 2015. They have also established a consolidated Learning Board to drive forward lessons from events such as this. (AI summary)
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Dear Ms Voirin In the matter of the death of Christopher David Taylor thank you for your letter dated 13th February 2015 and formally acknowledge receipt ofyour report made under Regulation 28 immediately recognise the circumstances leading to Mr Taylor's tragic death are such to demand proper consideration is given as to how the risk of similar events re-occurring can be addressed. would like to assure you and, through you Mr Taylor'$ family, that on behalf of Avon & Somerset Constabulary we take the process of learning lessons very seriously in order to collectively better serve our community. In preparing this response have reviewed the written statements submitted on behalf of the Constabulary: Without equivocation, share your assessment that any delay, such as this where there is no explanation, should not happen. The actions /'ve outlined below are those that have been initiated since Mr Taylor' $ death and which consider address the risks that are at the heart of your report Communications In his written evidence to the Inquest, Inspectorl loutlined the phases through which a call such a5 this would have progressed at that time_ For your ease of reference however, Inspector linformed the Inquest that Force Service Centre ('FSC' ) was the 'primary of contact for all emergency [calls] that come into the Constabulary' Designed to 'offer a comprehensive service for the public contact the Police' , FSC takes 'on average 2500 to 3000 call per day' which is roughly one call every 25 ~ 30 seconds It is evident enough from the calls logs disclosed to the Inquest, that the call taker' $ actions were efficient in gathering relevant information and prompt in transferring the call on for dispatch_ As per Inspector statement, once the call has been 'taken' it is transferred to from FSC to Dispatch, which is sited in different locations away from FSC. The disparity between the call taker'$ actions and the period of approximately 5 minutes during which no recorded action appears to have been taken is the first area the Constabulary has sought to address. It appears to me the risks of calls to be 'dropped' will be significantly lessened with Call Handlers and Dispatchers located together. Thus, from April 2015 the Constabulary will commence with the co-location of Call Handlers and Dispatchers who will then work as one team under a single supervisor. The unification of the two aspects of Communications will better enable information to be shared, ensure clear accountability of decision making and promote holistic thinking: In terms of these events, consider point
that co-location with single supervision is to have the effect of minimising the risk of an undocumented recurring: Secondly, the Constabulary is introducing a new THRIVE (Threat; Harm, Risk, Investigation, Vulnerability, Engagement) call grading matrix, as is in use by other Forces nationally: The focus of this new grading matrix is to ensure deployment decision making is in line with threat; harm and risk In the context of this system should operate to ensure that decision making processes, such as that which lead to the decision to call the ambulance service, are prompted at stage_ Thirdly, and in order to best embed effective use of THRIVE, the Call Handling role has been re-written to require a greater range of skills and capacity, such as were in evidence in this case_ All new staff recruited into this role will be trained in accordance with the enhanced requirements_ Fourthly, and in addition to the revamping of the Call Handler role; we are investing in our staff in rolling out a comprehensive scheme of training for Call Handlers and Supervisors to enable the modifications to their respective roles to be supported by learning: Finally, and perhaps most fundamental to the redesigning of our communication services, April 2015 the Constabulary will adopt a new call scripting system which is designed with tags and alerts for the benefit of the Call Handler/Dispatch team'$ ability to dynamically and continually assess of needs/priority of any one call: If taken in isolation, none of the above steps comprehensively addresses the specific concern in your report that staff may not be able to 'see at all-times a screen which displays incoming incidents_ However, | hope you would share my view that when put into operation in concert with each other; the cumulative effect is such that staff no-longer rely solely upon visual access to any specific screen: Organisational Learning Though not as a direct result of these tragic events, would also wish to impress upon you the Constabulary' s renewal approach to Organisational Learning, for which am portfolio lead. From February 2015 the Constabulary' s approach to Organisational Learning has been refreshed with the establishing of one consolidated Learning Board, which Iead, with wide ranging terms of reference intended to capture and drive forward lessons from events such as this. To ensure the engine room for corporate learning and change remains fuelled, each separate portfolio within the Constabulary has its' own Learning Forum with a similarly wide remit to feed into the Learning Board: do not believe that in their own right, these steps outlined above will ensure prevention all such incidents having tragic conclusions: do however believe and commend to you however; that these steps represent the Constabulary's belief in learning and implementation of that learning drawn specifically on these events My hope is that once implemented we, as an organisation will be better placed to respond to incidents such as this, in a way that will greatly enhance the chances of a different outcome_
that co-location with single supervision is to have the effect of minimising the risk of an undocumented recurring: Secondly, the Constabulary is introducing a new THRIVE (Threat; Harm, Risk, Investigation, Vulnerability, Engagement) call grading matrix, as is in use by other Forces nationally: The focus of this new grading matrix is to ensure deployment decision making is in line with threat; harm and risk In the context of this system should operate to ensure that decision making processes, such as that which lead to the decision to call the ambulance service, are prompted at stage_ Thirdly, and in order to best embed effective use of THRIVE, the Call Handling role has been re-written to require a greater range of skills and capacity, such as were in evidence in this case_ All new staff recruited into this role will be trained in accordance with the enhanced requirements_ Fourthly, and in addition to the revamping of the Call Handler role; we are investing in our staff in rolling out a comprehensive scheme of training for Call Handlers and Supervisors to enable the modifications to their respective roles to be supported by learning: Finally, and perhaps most fundamental to the redesigning of our communication services, April 2015 the Constabulary will adopt a new call scripting system which is designed with tags and alerts for the benefit of the Call Handler/Dispatch team'$ ability to dynamically and continually assess of needs/priority of any one call: If taken in isolation, none of the above steps comprehensively addresses the specific concern in your report that staff may not be able to 'see at all-times a screen which displays incoming incidents_ However, | hope you would share my view that when put into operation in concert with each other; the cumulative effect is such that staff no-longer rely solely upon visual access to any specific screen: Organisational Learning Though not as a direct result of these tragic events, would also wish to impress upon you the Constabulary' s renewal approach to Organisational Learning, for which am portfolio lead. From February 2015 the Constabulary' s approach to Organisational Learning has been refreshed with the establishing of one consolidated Learning Board, which Iead, with wide ranging terms of reference intended to capture and drive forward lessons from events such as this. To ensure the engine room for corporate learning and change remains fuelled, each separate portfolio within the Constabulary has its' own Learning Forum with a similarly wide remit to feed into the Learning Board: do not believe that in their own right, these steps outlined above will ensure prevention all such incidents having tragic conclusions: do however believe and commend to you however; that these steps represent the Constabulary's belief in learning and implementation of that learning drawn specifically on these events My hope is that once implemented we, as an organisation will be better placed to respond to incidents such as this, in a way that will greatly enhance the chances of a different outcome_