Shay Middleton-Pierce

Dear Ms Loxton Inquest into the Death of Shay Middleton-Pierce Regulation 28 Report to Prevent Future Deaths The following is provided in response to the Report to Prevent Future Deaths (the Report) arising from the Inquest into the Death of Shay Middleton-Pierce, as required under paragraph 7(2) of Schedule 5 of the Coroners and Justice Act 2009 and under regulation 29 of the Coroners (Investigations) Regulations 2013. British Transport Police (BTP) recognises HM Coroner’s concerns and is committed to ensuring that the circumstances identified are addressed robustly. We again extend our sincere condolences to the family of Shay Middleton-Pierce. Coroner’s Concern HM Coroner has identified a risk whereby a dispatcher in BTP’s Force Control Room (“FCR”) could move an incident log from the dispatch queue on the computer system to a sub-queue in error, removing it from active oversight from Team Managers and Force Incident Managers within the FCR. This means that actions on an urgent case were not progressed and contributed to a lack of communication with partner agencies. BTP acknowledges that, at the time of the incident, safeguards to prevent or detect such an error were insufficiently robust in practice. BTP confirms that the matters raised have been subject to detailed review. Measures have been implemented and are continuing to be embedded to significantly reduce the likelihood of recurrence to as low as reasonably practicable, via an integrated leadership, management oversight and training response complemented by exploring potential additional software system controls. Operational Roles and Accountability Force Incident Managers (FIMs), Deputy FIMs (DFIMs), and Team Managers (TMs) provide the supervisory structure within the FCR.

Not Protectively Marked Not Protectively Marked They are responsible for:
• Assessment and grading of incidents.
• Command and control of operational activity.
• Deployment of resources to critical incidents.
• Continuous monitoring of incidents involving threat, harm, or vulnerability. In practical terms:
• FIMs and DFIMs provide strategic and tactical command oversight of incident management, including review of immediate and priority incidents, decision- making, and escalation.
• Team Managers provide direct supervision of around 8 dispatchers and call handlers, ensuring logs are progressed appropriately and that operational standards are met. The Operations Manual clearly requires that all priority and immediate incidents must be subject to active supervisory review and endorsement. Strengthened Supervisory Oversight and Controls Recognising that supervision by the FIM/DFIM and Team Managers is a critical safeguard, BTP has implemented a comprehensive set of procedural and supervisory controls: Embedding Mandatory Oversight
• All Command and Control logs (CW logs) are to be actively reviewed and endorsed by a FIM, DFIM, or Team Manager before being progressed or deprioritised.
• Immediate and priority incidents are reviewed by FIMs/DFIMs; welfare-related scheduled incidents are reviewed by Team Managers.
• Team Managers and/or FIMs/DFIMs are to verify that appropriate deployment decisions and inter-agency communications have been completed before any log leaves active management.
• This expectation has been reinforced through mandatory one-to-one training with all supervisory staff. Review of Team Manager Workloads
• A structured review of Team Manager workloads is underway, aimed at removing non-operational tasks, to ensure focus on operational supervision. The review will conclude by July 2026. Increased Leadership Capacity
• Revised rostering models are also being consulted to help safeguard consistent supervisory coverage during peak demand periods.

Not Protectively Marked Not Protectively Marked Training and Capability Development Targeted Supervisory Training An intensive one-to-one training programme for all FIMs and DFIMs commenced in April 2026, providing a full 8-hour day of training for each FIM/DFIM every 10 weeks, including:
• Command and control expectations.
• Application of the Operations Manual.
• Oversight responsibilities in threat-to-life incidents.
• Decision-making and accountability. All supervisors will complete this programme by September 2026. Force Control Room Staff Training
• Dispatchers and call handlers receive 7 weeks of initial raining on call handling and on radio talk-groups. Upon completion of this initial training, each Dispatcher / call handler is assigned a tutor who supports their ongoing development in live control room. Each call handler / dispatcher must satisfy a set of competency criteria in the live control room before they can be signed off as able to act independently as a call handler / dispatcher.
• Our current programme of ongoing training for call handlers and dispatchers, providing a full 8-hour day of training for each FIM/DFIM every 10 weeks, is being delivered in partnership with BTP Learning & Development, with completion expected by Q3 2026.
• FCR staff are now being provided with the same Railway Safety Awareness training as operational BTP Officers. Scenario-Based Learning BTP is introducing new immersive, scenario-based training using a simulated control room environment to:
• Practice real-time incident management.
• Reinforce THRIVE decision-making: o Threat: Is there an immediate danger or threat to life? o Harm: What is the potential level of harm or damage? o Risk: What is the likelihood of the threat or harm escalating? o Investigation: Are there investigative opportunities, forensic opportunities, or evidence to be gathered? o Vulnerability: Is the caller, victim, or person of interest particularly vulnerable? o Engagement: What is the most appropriate action, agency, or engagement required to resolve the incident safely?
• Improve communication with partner agencies.

Not Protectively Marked Not Protectively Marked This training will be delivered to all teams from November 2026. Improved Processes and Operational Guidance Operations Manual The existing Operations Manual has been reinforced with strengthened implementation:
• Delivered through direct one-to-one engagement.
• Supported by daily compliance monitoring.
• Clearly defining supervisory roles and escalation requirements. Additional embedding has been completed for supervisory roles and will be completed for all staff by July 2026, with ongoing inclusion in new staff onboarding. FIM Guide
• A new FIM Guide has been developed as a practical reference for supervisory staff, setting out consistent expectations for command and control. Monitoring, Audit and Performance Management THRIVE Compliance
• Daily THRIVE compliance reviews are now undertaken by FCR management, and any deviations are addressed through formal performance management processes. Impact of Measures The combined effect of these measures ensures that:
• A dispatcher acts in union with supervisory oversight.
• Any movement of a log (e.g. into a sub-queue) is subject to active supervision and review by a Team Manager, and also by a FIM/DFIM in the case of Immediate and priority incidents.
• FIMs/DFIMs or Team Managers are accountable for ensuring: o Deployment decisions are made. o Partner agencies are informed. o Threat-to-life risks are actively managed. In practical terms, were a similar situation to arise as that that arose in relation to Shay Middleton-Pierce:
• The log would be reviewed and endorsed by a FIM/DFIM before any change in status.
• Failure to deploy or communicate would be identified by the FIM/DFIM immediately. The FIM/DFIM would intervene to ensure appropriate action is taken.

Not Protectively Marked Not Protectively Marked Technology Opportunities As part of an cohesive approach, BTP is exploring with the provider of its FCR Information Technology system whether a technological software safeguard or prompt could be developed to either reduce the potential for this user error, or to add an additional supervisory control on the computer system before a log is released from a sub-queue dispatch control group. This will be examined to accompany the controls of the current command and control system, balanced against the overall significant daily service demand and other operational requirements. Summary BTP fully acknowledge the seriousness of HM Coroner’s concerns. While software- based prevention is explored, BTP has implemented a comprehensive integrated framework of:
• Strengthened supervision.
• Enhanced training.
• Clear operational guidance.
• Continuous monitoring and accountability. These measures collectively ensure that the identified concern has been significantly reduced and is subject to ongoing review. There remains a legitimate operational need for logs to move between queues and control groups in certain cases; however, the strengthened supervisory framework maximises the opportunities to ensure that any errors are identified and corrected. We again extend our sincere condolences to the family of Shay Middleton-Pierce.