Dear Dr Cummings, Re: Regulation 28: Report to prevent future deaths I was saddened to read of the death of Police Sergeant Sean Duignan in such regrettable circumstances. Mr Duignan’s untimely death will undoubtedly have had a dreadful impact on his family, friends and colleagues. HMICFRS’s purpose is to promote improvements in policing and fire and rescue services to make everyone safer. I am grateful for the opportunity to comment and contribute to efforts that seek to prevent future such tragedy. In preparing my response I made a number of enquiries. I was encouraged to learn from others that the following action has already been taken following Mr Duignan’s death:
• In July 2021, the College of Policing armed policing lead and deputy conducted a review of the armoury procedures at Bedfordshire Police, focusing on Luton Airport. Observations were made to the Chief Constable of Bedfordshire Police.
• The Independent Office for Police Conduct has carried out an investigation.
• In October 2022, armed policing chief firearms instructors were presented with the lessons learned at the national chief firearms instructor seminar, which was overseen by the College of Policing.
• In November 2022, temporary Deputy Chief Constable wrote to Chief Constable (National Police Chiefs’ Council armed policing lead) to advise him of the inquest finding and the work undertaken by Bedfordshire to address Independent Office for Police Conduct recommendations and College of Policing observations.

2 Coincidently, under the leadership of my colleague, His Majesty’s Inspector , HMICFRS has very recently completed the fieldwork phase of a national thematic inspection of armed policing. The terms of reference for that inspection include elements of munitions and weapons storage and issue. We did not specifically test armoury access. The inspection visited nine forces; Bedfordshire wasn’t one of these. The inspection methodology included a review of those nine forces’ armoury standard operating procedures. All use the system known as ‘Chronicle’ to manage access. While single access is possible, dual access is the norm. Only a small number of documented and authorised individuals (for example, armourer, chief firearms instructor) have single access. Manual override processes involve the force incident manager. The Armed Policing inspection report is due to be published in summer 2023 and will refer to our findings and recommendations, including in respect of force armouries. Further to the inspection work, I intend to take the following action:
• Make sure the College of Policing and the National Police Chiefs’ Council armed policing lead issue a relevant national circular to all forces by 31 March 2023. That circular should include the lessons learned and ask for a suitable auditable review of all force armoury access procedures. I understand both organisations intend to take such action following the inquest conclusion.
• Instruct my team to monitor Bedfordshire Police’s armoury processes as part of the HMICFRS police efficiency, effectiveness and legitimacy inspection programme 2023–25.

Dear Dr Cummings, RE: Regulation 29 response to Coroners’ regulation 28 report to prevent future deaths in relation to the inquest into the death of Sergeant Sean Duignan I write in my capacity as the Deputy Chief Constable of Bedfordshire Police and in response to the regulation 28 notice issued to the force. I provide details of the action taken in response to the concerns you have identified;
1. Single access to the armoury and incorrect access levels
2. Awareness of who should not have access to the armoury
3. Failures by senior management to effectively and safely manage the south base armoury
4. ICT failures resulting in armoury access challenges
5. Safety and security at the south base armoury
1. Single access to the armoury and incorrect access levels This area was highlighted as the officer who admitted Sergeant Sean Duignan had single access to the armoury, when standard practice is that all officers should be seconded into the armoury. A review of armoury access was commissioned by the Operations Superintendent on 3 June 2021 which found that two officers within the unit had incorrect access, and this was rectified immediately. The IOPC report of 28 June 2021 also highlighted this (see appendix 1). Single access was therefore confirmed as restricted to National Firearms Instructors, Armourers and Operational Firearms Commanders and this was communicated across the unit. This is common practice nationally and in line with operational requirements.

On 28 June 2021, the Eastern Region Armed Policing Coordinator also shared these recommendations with regional colleagues. These restrictions were specified in the amended Standard Operating Procedures, as detailed in the initial College of Policing report (see appendix 2). These restrictions are reviewed monthly under a standing agenda item at the armed policing managers meeting to confirm access is still afforded at the correct levels. The Chronicle system holds the single access user list which is checked line by line within the meeting. There have been no further incidents of incorrect single access records to date.
2. Awareness of who should not have access to the armoury The regulation 28 report highlighted that the officers who were present on that day were not aware of the restriction from accessing the armoury already placed on Sgt Duignan, following his arrest on 29 May 2021. This was rectified following Sgt Duignan’s death. On 28 June 2021 we introduced a standard email which is sent to all officers with armoury access, advising of individuals who have had their armoury access removed. The most recent example of a teamwide authority email was sent by the base inspector on 9 January 2023 (see Appendix 3). Since the introduction of this process the armed policing management team have sent 15 such emails. Whilst this is a balance of privacy against safety, safety must be the overriding factor. This was a recommendation of the original College of Policing report (see Appendix 2). The decision was briefed to all officers and commanders and included in the Standard Operating Procedures.
3. Failures by senior management to effectively and safely manage the south base armoury Following the death of Sgt Duignan and the subsequent coronial process, communication between managers and armed officers has been brought into sharp focus. Significant steps have been taken to enhance the security provision regarding armoury access, the communication to officers and the governance that supports this updated operating model. Structured meetings are routinely scheduled, both daily and monthly. A daily meeting is chaired by a duty manager often independent from armed policing; also in attendance is the

Operations Superintendent. The purpose of this meeting is to discuss any staffing abstractions, sickness, health and safety issues and any current operational challenges including a review of the armoury access status. The daily meeting provides greater situational awareness for senior officers with a focus on issues faced by staff on the ground. A monthly meeting, chaired by the Operations Chief Superintendent is held to cumulatively review operational and tactical issues through the strategic lens. This will include items bought to the daily meeting which have not been successfully actioned the same day. The strategic overview of outstanding matters ensures there is a method for escalation to resolve problems both in a timely manner and within the best possible terms. This meeting is attended by all members of the Joint Protective Services (JPS) Operational Senior Management Team. Further oversight is maintained through the Bedfordshire, Cambridgeshire and Hertfordshire (BCH) Firearms Strategic Board chaired by the JPS Assistant Chief Constable.
4. ICT failures resulting in armoury access challenges The areas covered in the Prevention of Future Death notice relate to access to the armoury. The clarification between the areas that are covered by the phrase ‘Chronicle’ are detailed in the report submitted to yourself from the owners JML, dated 16 February 2023. The access issue as detailed focused on single access as addressed in point 1 above. Access can also be granted via the emergency access function should either the door access fail or due to an overall power failure. Following the death of Sgt Duignan, the access code for the emergency access at the southern base was reviewed and amended so that only the Force Incident Manager, stationed at Bedfordshire Police Headquarters, and the Superintendent of Specialist Operations were aware of the code. Any requirement for use would necessitate a request directly to the Force Incident Manager and confirmation of the presence of a second officer. Following use of the code, it would be changed immediately by the Superintendent or the Chief Superintendent in their absence. Since the introduction of the armoury access outage recording process on 11 November 2022 there have been 15 access issues identified. The majority have been resolved without any requirement for support from ICT or JML by ‘rebooting’ the computer, the remainder have resulted in the utilisation of the backup system where a pin code change was required.

We have also introduced a specific escalation process should any difficulties be found in our use of Chronicle. This increases our ability to monitor the effective functioning of the systems and processes, including the escalation to ICT and JML. These have been reviewed, introduced and are now well-embedded across the unit to ensure that any impasses are easily identified and strictly monitored. As the access failures referred to above identify, there are still problems with the computer hardware, specifically in relation to USB ports, these are being addressed by ICT and JML. A USB fix was implemented on the 24 February 2023, since that date there has been no related outages. Access failures do not result in any risk to the public or officers. Access to the armoury can be carried out via keys through the secure and managed process outlined above. This escalation process was part of the work completed in conjunction with JML and BCH ICT following the inquest. This included:
• identifying previously unknown USB settings which hampered the system,
• increasing cameras across BCH armouries,
• connection and broadband monitoring at relevant sites,
• and increasing knowledge of both officers, supervisors and ICT around the capabilities and functions of the Chronicle system.
5. Safety and security at the south base armoury The safety of the public and our people is paramount which is why the security surrounding armoury access at the base is of a high standard. All our security enhancement actions following the death of Sgt Duignan are captured within the Armed Policing Unit Standard Operating Procedures (SOPs) and have been communicated to all officers in the unit. SOPs are supported by relevant risk assessments, there are currently 34 relating to the Armed Policing Unit including a specific assessment pertaining to armoury access at the southern base. These assessments are further supported by site inspections by both the armed policing health and safety single point of contact and the armed policing senior responsible person, these inspections being quarterly and every six months respectively. In conjunction with the tri force Health and Safety department, we have also carried out a comprehensive and in-depth review of all those armed policing-related risk assessments.

Whilst we do continue to have ICT challenges where officers are on occasion refused access to the armoury, we now have robust measures in place that ensure these are recorded, effectively managed, and follow an escalation process through to resolution. The backup armoury key safe code is only known to the Bedfordshire control room inspector and the Operations Superintendent, so whilst failures are frustrating for officers there is no risk to the public or workforce. We are, of course, working with both ICT and JML to ensure the armoury access hardware at the southern base is as reliable as the other two armouries within our organisation. This work is captured within an action tracker that I attach for reference. (see appendix 4). Conclusion In conclusion, I sincerely hope that the above actions along with our engagement with the College of Policing (CoP) in terms of armoury reviews provides you reassurance that we have taken all possible measures to prevent future deaths. In relation to future auditing and monitoring, on 10 January 2023, there was a follow-up review of the armouries within BCH by the College of Policing (see Appendix 5), confirming the completion of the amendments already made from the initial inspection, carried out on 16 July
2022. As detailed in the letter from HMICFRS dated 31 January 2023, armouries within Bedfordshire, Cambridgeshire and Hertfordshire will be specifically included within their next set of inspections over the next two years. With regard to the attached action tracker (see Appendix 4), we have made significant progress but still have four actions being progressed; the first is in relation to some residual issues pertaining to ICT armoury hardware improvements and monitoring at the southern base. I am assured these will be addressed in the coming weeks, however the installation of CCTV is an action that is currently pending due to the base being within a building that is shared with users outside of policing. We are currently at the final stages of agreeing a contract for a new south base premises, which will see CCTV installed at point of build. The remaining three actions relate to feedback from the CoP following their visit to our northern base armoury in January 2023. Work is in progress to make all the required changes and should be in place by 30 April 2023.

We have continued to work on any issues identified or raised following the death of Sgt Duignan to negate the possibility of future deaths in this area. I extend an open invite to you, and your office, to attend armed policing bases within BCH to see for yourself the measures and governance that are in place to ensure the department can operate efficiently and effectively at keeping the public safe, whilst also ensuring the safety of our officers and staff.

Dear Dr Cummings, Re: Regulation 28: Report to prevent future deaths I am writing to provide you with an update on my letter dated 31 January 2023. In this letter to you, I said I would instruct my team to monitor Bedfordshire Police’s armoury processes. This was as part of the HMICFRS police efficiency, effectiveness and legitimacy (PEEL) inspection programme 2023–25. Since my last correspondence, my team has been reviewing Bedfordshire Police’s armoury processes. It has focused on the Regulation 28 ‘Prevention of future deaths report’ published on 16 January 2023. The report detailed five concerns:
1. Single access to the armoury and incorrect access levels.
2. Lack of awareness of who shouldn’t have access to the armoury.
3. Failures by senior management to effectively and safely manage the South Base armoury.
4. IT failures resulting in armoury access challenges.
5. Safety and security at the South Base armoury. I am pleased to report that the force has made progress in all five areas listed above to make sure access to the armoury is regulated and controlled. The force has introduced systems and technology to control access to the armoury. These are working effectively. Senior management are now able to effectively manage the armoury to make sure their officers are safe. As part of our PEEL inspection of Bedfordshire Police’s armoury procedures, we carried out interviews and ran focus groups with both senior leaders and practitioners. We also inspected the Luton Firearms base.

2 We have reviewed a range of strategic and tactical documents which illustrate policy, procedure and audits of key decisions, actions and risks. And we attended key governance forums, boards and meetings across the collaborated firearms provision. Bedfordshire Police is part of the Joint Protective Services Command (JPS) which is a collaborated service with Hertfordshire and Cambridgeshire Constabularies. This provides armed policing across the three counties. Key progress against the five areas Single access to the armoury and incorrect access levels The force has reduced single access to the armoury to make sure that only officers who need single access can have it. Only five people have single access to the armoury. All five are operational firearms commanders and armourers. The force has taken the added precaution of removing single access to the armoury from national firearms instructors. The force states these restrictions in its standard operating procedures, which have been distributed to all officers. Managers review these restrictions at the monthly managers’ meeting which is audited and recorded. We found that this process was tightly managed and regularly scrutinised. Awareness of who shouldn’t have access to the armoury Officers can choose not to carry firearms. They can also request that their armoury access is revoked for a defined period, should any welfare/well-being or professional standards concerns arise. Managers can also restrict armoury access if a person meets the same criteria. The firearms command has focused on enhancing its culture around ‘it’s ok not to be ok’. And we found that the force has made significant progress with its well-being/welfare provision. We found evidence of officers feeling supported and cared for by their leaders. Once access for a person is restricted, the sergeant sends an email to all officers informing them of who has had their access revoked. The force duty inspectors are also made aware, and a restricted duties note is placed on the individual’s shift management system. We found improvements to the culture around carriage of firearms and to the way the command communicates with officers. These were effective in keeping officers safe. Failures by senior management to effectively and safely manage the South Base armoury The force holds a daily management meeting chaired by the duty manager with the operations superintendent in attendance. We found these meetings are effective at monitoring the times when officers are diverted from their duties. They are also effective at monitoring operational challenges, armoury access status, health and safety and sickness. There is good senior officer oversight through the monthly managers’ meetings. At these meetings, managers identify themes and trends and monitor armoury access. Key risks and issues are used to inform the firearms strategic board. The JPS assistant chief constable chairs this board, which provides good senior officer oversight and support.

3 IT failures resulting in armoury access challenges The firearms command has invested in new and improved technology to reduce the number of Chronicle failures. Chronicle is the system that the force and the firearms command use to manage firearms accreditations and armoury access. The firearms command has moved to new premises at Luton airport. This means that there are better wiring and charging points to service Chronicle. As a result, the number of Chronicle system faults has reduced to zero in the last six months. JPS tracks and monitors system faults through the monthly managers’ meeting. JPS has a manual key process which provides access to the armoury when Chronicle faults occur. The force’s daily manager checks the manual key process following a clearly defined procedure. This makes sure the workforce is safe and secure. We found the new processes were effective in keeping officers safe. Safety and security at the South Base armoury The new firearms base in Luton is a modern, secure premises. It is fit for purpose, with several enhanced security measures. The new site has fencing to restrict access and enhanced 360-degree CCTV coverage in the armoury. It also has an enhanced armoury design, to control the access and distribution of weapons to officers. We found moving to the new site has significantly increased the safety and security of the officers. Conclusion In conclusion, I am satisfied that the firearms base at Luton airport is managed correctly. It has the correct procedures, policies and processes in place to keep officers safe while on the site. I am pleased to report positively on the force’s efforts to improve. They take all reasonable steps to continually improve the safety and well-being of their officers.