Marcel Wochna
PFD Report
All Responded
Ref: 2023-0332
All 2 responses received
· Deadline: 9 Nov 2023
Response Status
Responses
2 of 1
56-Day Deadline
9 Nov 2023
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner’s Concerns
1. Lack of awareness of Cold Water Shock and the associated immediate risk to life;
2. Lack of awareness of the recognised "Shout, Reach, Throw, Row, Go” procedure ;
3. Lack of awareness of risks associated with the use of handcuffs, particularly so to the rear, when detaining a person near water;
4. Absence of effective dissemination, access and awareness of the Hampshire Constabulary “Working near Water Procedure” and the risks, mitigations and the need for necessary dynamic risk assessments set out therein.
2. Lack of awareness of the recognised "Shout, Reach, Throw, Row, Go” procedure ;
3. Lack of awareness of risks associated with the use of handcuffs, particularly so to the rear, when detaining a person near water;
4. Absence of effective dissemination, access and awareness of the Hampshire Constabulary “Working near Water Procedure” and the risks, mitigations and the need for necessary dynamic risk assessments set out therein.
Responses
Hampshire and Isle of Wight Constabulary has produced an updated 'Working Near Water Procedure' that now properly describes Cold Water Shock and the 'Shout, Reach, Throw, Row, Go' method. They will update their E-Learning package by November 2023 and annual Personal Safety Training to include these risks and guidance on handcuffing near water, and disseminate the revised procedure.
AI summary
View full response
Dear His Majesty’s Area Coroner Mr Pegg, This letter is intended to provide a formal response to the Regulation 28 report issued on 13th September 2023 following the Inquest into the death of Marcel Wochna. I will detail our response to each of the four areas of concern you have identified within the report. Prior to doing so, I wanted to reassure you that as Chief Constable for Hampshire and the Isle of Wight Constabulary, I take these areas of concern very seriously and have taken time to reflect on the detail within the Regulation 28 Report.
Matter of concern 1 - Lack of awareness of Cold Water Shock and the associated immediate risk to life. Frontline officers and staff are regularly provided with training informed by operational policy and procedure, which is intended to ensure they have working knowledge of what is required of them in their role. Cold Water Shock is described within the Constabulary’s ‘Working Near Water Procedure’. However it is recognised that this aspect of the procedure is absent from the E-Learning Training package. This is being rectified and the revised E-Learning package will be made available to officers and staff by the end of November 2023. In addition, an updated ‘Working Near Water Procedure’ has been produced which highlights the impact and immediate risks associated with Cold Water Shock. This forms the basis of the revised E- Learning package and key aspects will be revisited with operational officers and staff annually through face to face training delivered as part of the force’s Personal Safety Training.
Matter of concern 2 - Lack of awareness of the recognised "Shout, Reach, Throw, Row, Go” procedure. Hampshire and the Isle of Wight Constabulary’s Marine Unit has provided their expertise and support to the rewriting of the force’s updated ‘Working Near Water Procedure’. This means that the "Shout, Reach, Throw, Row, Go” method is now properly described for all frontline officers and staff. In addition, this method will be included in the revised ‘E-Learning package’ and will be part of the annual Personal Safety Training refresher for frontline operational officers and staff.
Matter of concern 3 - Lack of awareness of risks associated with the use of handcuffs, particularly so to the rear, when detaining a person near water. It is my position that there should be no ‘blanket ban’ on the use of handcuffs near water as it is critical that frontline officers are able to make informed assessments on the most appropriate means to ensure the safety of the public, their colleagues and themselves. Frontline officers and staff in specific roles complete Personal Safety Training during their initial training and complete annual refreshers throughout their service. This training provides them with direction on decision making and techniques associated with the use of force (such as handcuffing). Hampshire & Isle of Wight Constabulary is licensed by the College of Policing to provide this training, which is based upon the National Police Chiefs Council and College of Policing published Personal Safety Manual of Guidance. Through this training officers and staff are taught to use the National Decision Model, empowering those staff to make good and objective decisions regarding the use of force so that their actions are reasonable, necessary and proportionate to the circumstances. To directly address the matter of concern related to the use of handcuffs near water, it is important that officers are provided with sufficient information about the risks associated with doing so. The force’s revised ‘Working Near Water Procedure’ and the annual Personal Safety Training refresher will set out that: Officers should, where possible, avoid handcuffing near water where there is a risk of the detained person falling in and becoming submerged. If the officer, following a dynamic risk assessment, decides that the most appropriate action is to cuff the detained person then they should handcuff to the front.
Matter of concern 4 - Absence of effective dissemination, access and awareness of the Hampshire Constabulary “Working near Water Procedure” and the risks, mitigations and the need for necessary dynamic risk assessments set out therein. The Constabulary’s revised ‘Working Near Water Procedure’ will be disseminated to all officers and staff. In support of learning and understanding, this will include a link to the updated E-Learning package associated to this procedure. Frontline operational officers and staff will be directed to complete the updated training package. Every year, frontline operational officers and staff in specific roles (including all Police Officers and PCSOs) are required to complete a Personal Safety Training refresher. This annual refresher will be revised to include: a) Cold Water Shock b) "Shout, Reach, Throw, Row, Go” c) The risks associated with handcuffing near water
I believe the implementation of the revised ‘Working Near Water Procedure’, that will mandate the completion of training packages both virtually and in person, will sufficiently address the concerns set out in the Regulation 28 notice and will equip our officers and staff to maximise the safety of the public when working near water and prevent such tragic circumstances being repeated in the future. Thank you for providing the opportunity to respond.
Kind regards
Scott Chilton Chief Constable
Matter of concern 1 - Lack of awareness of Cold Water Shock and the associated immediate risk to life. Frontline officers and staff are regularly provided with training informed by operational policy and procedure, which is intended to ensure they have working knowledge of what is required of them in their role. Cold Water Shock is described within the Constabulary’s ‘Working Near Water Procedure’. However it is recognised that this aspect of the procedure is absent from the E-Learning Training package. This is being rectified and the revised E-Learning package will be made available to officers and staff by the end of November 2023. In addition, an updated ‘Working Near Water Procedure’ has been produced which highlights the impact and immediate risks associated with Cold Water Shock. This forms the basis of the revised E- Learning package and key aspects will be revisited with operational officers and staff annually through face to face training delivered as part of the force’s Personal Safety Training.
Matter of concern 2 - Lack of awareness of the recognised "Shout, Reach, Throw, Row, Go” procedure. Hampshire and the Isle of Wight Constabulary’s Marine Unit has provided their expertise and support to the rewriting of the force’s updated ‘Working Near Water Procedure’. This means that the "Shout, Reach, Throw, Row, Go” method is now properly described for all frontline officers and staff. In addition, this method will be included in the revised ‘E-Learning package’ and will be part of the annual Personal Safety Training refresher for frontline operational officers and staff.
Matter of concern 3 - Lack of awareness of risks associated with the use of handcuffs, particularly so to the rear, when detaining a person near water. It is my position that there should be no ‘blanket ban’ on the use of handcuffs near water as it is critical that frontline officers are able to make informed assessments on the most appropriate means to ensure the safety of the public, their colleagues and themselves. Frontline officers and staff in specific roles complete Personal Safety Training during their initial training and complete annual refreshers throughout their service. This training provides them with direction on decision making and techniques associated with the use of force (such as handcuffing). Hampshire & Isle of Wight Constabulary is licensed by the College of Policing to provide this training, which is based upon the National Police Chiefs Council and College of Policing published Personal Safety Manual of Guidance. Through this training officers and staff are taught to use the National Decision Model, empowering those staff to make good and objective decisions regarding the use of force so that their actions are reasonable, necessary and proportionate to the circumstances. To directly address the matter of concern related to the use of handcuffs near water, it is important that officers are provided with sufficient information about the risks associated with doing so. The force’s revised ‘Working Near Water Procedure’ and the annual Personal Safety Training refresher will set out that: Officers should, where possible, avoid handcuffing near water where there is a risk of the detained person falling in and becoming submerged. If the officer, following a dynamic risk assessment, decides that the most appropriate action is to cuff the detained person then they should handcuff to the front.
Matter of concern 4 - Absence of effective dissemination, access and awareness of the Hampshire Constabulary “Working near Water Procedure” and the risks, mitigations and the need for necessary dynamic risk assessments set out therein. The Constabulary’s revised ‘Working Near Water Procedure’ will be disseminated to all officers and staff. In support of learning and understanding, this will include a link to the updated E-Learning package associated to this procedure. Frontline operational officers and staff will be directed to complete the updated training package. Every year, frontline operational officers and staff in specific roles (including all Police Officers and PCSOs) are required to complete a Personal Safety Training refresher. This annual refresher will be revised to include: a) Cold Water Shock b) "Shout, Reach, Throw, Row, Go” c) The risks associated with handcuffing near water
I believe the implementation of the revised ‘Working Near Water Procedure’, that will mandate the completion of training packages both virtually and in person, will sufficiently address the concerns set out in the Regulation 28 notice and will equip our officers and staff to maximise the safety of the public when working near water and prevent such tragic circumstances being repeated in the future. Thank you for providing the opportunity to respond.
Kind regards
Scott Chilton Chief Constable
Hampshire Constabulary has produced an updated 'Working Near Water Procedure' that now properly describes Cold Water Shock and the 'Shout, Reach, Throw, Row, Go' method. They will update their E-Learning package by November 2023 and annual Personal Safety Training to include these risks and guidance on handcuffing near water, and disseminate the revised procedure.
AI summary
View full response
Dear His Majesty’s Area Coroner Mr Pegg, This letter is intended to provide a formal response to the Regulation 28 report issued on 13th September 2023 following the Inquest into the death of Marcel Wochna. I will detail our response to each of the four areas of concern you have identified within the report. Prior to doing so, I wanted to reassure you that as Chief Constable for Hampshire and the Isle of Wight Constabulary, I take these areas of concern very seriously and have taken time to reflect on the detail within the Regulation 28 Report.
Matter of concern 1 - Lack of awareness of Cold Water Shock and the associated immediate risk to life. Frontline officers and staff are regularly provided with training informed by operational policy and procedure, which is intended to ensure they have working knowledge of what is required of them in their role. Cold Water Shock is described within the Constabulary’s ‘Working Near Water Procedure’. However it is recognised that this aspect of the procedure is absent from the E-Learning Training package. This is being rectified and the revised E-Learning package will be made available to officers and staff by the end of November 2023. In addition, an updated ‘Working Near Water Procedure’ has been produced which highlights the impact and immediate risks associated with Cold Water Shock. This forms the basis of the revised E- Learning package and key aspects will be revisited with operational officers and staff annually through face to face training delivered as part of the force’s Personal Safety Training.
Matter of concern 2 - Lack of awareness of the recognised "Shout, Reach, Throw, Row, Go” procedure. Hampshire and the Isle of Wight Constabulary’s Marine Unit has provided their expertise and support to the rewriting of the force’s updated ‘Working Near Water Procedure’. This means that the "Shout, Reach, Throw, Row, Go” method is now properly described for all frontline officers and staff. In addition, this method will be included in the revised ‘E-Learning package’ and will be part of the annual Personal Safety Training refresher for frontline operational officers and staff.
Matter of concern 3 - Lack of awareness of risks associated with the use of handcuffs, particularly so to the rear, when detaining a person near water. It is my position that there should be no ‘blanket ban’ on the use of handcuffs near water as it is critical that frontline officers are able to make informed assessments on the most appropriate means to ensure the safety of the public, their colleagues and themselves. Frontline officers and staff in specific roles complete Personal Safety Training during their initial training and complete annual refreshers throughout their service. This training provides them with direction on decision making and techniques associated with the use of force (such as handcuffing). Hampshire & Isle of Wight Constabulary is licensed by the College of Policing to provide this training, which is based upon the National Police Chiefs Council and College of Policing published Personal Safety Manual of Guidance. Through this training officers and staff are taught to use the National Decision Model, empowering those staff to make good and objective decisions regarding the use of force so that their actions are reasonable, necessary and proportionate to the circumstances. To directly address the matter of concern related to the use of handcuffs near water, it is important that officers are provided with sufficient information about the risks associated with doing so. The force’s revised ‘Working Near Water Procedure’ and the annual Personal Safety Training refresher will set out that: Officers should, where possible, avoid handcuffing near water where there is a risk of the detained person falling in and becoming submerged. If the officer, following a dynamic risk assessment, decides that the most appropriate action is to cuff the detained person then they should handcuff to the front.
Matter of concern 4 - Absence of effective dissemination, access and awareness of the Hampshire Constabulary “Working near Water Procedure” and the risks, mitigations and the need for necessary dynamic risk assessments set out therein. The Constabulary’s revised ‘Working Near Water Procedure’ will be disseminated to all officers and staff. In support of learning and understanding, this will include a link to the updated E-Learning package associated to this procedure. Frontline operational officers and staff will be directed to complete the updated training package. Every year, frontline operational officers and staff in specific roles (including all Police Officers and PCSOs) are required to complete a Personal Safety Training refresher. This annual refresher will be revised to include: a) Cold Water Shock b) "Shout, Reach, Throw, Row, Go” c) The risks associated with handcuffing near water
I believe the implementation of the revised ‘Working Near Water Procedure’, that will mandate the completion of training packages both virtually and in person, will sufficiently address the concerns set out in the Regulation 28 notice and will equip our officers and staff to maximise the safety of the public when working near water and prevent such tragic circumstances being repeated in the future. Thank you for providing the opportunity to respond.
Kind regards
Chief Constable
Matter of concern 1 - Lack of awareness of Cold Water Shock and the associated immediate risk to life. Frontline officers and staff are regularly provided with training informed by operational policy and procedure, which is intended to ensure they have working knowledge of what is required of them in their role. Cold Water Shock is described within the Constabulary’s ‘Working Near Water Procedure’. However it is recognised that this aspect of the procedure is absent from the E-Learning Training package. This is being rectified and the revised E-Learning package will be made available to officers and staff by the end of November 2023. In addition, an updated ‘Working Near Water Procedure’ has been produced which highlights the impact and immediate risks associated with Cold Water Shock. This forms the basis of the revised E- Learning package and key aspects will be revisited with operational officers and staff annually through face to face training delivered as part of the force’s Personal Safety Training.
Matter of concern 2 - Lack of awareness of the recognised "Shout, Reach, Throw, Row, Go” procedure. Hampshire and the Isle of Wight Constabulary’s Marine Unit has provided their expertise and support to the rewriting of the force’s updated ‘Working Near Water Procedure’. This means that the "Shout, Reach, Throw, Row, Go” method is now properly described for all frontline officers and staff. In addition, this method will be included in the revised ‘E-Learning package’ and will be part of the annual Personal Safety Training refresher for frontline operational officers and staff.
Matter of concern 3 - Lack of awareness of risks associated with the use of handcuffs, particularly so to the rear, when detaining a person near water. It is my position that there should be no ‘blanket ban’ on the use of handcuffs near water as it is critical that frontline officers are able to make informed assessments on the most appropriate means to ensure the safety of the public, their colleagues and themselves. Frontline officers and staff in specific roles complete Personal Safety Training during their initial training and complete annual refreshers throughout their service. This training provides them with direction on decision making and techniques associated with the use of force (such as handcuffing). Hampshire & Isle of Wight Constabulary is licensed by the College of Policing to provide this training, which is based upon the National Police Chiefs Council and College of Policing published Personal Safety Manual of Guidance. Through this training officers and staff are taught to use the National Decision Model, empowering those staff to make good and objective decisions regarding the use of force so that their actions are reasonable, necessary and proportionate to the circumstances. To directly address the matter of concern related to the use of handcuffs near water, it is important that officers are provided with sufficient information about the risks associated with doing so. The force’s revised ‘Working Near Water Procedure’ and the annual Personal Safety Training refresher will set out that: Officers should, where possible, avoid handcuffing near water where there is a risk of the detained person falling in and becoming submerged. If the officer, following a dynamic risk assessment, decides that the most appropriate action is to cuff the detained person then they should handcuff to the front.
Matter of concern 4 - Absence of effective dissemination, access and awareness of the Hampshire Constabulary “Working near Water Procedure” and the risks, mitigations and the need for necessary dynamic risk assessments set out therein. The Constabulary’s revised ‘Working Near Water Procedure’ will be disseminated to all officers and staff. In support of learning and understanding, this will include a link to the updated E-Learning package associated to this procedure. Frontline operational officers and staff will be directed to complete the updated training package. Every year, frontline operational officers and staff in specific roles (including all Police Officers and PCSOs) are required to complete a Personal Safety Training refresher. This annual refresher will be revised to include: a) Cold Water Shock b) "Shout, Reach, Throw, Row, Go” c) The risks associated with handcuffing near water
I believe the implementation of the revised ‘Working Near Water Procedure’, that will mandate the completion of training packages both virtually and in person, will sufficiently address the concerns set out in the Regulation 28 notice and will equip our officers and staff to maximise the safety of the public when working near water and prevent such tragic circumstances being repeated in the future. Thank you for providing the opportunity to respond.
Kind regards
Chief Constable
Report Sections
Investigation and Inquest
On 17th November 2021 I commenced an investigation into the death of Marcel Maksymilian WOCHNA aged 15. The investigation concluded at the end of the inquest heard between 4th and 13th September 2023 sitting with a jury. The conclusion of the inquest was: Narrative Conclusion: On 8th November 2021 the deceased drowned in the River Itchen, Southampton, Hampshire. The deceased jumped into the River Itchen feet first, voluntarily to evade arrest. There was insufficient immediate action taken by attending officers to attempt to rescue Marcel once he had entered the water which probably contributed to his death. The police officers had inadequate knowledge of the working by water policy. Marcel’s death was contributed to be neglect.
Circumstances of the Death
Two police officers attended Cobden Marina located on the River Itchen during the early hours of 8th November 2021. It was a dark, cold night, the river temperature was 12 degrees Celsius. The pontoon was unstable causing it to wobble. The police officers found the deceased and another young male on a moored boat. The other male, who was described as “compliant enough”, was moved onto the pontoon and handcuffed to the rear. The officers decided before arriving at the scene that they would handcuff any suspect found. The deceased then exited the boat and stood on the pontoon and held by an officer. The deceased pulled away from the officer and deliberately jumped into the River Itchen. When the deceased jumped into the river the attending police officers did nothing. The officers believed that the deceased had swam away. The officers did not recognise that there was a real and immediate risk to the life of the deceased when he entered the water. Neither officer had heard of Cold Water Shock. Expert evidence indicated that Cold Water Shock is likely to incapacitate within 2 minutes, cardio-pulmonary arrest is likely to follow within 4-5 minutes. Hampshire Constabulary had at the relevant time, and continues to have, a “Working near Water Procedure [21344]”. The Procedure sets out the risks of operating near water, including Cold Water Shock, together with mitigating measures and the necessity for a dynamic risk assessment when operating close to water.
Neither officer had seen nor was aware of the “Working near Water Procedure” on 8th November 2021. One officer had served for 11 years, one had recently completed their training. Both officers operated from a police station covering the River Itchen which flows through a busy city and has Southampton Water to the south. The attending officers accepted that had they been aware of the Procedure on 8th November 2021 they would have known of the real and immediate risk to life associated with Cold Water Shock. In 2011 Hampshire Constabulary introduced their own Constabulary wide on-line training package relating to working near water. That training package makes no mention of Cold Water Shock. The training package makes no mention of the procedure to adopt when seeking to effect a rescue from water namely, “Shout, Reach, Throw, Row, Go”. The "Shout, Reach, Throw, Row, Go" is a recognised procedure and utilised by Hampshire Constabulary Marine Unit. Hampshire Marine Unit apply handcuffs as a last resort to detain a person when operating near water, which includes on a pontoon. When handcuffs are used as a last resort the detained person is handcuffed to the front in order to afford the detained person the opportunity to tread water or take hold of an object in the event they come to be in the water. The risks of handcuffing a person to the rear whilst in close proximity to water were not recognised by the attending (Non-Marine Unit) officers.
Neither officer had seen nor was aware of the “Working near Water Procedure” on 8th November 2021. One officer had served for 11 years, one had recently completed their training. Both officers operated from a police station covering the River Itchen which flows through a busy city and has Southampton Water to the south. The attending officers accepted that had they been aware of the Procedure on 8th November 2021 they would have known of the real and immediate risk to life associated with Cold Water Shock. In 2011 Hampshire Constabulary introduced their own Constabulary wide on-line training package relating to working near water. That training package makes no mention of Cold Water Shock. The training package makes no mention of the procedure to adopt when seeking to effect a rescue from water namely, “Shout, Reach, Throw, Row, Go”. The "Shout, Reach, Throw, Row, Go" is a recognised procedure and utilised by Hampshire Constabulary Marine Unit. Hampshire Marine Unit apply handcuffs as a last resort to detain a person when operating near water, which includes on a pontoon. When handcuffs are used as a last resort the detained person is handcuffed to the front in order to afford the detained person the opportunity to tread water or take hold of an object in the event they come to be in the water. The risks of handcuffing a person to the rear whilst in close proximity to water were not recognised by the attending (Non-Marine Unit) officers.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.