Dear HM Senior Coroner Jacqueline Devonish We write in response to your Regulation 28 report following the investigation and inquest into the tragic circumstances of the death of Carl Fullalove on the 13th December 2015. We hope to answer the concerns you raised that are listed within section 5 of your report, which are listed as follows: (1) Whilst the jury did not make any finding of acute behavioural disturbance (ABD) in this case, much evidence was heard about the training in identification of the signs and symptoms. National training of police officers on the identification of ABD is focused on a triad of warning flags being, hot to touch, exhibiting constant or near constant activity and extreme agitation or aggression. Some evidence identified that Carl Fullalove did not exhibit these triad symptoms but did exhibit other nuanced symptoms in the long list delivered in training. It was evident that his symptoms were not recognised as ABD due to drug intoxication, and that the consequential risks associated with prone restraint were not therefore considered. Prone restraint ultimately led to his death. There were six experts providing evidence to the inquest two of whom identified that Carl would not have died had he been recognised as unwell at the point of arrest and assessed by a health care practitioner. Such attention would have provided a calming intervention for his heart rate and breathing prior to being placed in prone restraint, which exerted additional pressure on his ability to breath freely. In 2020, the College of Policing commenced a national working group to update the First Aid Learning Programme (FALP). The review that took place considered recommendations made by Coroners and

the IOPC, including the detail of learning outcomes on Acute Behavioural Disturbance (ABD). The FALP has now been published and includes a revised learning outcome “recognise the signs and symptoms of acute behavioural disturbance”. The College of Policing have designed and developed a new Public and Personal Safety Training (PPST) package for all police officers with the emphasis on de-escalation. It is twelve hours, scenario- based method of delivering training and is focused on learning, decision making, understanding decisions and de-briefing decisions. Some forces have already implemented the new training package, and all forces are to go live with this training in April 2024. From the evaluation of the training pilot, early, statistically significant data shows a reduction in police use of force incidents. The updated training will include a recently updated training package for ABD. The new ABD training includes an understanding of the signs, symptoms and possible causes of ABD, management of the incident with the focus now being on de-escalation, ‘contain rather than restrain’, whilst highlighting the risks of restraint where officers suspect a person to be experiencing ABD. There is an emphasis within the training that ABD can present in many ways and to always treat ABD as a medical emergency, seeking immediate, medical assistance.

(2)A research paper before the inquest, namely ‘Consensus on Acute Behavioural Disturbance in the UK, September 2023 recommends that the focus remain on the triad of warning signs. ABD is clearly difficult to distinguish from drug intoxication by a non-medical practitioner. The rigidity of the training with focus on specific symptoms can cause police officers to miss other signs. The Superintendent, and head of ‘Protecting Vulnerable People’ for Cheshire accepted that with hindsight the use of prone restraint was inadvisable in this case. The College of Policing have recently updated their training package for ABD with the emphasis being on the different ways that ABD can present, including confused behaviour and incoherent speech. The training also covers the different, possible causes of ABD, including medical conditions and intoxication through drink or drugs.

(3) Significant training on ABD had been delivered by Cheshire Constabulary through the College of Policing Personal Safety Training package module, the key to which was to identify an underlying medical condition to refer to a health care practitioner. That may be a lot to expect of police officers in a dynamic fast paced setting. The use of the term ABD may be a distraction. Assessment criteria for the new ABD training included within the new PPST includes a requirement that officers must be able to demonstrate to trainers the correct response to a person experiencing ABD and to provide details of the actual symptoms being displayed, not to attempt to diagnose ABD to medical professionals. Whilst knowledge of underlying medical conditions may be helpful, the emphasis is on continuous monitoring of a person’s condition and relaying this current information to ambulance or medical professionals.

(4) The effect of stimulant drugs and the need for calming de-escalation in an upright position, rather than prone restraint, had not been noted in either the training material or the research paper presented to the Court. This is on the background of recognising from College of Policing guidance that a high percentage of deaths in prone restraint are in drug related cases. (5) The First Aid Learning Programme (FALP) will be in place within Forces by April 2024 and includes amongst other things positional asphyxia, unconscious and not breathing, and ABD but does not mention training in calming intervention that on balance of probabilities may have led to a different outcome in this case. The recently updated College of Policing ABD training package includes specific reference to:
• Providing reassurance.
• Talking to the person calmly.
• Avoid restraint. The methodology of training delivery of the new PPST is a scenario based, intermittent style of training whereby the trainers will stop the scenario and the officers will be asked to provide their understanding of the legislation, the risks and ask the officers to provide their rationale for their decisions. It is a coaching style of training that focuses on learning and knowledge retention rather than the previous training style of teaching of tactics. We hope this helps to answer the points that were raised but if we can assist with anything further, please do not hesitate to contact us.