Dear Mr Cummings,

Re: Regulation 28: Report to prevent future deaths

Thank you for your Regulation 28 report dated 1 August 2025 following the inquest into the death of Brian Thomas Ringrose on 2 February 2021. The inquest concluded on 24 April 2025.

Central and North West London NHS Foundation Trust (CNWL) deeply regrets the death of Mr Ringrose and we would very much like to extend our condolences to his family.

I am writing to provide the Trust’s response to the concerns that you raised in your report.

Matters of Concern

a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition.

b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian.

c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police.

d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients.

e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety.

I am responding to the concers in the order that you have raised them. I would also like to make you aware that the Mental Health Liaison Team (HLT) Operational Policy has been updated and shared with Milton Keynes University Hospital (MKUH). The updates have been discussed at all staff meetings and interface meetings in June and July 2025 to ensure shared understanding.

a. Delay in Assessment We have revised our approach to ensure that referrals are accepted even when patients are not yet medically cleared. This enables earlier engagement, risk planning, and support. A key performance indicator for the HLT is timely response to referrals. In the past six months, over 95% of ED referrals have been responded to within one hour. This reflects not only operational improvements but a cultural shift towards proactive, parallel working with ED colleagues.

b. Inadequate Assessment Our revised protocol mandates that when a patient cannot engage due to intoxication (alcohol or drugs) or other factors rendering them unfit, the HLT must escalate concerns to the ED team, advise that the patient remains under ED care for ongoing medical management, and the HLT remain available for reassessment. This ensures continuity of care and avoids missed opportunities for intervention. This applies equally in cases where the patient is under police arrest within the ED.

c. Failure to Escalate Concerns We have strengthened our escalation pathways. A standing agenda item has been added to monthly cross-team meetings to review HLT practices. Our Operational Policy now explicitly requires immediate escalation of concerns to the treating medic or nurse in charge.

We have also embedded trauma-informed care principles through RESPOND training and the dissemination of the Side-by-Side guidance for hospital settings, ensuring staff are equipped to act decisively and collaboratively.

d. Unsafe Communication Practices To enhance the robustness and integrity of our documentation process, we have implemented a joint entry protocol. Under this approach, both assessors will contribute directly: the second assessor will either formally approve the initial entry or provide a complementary entry to ensure a more comprehensive and balanced record. Verbal handovers to the treating medic, or to the Nurse in Charge if the medic is unavailable, are now mandatory immediately post-assessment, followed by contemporaneous entries in ECare summarising the handover with a more detailed entry to follow based on the SystmOne entry. These changes aim to improve the

accuracy, timeliness, and reliability of clinical communication. HLT entries are randomly audited for quality assurance.

e. Inappropriate Discharge Recommendation We have reinforced the principle that discharge from ED should never proceed where there are unresolved concerns about a patient’s safety, whether related to physical or mental health. This has been reiterated in team meetings and supervision sessions. Refresher training and Human Factors Training are taking place to support consistent application of this principle.

All clinical matters are discussed in regular supervision with individual clinicians and in multidisciplinary team meetings. There is a monthly interface meeting with MKUK attended by senior management and Consultants from the Hospital Liaison Team for oversight.

Thank you for bringing your concerns to our attention. I hope that the content of this letter provides sufficient assurance that CNWL takes the concerns raised seriously and has taken action following the death of Mr Ringrose. CNWL has accepted the points raised and continues to work to improve the service we provide. Should you have any questions or comments, please do not hesitate to contact me.

Dear Dr Cummings,

Regulation 28 Report following an inquest into the death of Mr Brian Ringrose

I am writing following receipt of the Regulation 28 Report dated 1 August 2025, relating to the inquest into the death of Brian Ringrose which concluded on 24 April 2025.

The circumstances of Brian’s death were harrowing, and I would like to express my profound regret that Brian did not receive the care he deserved while he was a patient in the Emergency Department, and to again extend my heartfelt apologies to Brian’s mother, Mary, and to his children and wider family.

I would like to assure you that as a Trust we have learnt from Brian’s death and that Brian’s death has left an enduring legacy of improvement in how we care for patients in police custody, particularly in the Emergency Department.

In your Regulation 28 Report to prevent future deaths, you set out a number of areas of concern and I would like to detail the changes and improvements made in each of those areas, appending evidence where I believe it is helpful.

1. Non-existent Documentation Referenced in Policy The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation

This concern refers to a Standard Operating Procedure (Police Custody – Care in and Discharge from the ED) which was created using the Royal College of Emergency Medicine Guideline of the same name. I can assure you that it was not created in haste, but had not been updated to reflect work with Thames Valley Police which had continued to evolve and develop local processes and procedures after the guidelines had been published as a local SOP.

The Emergency Department has subsequently amended the local SOP to ensure that the language now used reflects local practices between Emergency Department healthcare staff and Thames Valley police offices. Local guidance is appended as Appendix 1, including the Thames Valley Police transfer protocol and patients in police custody guideline.

2. Misleading Discharge Documentation The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be.

The ED Discharge Summary is created in the ‘DEPART’ section of Firstnet the ED Module of Oracle Cerner Millenium our Electronic Patient Record known locally as eCare. If opened immediately after admission it looks like this:

On the left are the various sections that need completing and on the right is a preview of how the discharge summary is developing. Sections highlighted in yellow are mandatory, those in grey are optional. At this stage there is no actual discharge summary as the final document is not created and stored in eCare until the patient is admitted or discharged. The Discharge Date time displayed in the template will be the time the depart tool was opened and it will move on each time the tool is opened as the patient passes through the ED pathway.

As sections are completed the yellow sections turn grey and one can preview the discharge summary developing e.g.

The final section when opened appears like this:

This allows staff to indicate the summary is completed and also whether a copy will be given to patient. Once complete when previewing the summary it shows as ‘Finalised’:

In the ‘DEPART’ tool there is a ‘Print’ button and an in-progress discharge summary could be printed from here if required prior to actual discharge but should not routinely be needed and would quite likely be incomplete and /or subject to change. The same tool can be used to generate a ‘Pharmacy Discharge Summary’ which ED nursing staff or pharmacy staff need if medication to take home is being prescribed – it can only be printed from here, hence the need for a print button.

Once the patient is admitted or discharged the appropriate option is chosen from the DEPART tool:

If ‘Discharge’ is selected the following window opens with various mandatory fields to enter with the remaining discharge details, on completion and signing the patient will be discharged from the system and disappear from ‘Launchpoint’ – essentially the dashboard

view of all the patients in ED. This is the ‘Discharge conversation’ window and staff completing shouldn’t be in any doubt they are discharging the patient. e.g.

It is at this point that the document titled ‘Emergency Department GP Letters’ is created and stored in the record – it can be printed if required Looking in the ‘Documentation’ section following this the following are seen:

The final document ‘Emergency Department GP Letters’ is the actual discharge summary, also sent to GP and to Patient portal. The earlier four documents are each of the text rendered forms completed as part of the ‘DEPART’ process. The forms themselves are stored in ‘Form Browser’ in eCare but these do not pull into the medical record when extracts are prepared for Subject Access requests, Coroners Reports etc, instead the information they contain is in these text-rendered documents.

Although the information they contain is repeated in the final overall discharge summary, in circumstances where that was never created (for whatever reason) then the information on any completed component forms would be missing from the record.

The DEPART tool is one of the older sections of Oracle Cerner Millenium and is gradually being replaced by a Dynamic Documentation workflow. Similar workflows are currently in use for inpatients and outpatients and consist of workflow views from which users create a variety of notes. The first area in the Trust to use the newer discharge workflow is the Same Day Emergency Care (SDEC) department. Like ED they also use Firstnet so most other aspects of their workflow are very similar to ED; this went live in January 2025.

If a similar patient were in SDEC this would be the working view:

In the Discharge workflow page mandatory sections are indicated with a red star if incomplete or a green tick if completed; at the point of discharge when ready to complete the discharge summary one must ‘create’ SDEC Discharge summary, this then brings a preview which one can still edit and then sign, it then exists as a note and can be printed if required.

To discharge the encounter or admit the patient one can separately select options to ‘end visit, the resulting window that opens to collect final discharge details is the same as in ED. In SDEC each form still text renders for the same reasons, the naming of the resultant documents is perhaps clearer and there are slightly fewer than the current ED workflow.

In both SDEC and ED, but ED especially, patients may be discharged without all details of the discharge summary being completed, in such cases a different workflow allows the patient to be discharged from ED but to go onto a ‘Missing Documentation’ list so the discharge summary can be completed when time allows.

Discharge summaries are also created in eCare for inpatients (adult and paediatric), day- cases and maternity cases. All currently use the older DEPART tool but the creation of the discharge summary and discharging of the patient from the system are carried out separately. Overtime we would expect all areas to migrate onto the newer Discharge Workflow mPage and associated Dynamic Documentation.

With the exception of SDEC the discharge summary, processes have not changed materially since the Trust went live with eCare in 2018.

The system workflows are somewhat challenging to set out in writing. Training and awareness on how the system must be used will continue – for the discharge process in ED,

aligned with the Discharge Standard Operating Procedure and the protocols for discharge with third party agency involvement (notably the police and mental health services, covered in the SOP and related operational protocols). Roll out of Dynamic Documentation to the ED will include training and awareness on discharge processes and will use this case as an illustrative learning tool.

Whilst eCARE workflows gives structure to a process to ensure consistency in discharge, human override and miscommunication remain potential risks. In mitigation, having learnt from Brian’s death, staff in ED are acutely aware of the necessity of following our Trust processes, and our new suite of documentation supports and cements this.

3. Inadequate Discharge Review Process The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge.

I would like to address the reference to the timeline for making a safety decision, as described above, relating to discharge. As you are aware, the Emergency Department discharges more than 100,000 patients annually, with regulated professionals working within their professional scope and competencies to provide care along the patient pathway to discharge. The Trust has an established Discharge Policy, which has been in place for many years.

In the course of investigating Brian’s death and preparing for the inquest, the decision- making, documentation and processes surrounding his discharge were an area of focus for the Trust in the context of the individual decision making and the actions and inactions of the healthcare professionals involved in his care. To be plain, the omissions were felt to be particular to this case and not a systemic issue requiring a change in wider policy and practice. The forensic level of examination of this issue at inquest enabled the Trust to reflect further on this and to consider whether wider change was in fact necessary to improve safety and make professional expectations explicit in a local context. To that end, the Emergency Department has developed and implemented a Standard Operating Procedure for the discharge of adult patients. This is appended at Appendix 2.

Linked to point two, this SOP will be reviewed when Dynamic Documentation is rolled out in ED to ensure both are aligned.

Particularly relevant extracts from the SOP are included below for ease of reference:

1.0 Roles and Responsibilities:

1.1 ED Clinicians The responsibility for documenting that a patient is medically fit for discharge rests with the ED clinician who conducted the initial assessment and reviewed all relevant investigations. In cases involving suspected overdose, the clinician must document and adhere to the guidance provided by Toxbase. If the original assessing clinician is no longer available, the responsibility for confirming medical fitness for discharge passes to the clinician to whom the

case has been formally handed over, or to the Emergency Physician in Charge (EPIC).

1.2 ED Nursing Staff Are responsible that a clear discharge plan is in place. They must ensure the patient receives any required take-home medications (TTOs), along with a discharge summary, as appropriate, that includes safety netting advice and details of any necessary follow-up.

1.3 Mental Health Liaison Team Should respond within one hour of referral from the ED for urgent mental health assessments; conduct a full mental health and risk assessment; work collaboratively with ED clinicians in the decision to admit, refer, or discharge patients with mental health concerns; and document their findings in a timely manner.

3.0 Discharge Processes and Procedures:

3.1 Minimum Documentation Requirements All discharge summaries must include:
• Presenting complaint
• Summary of history and clinical findings
• Investigations performed and key results
• Diagnosis (working or confirmed)
• Treatment provided in ED
• Follow-up arrangements (including who is responsible)
• Clear safety netting advice
• Mental Capacity assessment (if relevant)
• Interpreter involvement (if required)

3.2 Special Considerations

• Mental Health Patients: o Must have a documented Mental Health Liaison Team (MHLT) assessment or clear reasoning why referral was not required. o Risk assessment must be completed. o Follow-up and safety netting should include mental health crisis contacts. o The final discharge decision should be made jointly by the Emergency Department (ED) clinician and the Mental Health Liaison Team (MHLT). A clear rationale for the discharge must be documented in the patient’s notes and electronic record. The patient should be given the opportunity to ask questions, and all relevant documentation must be completed before discharge.

• Patients Under Police Custody: o Refer to the MKUH SOP titled Patients in Police Custody (referenced below). o Confirm mental capacity and document any assessment regarding fitness for custody.

• Patients Discharged Against Medical Advice (DAMA): o Mental capacity must be clearly documented. o Detail discussion of risks, advice given, and patient's decision.

• Vulnerable Adults (e.g. elderly, learning disability, substance misuse):

o Consider safeguarding concerns. o Liaise with community services or GP if necessary.

3.3 Safety Netting All discharged patients must receive:
• Advice on when to return (e.g. red flag symptoms)
• Contact points (e.g. 111, GP, crisis line)
• Written discharge summary (or digital equivalent)

3.4 Standardised Discharge Statements for Clinical Notes:

For patients presenting with mental health needs who required medical assessment: “Patient medically assessed and deemed fit for discharge. Cleared by MHLT – Discharged home.”

For patients presenting with mental health needs not requiring medical assessment: “Mental health assessment completed – no medical concerns identified. Cleared by MHLT – Discharged home.”

For patients presenting with non-mental health conditions: “Medically fit for discharge – Discharged home.”

4. Ambiguous discharge process The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it.

This is addressed in the Emergency Department SOP for the discharge of adult patients described above and appended at Appendix 2. The individuals involved in this case have reflected at great length about their actions and inactions. Brian’s death was a seminal event for the Trust and learning from it has been widely shared within the Emergency Department. Further learning events using Brian’s case (anonymised) will continue in the Emergency Department, both to raise awareness of risk of unclear documentation and communication, and to ensure that there is an enduring legacy of improvement following Brian’s death.

5. Unsafe supervision There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened.

As described above, Brian’s death has resulted in deep reflection by individuals, within the Emergency Department and across the Trust, with continued awareness-raising and learning.

The Trust’s Restraint and Restrictive Practices policy has been re-drafted post the inquest (appended at Appendix 3) to incorporate Emergency Department specific guidelines (NICE NG10) and to make the roles and responsibilities of healthcare staff during any restraint unambiguously clear. The Trust’s training programme on restraint and restrictive practices for clinical staff is being reviewed under the new draft policy (Appendix 3). Breakaway and

conflict resolution training remains mandated for Emergency Department staff and security officers receive bespoke training to their roles.

Every incident of restraint is reported on the Trust’s incident system, Radar. Incidents of restraint by the police have been reported, and include instances where healthcare staff in the Emergency Department have intervened to raise concerns about the safety and welfare of the patients, and have appropriately escalated through professional management structures to seek immediate support.

6. Premature Discharge Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed)

Brian should not have been discharged. This is accepted and actions described above have been taken to mitigate the risk of a similar event occurring again. Toxbase guidelines have been reiterated to all Emergency Department clinicians, with a quick guide available on the Radar documentation system.

A recent audit on discharge compliance is included at Appendix 4 for information and assurance.

Thank you for the opportunity to demonstrate continuing improvements and learning from this case. I hope this response provides you with assurance of both what is already in place and our ongoing commitment to improvement. We will happily share further updates and information on any area explored in the Regulation 28 Report or meet with you to provide further detail or clarification if required.

Dear Mr Cummings Inquest into the Death of Mr Brian Thomas Ringrose Preventing Future Deaths response ofthe Chief Constable of Thames Valley Police am writing to outline the actions taken by Thames Valley Police in response to the Regulation 28 Report following the inquest into the death of Mr Brian Ringrose. We have carefully considered the concerns raised and implemented a series of measures to prevent future deaths in similar circumstances. Following the death of Mr Ringrose, a Gold Group was convened and chaired by Assistant Chief Constable Christian Bunt: This group had number of objectives including responding to the investigation conducted by the Independent Office for Police Conduct (IOPC) and the implementation of organisational learning: This group brings together supervisory and specialist from relevant policing business areas including Learning and Development; Professional Standards, Response Policing Supervisors and Legal Services: This group also monitors and responds to the investigation conducted by the IOPC The IOPC Investigation Report into death of Mr Brian Ringrose identified organisational learning and in summary made the following recommendations;
1. The IOPC recommends that Thames Valley Police (TVP) review its training material on handcuffing from prone (subject lying on their front) and the use of ground pin: TVP Response TVP utilise a series of resources to Public & Personal Safety Trainers through the delivery of the training: The training content is provided by the College of Policings Personal Safety Manual of Guidance: Timetable provides guidance regarding the order of training days for a particular course; a Session Plan provides the content to be ProtECTinG OUR Communities staff guide

delivered on any training day; and trainer notes provide the detail of technique is to be taught and the method of demonstration: Scenario Based Training (SBT) allows officers to utilise appropriate skills to control varying behaviours in an operational context This delivery style is in line with the College of Policing mandated programme for Public and Personal Safety Training (PPST) Following review, TVP made changes to their handcuffing from prone trainer notes and their ground pin trainer notes: This will provide further clarity on subject's arms are to be restrained during and after the application of handcuffs. With specific reference to handcuffing from the prone position, TVP do not teach the elevation or lowering of arms whilst handcuffed to achieve compliance or control TVP have also reviewed and published the following Snap Guides. These are summary documents available to officers through their mobile devices and are designed to be used whilst operationally deployed. They address identified matters such as ineffective welfare monitoring; inadequate application of police restraint training and risks associated with handcuffing to the rear and prone restraint: Safety Officer Snap Guide Safety Officer When Spit Guards Are Used Snap Guide ABD Snap Guide Alternative Ground Restraint Snap Guide Prone Restraint Ground Pin Snap Guide Prone Restraint - Use of Force Snap Guide
2. The IOPC recommends that Thames Valley Police ensure that its training and guidance on restraint and positional asphyxia clearly states the role and responsibilities of the safety officer_ TVP Response TVP have reviewed and expanded its operational guidance on the role of the safety officer. This can found within Mental Health Operational Guidance and follows a section on Acute Behavioural Disorder. This guidance includes the circumstance in which a safety officer should be used; that should identify themselves to those present; the role of the safety officer and that all officers regardless of role must speak up and speak out if they have any concerns about the subject's welfare TVP have introduced PowerPoint presentation on positional asphyxia into our Foundation Training for student officers: This presentation covers the definition of positional asphyxia, the position it may occur in including the increased risk around prone restraint; signs and symptoms and officer response: Officer response is centred on situational awareness, communication and decision-making: These areas promote the use of a safety officer where numbers permit: ProtecTinG Our Communities how have how they

TVP uses scenario based training (SBT), as mandated by the College of Policing: Within this training, positional asphyxia is integrated into a series of scenarios to evoke learning: These scenarios fall under the headings; vulnerable person, night time economy, public order, custody, house disturbance and suspicious person. In varying environments with differing impact factors known as layers, officers are expected to demonstrate prone restraint and multi officer control, which includes the use of a safety officer During this training and between the physical exposition and practice,TVP have introduced online training known as Time on Tasks. Mandated topic areas include managing a subject being restrained in the prone position: Below is a summary of the issues specifically identified in the Regulation 28 report and the corresponding actions taken by Thames Valley Police. Response to the Regulation 28 concerns Inadequate Application of Police Restraint Training It is of note that there has been considerable National development of PPST by the College of Policing and NPCC, with new Recertification and Foundation programmes, introduced into TVP in November 2023 and April 2024 respectively. The introduction of these training programmes has seen the PPST portfolio evolve significantly since the time of the incident: The annual 2-day Recertification programme requires Officers to complete two days of Scenario Based Training (SBT) covering 6 topic areas 1) Vulnerable Person in
2) Public Order, drunk and disorderly 3) Stop Search (Suspicious Person) 4) Fight in the street (Night Time Economy 5) Domestic Incident (House Disturbance) and 6) Custody. Officers are required to demonstrate competence against the assessment standard, which includes all aspects of the PPST program, operational tactics and decision making (based on the appropriate use of the National Decision Model to manage incidents in a safe and effective manner whilst dealing with range of attitudes, behaviours and resistance levels. This training includes all aspects pertaining the matters of concern identified: Officers are perceived to have base level of understanding regarding Public and Personal Safety, the session is designed to refresh knowledge and skills in order to bring Officers back into licence. Scenario Based Training (SBT) is used to replicate an operational environment and assess performance, whilst providing group or individual development where required: Scenarios have the opportunity to reflect organisational learning and can be directed as such_ Officers are required to demonstrate effective communication skills across both training through performance in scenarios and knowledge during 'time on protecting Our communities park days,

tasks' which are implemented between SBT rounds. Officers are encouraged to use safe restraint through prompts provided to role players whereby resistant behaviour requires control. Appropriate Decision Making is reviewed by way of debrief following each round and discussions on justification and alternative options ensure learning needs are met: Subject welfare is the focus of all learning; once threat has been eradicated and control achieved. Officers are encouraged to move on to aftercare at the soonest most practical time during all scenarios. Where numbers permit; a Safety Officer is to be used, replicating the operational environment: Instructors will pause scenarios to direct Officers towards this best practice, and spotlight positive actions. Should a Student Officer fall short of the expected standards around any of these topic areas whilst learning; this is immediately addressed through the SBT methodology: Actions may be paused and rewound, or zoomed in on to address any issues more specifically. Good practice can be spotlighted for peer-to-peer learning or breakouts utilised (advanced teaching to ensure components are covered) Time on Tasks activities are used between SBT rounds to further compound learning: These Time on Tasks can be tailored to meet organisational learning: Trainer notes for handcuffing from prone and ground pin techniques have been updated. Snap Guides were published for officers to access operational guidance on mobile devices Training now explicitly prohibits elevation or lowering of arms to achieve compliance: The new PPST Foundation Training (as with Recertification), is now also scenario based. Officers are taken through ten day programme with ad hoc development where required: This programme is progressive in nature, introducing Learning Outcomes throughout an initial five-day core, before Summative Assessment is completed on the sixth day. Failure to show competence during the Summative Assessment results in further development on top of any outstanding Learning Outcomes: Restraint Training is spiralled through the core and assessed at the summative stage, with various control and restraint techniques introduced. This learning takes place through SBT, series of breakouts and supportive materials such as videos and PowerPoint presentations: With Scenarios being the basis of all learning, Decision Making utilizing the National Decision Model (NDM) is continually developed and communication methods explored and reviewed All scenarios are run from Contact to Resolution, with decisions also made around prioritisation of tactics and when to transport subjects. The welfare of individuals is paramount to Public and Personal Safety: The Use of a Safety Officer is encouraged in all training where numbers permit (replicating the operational environment); but should someone be available or not; officers are taught that focus is always on the welfare of the subject: Topics such as Acute Behavioural Disturbance and Positional Asphyxia compound learning on monitoring subjects, sharing information and challenging colleague's actions. protecting Our Communities key

Should a Student Officer fall short of the required standards around these topic areas during initial core delivery, this is immediately addressed through SBT methodology. An inability to attain competence will result in additional development sessions being timetabled. If an Officer falls short of any topics during Summative Assessment; further development sessions are specifically orchestrated to address learning: The number of Police Officers completing this training has increased for recertification, with 4487 officers being licenced between November 2023 and November 2024 in a 2- programme. Depending on intake numbers, Foundation Training is delivered to approximately 500 Officers a Failure to Apply the National Decision Model In addition to the above; Operational guidance has been expanded to define the role and responsibilities of the Safety Officer in line with College of Policing Guidance: Scenario-based training includes decision-making and reassessment protocols Ineffective Welfare Monitoring In mid-March 2025, ACC Bunt delivered a force wide communication to all officers and staff. This included changes to training and guidance as a consequence of the death of Mr Ringrose: All officers and police staff detention officers were mandated to complete an online E-Learning package titled 'Safer Restraint. This training covers the medical issues that can arise with prolonged restraint; welfare monitoring, situational awareness and the importance of the role of Safety Officer. The completion of this learning is being actively monitored and to date 4760 Officers and Detention Officers have completed this training (95% of the target audience) Failure to "Speak Up Speak Out" Guidance now mandates officers to speak up and speak out when concerns arise. Safety officer role includes responsibility to challenge unsafe practices. Training scenarios now include communication and handover protocols. Officers are instructed to actively engage with medical during incidents: In addition, in June 2025, TVP rolled out the College of Policings 'Upstander' E-Learning to all officers and staff, designed to encourage people to 'speak up and speak out'. A part of this training is the 4Ds model, which provides practical strategies for being an effective upstander. The 4Ds stand for: Direct Confront the behaviour directly in the moment: Distract- Interrupt the situation without confrontation (e.g , change the subject). Delegate Seek help from someone else who may be better placed to intervene: Delay - Check in with the person affected afterwards if immediate action isn't safe or possible: Protecting OUR communities day year. police and staff key

To date, 5861 people have completed this learning: Inadequate Communication and Handover Training scenarios now include communication and handover protocols as detailed above_ Officers are instructed to actively engage with medical staff during incidents Inappropriate Prioritisation of Transport Over Welfare As outlined above, PPST emphasises welfare monitoring during transport and restraint: Thames Valley Police remains committed to learning from this tragic incident and ensuring the highest standards of safety and accountability. If can be of further assistance, please do not hesitate to contact me