Dear Ms Mutch Re: Regulation 28 Report following the inquest into the death of Adam Harris Thank you for your report sent by email dated 23" July 2019 in respect of Adam Harris (deceased) and pursuant to Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 and paragraph 7 , schedule 5 of the Coroners and Justice Act 2009 Having carefully considered your report and the matters therein, reply to the concerns raised as follows: Extract from Regulation 28, point 1: The inquest heard that there was no formal documented triagelrisk assessment in place when a prisoner was held in the van dock area pending space becoming available in the custody suite. The inquest heard that whilst lhe average wait time in (he van dock area across GMP was 15 minutes on occasions the waiting period could be in excess of 60 minutes Response: With regard to the waiting time in the van dock detainee cell space is allocated presently by a centralised GMP "cell allocation team They monitor detainee numbers in situ or those enroute) , detainee needs, complexities and staffing levels in order to make an informed decision as to which is the most appropriate custody office to send the arrested person to. The allocation team make direct contact wilh the custody office to advise them a detainee is en-route this in itself is further check to determine that the custody suite has the capacity and means to accept the detainee Where there is any need to escalate an allocation decision there is always a Custody Inspector (Custody Bronze) designated to assist. This approach ensures that the waiting time that a detainee has, Is as short as possible taking account of all contribuling factors. It is not current procedure to complete a formal documented risk assessment whilst a detained person remains in a police vehicle, in a van dock, awaiting authority to proceed into the custody suite. Procedures that are in place demonstrate risk assessment is a ongoing process from arrest through to custody handover: It is explicit in (he GMP Transportation of Detained Persons procedure, (revised and republished in December 2017) that dynamic risk assessment must be done, on arrest, on placing the detainee in police vehicle and on considering whether an additional escort is required. It is then explicit that the transporting officer ongoing responsibility in relation to risk and detainee management until the detainee has been handed over to the Custody officer from the van dock Mila4e auLut has

An arresting officer may not be same person as the transporting officer: The arresting officer will consider detainee risk to help determine the correct type of transport and whether handcuffs are required_ With regard to the transporting officer ~the "Transportation of Detained Persons" procedure identifies and designates specific responsibilities "Prior to placing a detainee police vehicle, a dynamic risk assessment must be conducted" it expands upon this, to list the considerations Ihat an officer would make to inform that risk assessment_ Implicil within this , would be dialogue with the arresting officer to obtain the relevant information; The circumstances when an escort is required in_addition to transporting officer are also listed ie where a detained person: Is intoxicated through drink or Is violent or known to be violent: Is believed t0 be at risk from suicide or self-harm. Has increased susceptibility to positional asphyxia eg factors including druglalcohol intoxication, physical exhaustion, obesity: Has a mental health issue It continues to state that the escorting officer is responsible for the safety, welfare, supervision and monitoring of a detainee: The role requires that a detainee is not left unsupervised in any Police vehicle All detained persons arriving in custody van dock area must remain under the direct control of at least one police officer; that requirement does not end until the detainee is accepted into the control of the custody staff Transporting officers must alert the Custody staff of their arrival at the Police Station and slate Ihe risk stalus of the detainee making specific reference to any medical condition, vulnerability or evidence of violence presented by the detainee. This will allow the Custody Officer to triage and prioritise vulnerable detainees as part of the booking in process GMP Custody Operaling ProcedureNNVersion 6 / February 2019 ~paragraph 5.6.10 states: When several people are waiting to be booked in to custody it is the responsibility of the nominated CDO to assess these detainees with regard to their condition and urgency for being booked in: For example & person requiring intoxilyser may be booked in ahead of a compliant shoplifter. Sergeants must be involved in this decision making This is not medical assessment; rather pragmatic process of prioritisation. circumstances which give rise for the risk assessment of the detainee to change are to be relayed to the Custody Officer immediately so that a review of the requirement to remain in the van dock can be carried out; From August 2019 the contents of the revised "Transportation of Detained Persons" procedure features in the initial Student Police Officer foundation training course delivered to all Student Police Officers on appointment There are also components of the policy currently being reviewed with a view to incorporated into the Personal Safety Training courses which all operational Police Officers and staff undertake annually: It is anticipated that the revised (raining will commence in Autumn Winter 2019. Greater Manchester Police are currently working wilh Greater Manchester Combined Authority and are exploring the introduction of a formal pre-detention medical assessment carried out by a Health Care Professional where detainee remains in a Police vehicle in a van dock for period in excess of 30 minutes 2/'a%" the drugs Ihe Any being

Extract from Regulation 28, point 2: Adam Harris was not arrested until he was in the rear of the Police van. None of the officers present searched him before he was placed in the van or before he was transported to Ashton Police Station. Response: A person not under arrest may be asked to sit in (he rear of a van for a variety of reasons ie that the decision to arrest has not been made and the person voluntarily agrees to wait; that the voluntary removal of the person to the van will help diffuse a situation; or that the person is being spoken t0 as a witness and the van is convenient for conversation: Equally, the decision to arrest, may be made but where there is not suitable transport available or where more resources are required, then the detainee might not be told of that decision until the prevailing circumstances have changed and are more appropriate. The decision to arrest, at what location and at what exact point is like many other aspects subject to dynamic risk assessment PACE Section 32 sets out Ihe powers of a Police Officer to search a person upon arrest The Force procedure in relation to the Transporlation of Detained Persons specifically emphasises the importance of officers searching all arrested persons prior to placed in any Police vehicle in accordance wilh Seclion 32 PACE; The procedure does however recognise that there are some circumstances where this may not be immediately achievable e.g: a Public Disorder situation where there is a risk of harm lo the detained person or the attending officers Where that situation does arise it is suggested that the detained person is moved a short distance away and then searched when practicable. From August 2019, the contents of the "Transporting a Detained Person" procedure now feature in the inilial Student Police Officer foundation training course delivered to all Student Police Officers on appointment: There are also components of procedure currently reviewed with a view to incorporated into the Personal Safety Training courses which all operational Police Officers and staff undertake annually: It is anticipated that the revised training commence in Autumn Winter 2019. Extract from Regulation 28, point 3: Adam Harris was not transported by the Arresting Officer but by Police Officers operating divisional van. There was no evidence of a clear and detailed handover between the Arresting Officer and the Transporting Officers. One of the Transporting Officers described the role they played as a Police taxi service_ Response: The aforementioned training in relation to the Transporting of Detained Persons is delivered to newly appointed student police officers during Ihe foundation course: It is also reviewed for inclusion in the annual Personal Safety Training course issued to all operational Police Officers and staff. The training emphasises the absolute requirement for an arresting Itransporting officer to be aware of: The circumstances of arrest Necessity of the arrest Any force used on arrest Time, location and details of arresting officer It is a requirement of the transporting officer to obtain this information from the arresting officer where one is not the same. Jip'a" being the being being will being

Extract from Regulation 28, point 4: The Custody Sergeant did not open a custody record immediately on Adam Harris's arrival at the custody office. He used a piece of paper to record the details that were given to him: He did not input details into the custody record until after Adam Harris had been placed in a cell: He indicated that the Custody Sergeant course encouraged use of paper and he had developed his practice from the guidance on the course. It was unclear how the paper was stored and how it supported the requirement to follow the process generated through using the custody system: Response: Current practice does not "train" the use of pieces of paper as "aide memoires" but we accept that there are occasions when the making of notes can expedite or better manage the detainee- booking in process The booking in process and the number of questions asked, is lengthy and detailed. It is often case that detainees will talk and offer information that is outside of the immediate question being asked: for example the Custody Sergeant may ask "Do you have epilepsy", prompting the detainee to reply "no, but im really struggling with my diabetes at the moment" . Where such information is offered, that is not directly pertinent at that point in the computer system , it is right to allow the detainee to talk where that information is as important as health relaled information_ It is possible may not offer that information elsewhere and it would therefore be important to note anything said, on paper if need be ad transpose those notes to the computerised record at the relevant point in the system It is also the case (hat persons who have been arrested before are familiar with the process and are therefore keen lo begin offering a name and a phone number of solicitor require informing Again; this may be at a point in the booking in process where the Sergeant is not able to update the computer, so may record that information on paper as an aide. It is also Ihe case Ihat may be a need to input duplicate information into the computer system ie a name or an address; again il can be useful that this is noled on a piece of paper to avoid causing the detainee to repeat themselves and have them believe are not listened to. This can help reduce any risk of antagonism with a detainee that may already be agitated. Maintaining positive relation wilh detainees is Ihe best means by which we can undersland and manage their needs ad moods; allowing Ihem to talk freely, if they need to do s0, without interruption is a useful means by which we can achieve this_ There are occasions where it will be impossible to complete custody record in full when detained person first arrives in the Custody Office because of their condition or behaviour. It may be for example that a violent non-compliant person has to be restrained and taken to a cell almost immediately for their own safely as well as that of others. In those circumstances it may be that the Custody Sergeant will make short notes to assist with the completion of an electronic custody record as soon as it is practicable. There are confidential waste bins available in custody office where any notes that do not need to be retained, would be disposed of. Extract from Regulation 28, point 5: The inquest was told by one officer that Mr Harris was left in (he cell on his back and that position was correct and in accordance with GMP guidance. Another officer indicated that he was left in the recovery positionlface down and that was correct appropriate: Given Mr Harris's level of confusion and suspected intoxication it was unclear how placing him on his back would assist with managing risk of aspiration: 411*.@ " the the (hey the they there they being

Response: All operational Police Officers and Staff are trained annually by our own specialists who teach the latest restraint techniques for detainees. The restraint techniques taught are derived from First Aid Training: Police Personal Safety Manual (College of Policing) HM Prison Service Control & Restraint Manual. The methods taught are continually reviewed and based on a number of factors which include: Force requirements Officer feedback Professional Standards Branch feedback Civil litigation feedback IOPC feedback: Coronial case review feedback; Presently there is no technique which permits the leaving of a detainee on their back in a police cell: