Dear

Re: Prevention Future Deaths Report for Ian Taylor DoD 30.06.2019 Case Ref:15980 Further to your letter of the 13th June 2022, I was sorry to hear about the death of Mr Taylor and I have read the associated report on the prevention of future deaths. The provision medical cover to police custodial units does not fall within the remit of the Royal College of Emergency Medicine (RCEM). RCEM does not have responsibility for either determining in the access to healthcare staff within police custody units or the training of these staff. With regards to any decision concerning statutory changes to allow Police Officers to administer medication; RCEM is of the opinion that the safest approach to this issue would be to ensure adequate and timely access to healthcare assessment to police custody units for the whole 24hr period. Yours,

Chair of the Quality in Emergency Care Committee, Royal College of Emergency Medicine Excellence in Emergency Care Incorporated by Royal Charter, 2008 VAT Reg. No. 17320[i823 Registered Chnrity Number: 1122689 Scottish Chnrity Number: SC044373

Dear Sir Inquest touching on the death of Ian Taylor Case Ref: 159801 Prevention of future death report I write on behalf of the Director General of the IOPC , with regards to the first matter of concern raised in your Prevention of Future Death report arising from the inquest into the death of Mr Taylor, which concluded on 19 May 2022. This letter is the IOPC’s formal response to your report in accordance with Regulation 29 of the Coroners (Investigations) Regulations 2013. Matter of concern: the current fitness of to serve as a police officer In your report you highlighted the following evidence heard in court from officers in person and the body worn footage (BWV):
• At 18.18hrs officers decided to move Mr Taylor to the police car where it was cooler. Mr Taylor was lying down and had to be assisted to stand. My Taylor told officers that he was going to die and asked them to help him stand up. reassured Mr Taylor that he was not doing to die and told the court that officers had to support Mr Taylor to walk to the car as he initially did not support his own weight. BWV captured Mr Taylor saying something like ‘I’m fading’ and ‘I’m going to die now’.
• Shortly before the above interaction (at 18.14hrs) while was away from Mr Taylor he stated to his sergeant on the radio that ‘[Mr Taylor] was currently on

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the floor playing the whole poor me poor me; he’s going to have to go to hospital though as a matter of course.’
• Shortly after the above interaction (at 18.24hrs) also stated to his sergeant on the radio that ‘[Mr Taylor was] saying he has chest pains he can’t breathe blah blah; it’s a load of nonsense but there we go’.
• In his evidence to the court denied that he thought Mr Taylor was faking illness and stated he formed the views (relayed to the Sergeant) as Mr Taylor seemed iller than he would expect from the nature of the previous altercation.
• He further gave evidence that his views were influenced by a previous incident in which a man sprang to violence from previous calmness.
• claimed to have made a continual risk assessment, but there was no record or evidence of this before the court.
• stated the views he expressed to his sergeant were not his final conclusion but there was no evidence suggesting he formed a different conclusion in the 8 minutes between his radio comments and Mr Taylor’s cardiac arrest.
• did not acknowledge that he had learnt any lessons from the incident and, in response to questioning about whether he would do anything different in future, made excuses for his comments and said that he would be more sensitive in future.
• He did not accept that he had made an inadequate risk assessment or that such comments could have or might in future contribute to death by indicating a lack of urgency to a sergeant not at the scene.
• Although given an opportunity to make any other comment, did not apologise to Mr Taylor’s family.

In your report you also highlighted the level of the family’s concern with regards to public safety arising from these matters.

In light of the above, you asked the IOPC to consider whether further investigations or reports are warranted to give reassurance to the public about the fitness of this officer to serve.

Action taken

In response to your report, I have considered whether the matters raised by the inquest with regards to would require any further handling under the Police Reform Act 2002.

Under this legislation, concerns about the conduct of a person serving with police may be recorded and referred (subject to meeting the relevant statutory criteria) to the IOPC for consideration whether an investigation is necessary, and if so, whether an independent investigation is required. Decisions to record and refer are usually made by the force with

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whom the officer in question is serving (known as the appropriate authority). However, the IOPC can also require an appropriate authority to refer a matter or, in some circumstances, treat a matter as having been referred.

Conduct matters are defined in the legislation as any matter which is not and has not been the subject of a complaint where there is an indication that a person serving with the police may have committed a criminal offence or behaved in a manner which would justify the bringing of disciplinary proceedings. Disciplinary proceedings are justified where the conduct, if proven, would justify a sanction of at least a written warning.

Conduct matters which must be referred to the IOPC are:
• matters which relate to any incident or circumstances in which (or in consequence of which) a person has died or suffered a serious injury;
• serious assaults;
• serious sexual offences;
• serious corruption;
• a criminal offence of behaviour liable to lead to disciplinary proceedings which was aggravated by discriminatory behaviour;
• a relevant offence;
• conduct alleged to have taken place in the same incident as one in which one or more of the foregoing types of conduct is alleged.

I have given careful consideration as to whether the matters reported in respect of

would meet the definition of a conduct matter described above.

The distress that comments to his Sergeant, and the lack of insight and reflection shown in his evidence to the inquest, will have caused to Mr Taylor’s family, is a harm resulting from his behaviour which will also be capable of harming public confidence in the police service more widely. I agree that this behaviour does need appropriate intervention. Balanced against this, this appears to be a one off incident rather than a pattern of behaviour and while the inquest jury concluded that the dynamic risk assessment of the officers present was not adequate, the evidence did not suggest that comments to his Sergeant delayed or otherwise affected the treatment of Mr Taylor. Taking all these factors into account, I have concluded that the behaviour would not meet the threshold for justifying disciplinary proceedings for the purpose of being treated as a conduct matter under the 2002 Act.

The appropriate authority, the MPS, have informed the IOPC that they propose to refer

to the reflective practice review process, a formal but non disciplinary process set out in Part 6 of the Police (Conduct) Regulations 2020. This process can be used where the appropriate authority has identified ‘practice requiring improvement’, defined as underperformance or conduct not amounting to misconduct justifying disciplinary

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proceedings or gross misconduct, which falls short of the expectations of the public and the police service as set out in the Code of Ethics issued by the College of Policing.

I agree that this is an appropriate intervention. behaviour is evidenced in the BWV capturing his comments at the time, and the record of his evidence to the inquest. A further investigation therefore does not appear to be necessary in order to establish the extent of his behaviour or test the evidence. Under the Police (Conduct) Regulations 2020, the appropriate authority has the power to refer an officer to the reflective practice review process without an investigation. The Home Office Guidance on Conduct, Efficiency and Effectiveness 2020 states that the reflective practice review process is intended to:

“involve accountability for actions and taking responsibility by individual officers and the organisation. The process is intended to provide an open and reflective environment to approach issues and mistakes that have arisen. There should therefore follow a greater willingness to discuss the facts at issue and a positive attitude about taking steps to put things right and improve for the future.”1

The reflective practice review process leads to a reflective review development report, which (among other things) must contain key actions to be undertaken within a specified time period, any lessons identified for the participating officer (and for the line management or police force concerned) and specify a period of time for reviewing the report and the actions taken.

I am satisfied that this process can be used effectively to prompt the reflection and insight into this incident lacking in testimony and lead to a recognition of the potential for future harm were his behaviour to be repeated. It is not for the IOPC to set the terms of the intervention, but I express my hope that among other things there may be reflection on the missed opportunity to offer an apology to Mr Taylor’s family which you highlighted in your report.

Conclusion

I would like to myself express my sincere condolences to the family of Mr Taylor.

I am grateful to you for raising this issue with the IOPC and trust this response provides reassurance that I have considered the matter of concern raised in your report. Please do not hesitate to contact me if you have any queries arising from this letter.

1 Paragraph 13.8, p154 Home Office Guidance Home_Office_Statutory_Guidance_0502.pdf (publishing.service.gov.uk)

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Dear Dr Harris,

Thank you for your letter of 8 June 2022 to the then Secretary of State for Health and Social Care, Sajid Javid, about the death of Ian Taylor. I am replying as Minister with responsibility for Health and Secondary Care, and thank you for the additional time allowed.

Firstly, I would like to say how saddened I was to read of the circumstances of Mr Taylor’s death and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention.

You may wish to note that allowing non-prescribed storage of salbutamol inhalers1 by police officers will require a change in legislation - which in this case is the Human Medicines Regulations 2012. The Medicines and Healthcare products Regulatory Agency (MHRA) own these regulations, and will need to be presented with evidence that supports the case for making a change to the regulations.

With regard to the use of inhalers, there are several considerations that need to be well- thought-out:
• salbutamol inhalers are single use devices, therefore, there would need to be means by which Police Officer could obtain replacement devices
• monitoring on the use of the inhalers would also be essential
• multiple inhalers will need to be stored by the police, to ensure one is always available for use and to meet the needs of each salbutamol inhaler user in a given situation
• specific people would have to be trained and responsible for the device in each police setting - this training will be essential to ensure that the inhalers are used appropriately and not as interventions for unrelated emergencies such a blocked windpipe for example

In order for these legislative changes to be considered evidence would need to be gathered to support the need for the change to show that the medicine could be safely handled and used in the proposed emergency circumstances, and that risks identified have been satisfactorily mitigated.

1 Short-acting bronchodilator inhalers, also known as blue inhalers.

You may wish to note that in 2015 the legislation was amended to allow schools to procure and store non-prescribed salbutamol inhalers. These changes were made following an evidence gathering exercise by the Department for Education, including information being collected by surveys of patients, as well as, teachers and schools. The potential advantages and disadvantages of storing non-prescribed salbutamol were considered and informed by pilot schemes of holding inhalers in some schools.

The evidence would also need to demonstrate that wider availability of non-prescribed salbutamol inhalers would have in reducing severe asthma attacks and deaths, and would outweigh any risks that would arise from non-prescribed use of salbutamol inhalers.

Once all relevant evidence is collected, a paper would need to be presented to the Commission for Human Medicines (CHM) for consideration. If the advice of the CHM is that the benefits of the wider availability of inhalers outweigh the risks, then the Department would then undertake public consultation on changing the Human Medicines Act Regulations 2012. The feedback from the public consultation would also be taken on board before a final decision on implementing the legislative change is made.

In terms of process for considering whether inhalers should be available to police officers, this would need to be undertaken by the Home Office (as the sponsor department for the police services) supported by the Department.

Part of the argument as to why schools were allowed to have access to inhalers, was that these are controlled environments. Schools require parents to inform them if their children need an inhaler, which in turn enables the school to maintain a stock of inhalers respective to the number of children with that need. Local police services would need to undertake an assessment of the frequency of arrests involving individuals where the need for a salbutamol inhaler was identified, to gauge the stock of inhalers which would need to be maintained.

Finally, you may wish to note that NHS England has placed a particular focus in encouraging the use of preventer inhalers, inhaled corticosteroid inhalers, and reducing overuse of reliever inhalers, short-acting bronchodilator inhalers. However, overuse of reliever inhalers is associated with poorer clinical outcomes. The MHRA has noted that asthma suffers who use the inhalers must visit their GP to request one. This means that a GP could monitor a patient’s asthma, their exacerbations, and whether they have an overreliance on inhalers. Ad hoc use of reliever inhalers, such as during a police arrest, may prevent GPs from fully monitoring a patient’s asthma.

I hope this response is helpful. Thank you for bringing these concerns to my attention.

Dear Mr Harris

I am the Deputy Assistant Commissioner for the Directorate of Professionalism in the Metropolitan Police Service (MPS), and I am responding on behalf of the Commissioner of Police of the Metropolis in relation to the matters of concerns raised following the conclusion of the inquest into the death of Mr Ian McDonald Taylor who sadly died on 29th June 2019.

Matters of concern: Given the evidence heard in court before the family and members of the press, it is in the public interest that statutory bodies consider whether further investigations or reports are warranted to give reassurance to the public about the fitness of this officer to serve by

1. The IOPC, not only on the basis of conduct at the scene, but the evidence of his attitude, insight and extent of learning in court.
2. The Metropolitan Police Service as to his supervision after the incident, assessment of training needs and provision of any further training.

You will note from the IOPC’s response to matter of concern 1 in their letter dated 30th June 2022, that the MPS has reviewed the evidence provided and concluded that the officer should be referred to the reflective practice review process. In coming to this conclusion, the Appropriate Authority (AA) for the MPS considered whether the matters you have highlighted require any further handling under the Police Reform Act 2002 (PRA).

The AA carefully considered whether the matter should be recorded as a public complaint. This was considered during the original review which was handled as a Death or Serious Injury incident. The AA is unaware of any person who meets the definition of complainant as described in the PRA as ever having made a complaint. However, given that the coroner has relayed the family’s continued concern it remains open to them to make a complaint to the MPS, and should they wish to do so, it will be handled under the provisions of the PRA.

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Mr Andrew Harris/2

In the absence of a public complaint, the AA has applied the PRA using the Police (Complaints and Misconduct) Regulations 2020 (PCMR). The following definition of conduct can be found within the PCMR.

“A conduct matter is any matter which is not and has not been the subject of a complaint, where there is an indication (whether from the circumstances or otherwise) that a person serving with the police may have committed a criminal offence or behaved in a manner which would justify disciplinary proceedings. Section 12, Police Reform Act 2002”.

The PCMR also includes a duty to refer certain conduct matters to the IOPC.

Conduct matters which must be referred to the IOPC are:

• matters which relate to any incident or circumstances in which (or in consequence of which) a person has died or suffered a serious injury;
• serious assaults;
• serious sexual offences;
• serious corruption;
• a criminal offence of behaviour liable to lead to disciplinary proceedings which was aggravated by discriminatory behaviour;
• a relevant offence;
• conduct alleged to have taken place in the same incident as one in which one or more of the foregoing types of conduct is alleged.

The AA has considered whether the matters reported would meet the definition of a conduct matter described above. There are two occasions when one of the attending officers makes comments. On the first occasion he is speaking to a supervisor on a private call. Mr Taylor can be seen in the background of the footage lying on the pavement in handcuffs, he is being tended to by two other officers. The officer is providing an update on the scene and explains that he does not believe that the breathing difficulties Mr Taylor is complaining of are genuine. His tone is flippant when he states; “poor me, poor me,” however he confirms that they will be taking Mr Taylor to hospital. Later on in the footage when he is not in the vicinity of Mr Taylor, he is on a further private call on his radio and again expresses the opinion that the breathing difficulties are not genuine by using the phrase; ‘chest pains, blah, blah, blah all a load of nonsense’. The AA recognises the severe distress that these comments made at the scene and the lack of reflection shown by the subject officer at the inquest, will have caused to Mr Taylor’s family. This is conduct which could damage public confidence in the police service.

It is the position of the AA that whilst the officer’s comments had no bearing on the circumstances of the incident, the flippant nature of the words demonstrate a lack of professionalism and are in breach of the standards of professional behaviour outlined in the code of ethics issued by the college of policing.

The AA also considered whether the comments made indicated a racial prejudice. The Angiolini Report, was referenced in the Inquest. The AA understands that the report suggests that officers are more likely to believe a person is faking illness if they are black. There is nothing in the words or behaviour that indicate that the comments made were due to the fact that he was treating Mr Taylor differently. In support of this opinion the AA took note of the

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Mr Andrew Harris/3

officer’s actions when Mr Taylor’s condition deteriorated. The officer reacted in accordance with his emergency life support training assisting his colleagues in administering the first aid.

The AA has determined that the conduct does not meet the threshold for justifying disciplinary proceedings. The AA has identified practice requiring improvement and determined that the officer will be referred the reflective practice review process, as set out in Part 6 of the Police (Conduct) Regulations 2020. In particular the AA has determined that the reflective practice review process will include an opportunity for the officer to reflect on the missed opportunity to offer an apology to Mr Taylor’s family.

Therefore, in response to your matter of concern, “The Metropolitan Police Service as to his supervision after the incident, assessment of training needs and provision of any further training”, the Reflective Practice Review Process (RPRP) will be implemented for this officer. It is a reflective practice designed to give officers, line managers and Forces an opportunity to discuss, learn and develop when things could have gone better, with a view to improving ways of working in the future and look for ways of addressing issues. It should demonstrate the officer’s ability to reflect, learn and improve. As part of the process, the officer’s line manager will identify whether there are any additional training needs for the officer.

In Conclusion

I wish to express my sincere condolences to the family of Mr Taylor. I trust this provides the reassurance that the MPS has considered the matters of concern raised by Her Majesty’s Coroner and that they have been addressed in relation to this matter. Please do not hesitate in contacting me should you have any queries.