Dear Ms Hayes, Re: Regulation 28 Report to Prevent Future Deaths – Scott Taylor (Ref: 2026-0092) I write in my capacity as the senior officer responsible for overseeing the matters arising from your Regulation 28 Report dated 2 February 2026, issued following the inquest into the tragic death of Mr Scott Darren Taylor, which concluded on 31 July 2025. I would like to take this opportunity to express my sincere condolences to Mr Taylor’s family. Essex Police remain committed to learning from this inquest and taking appropriate steps to prevent future deaths. Your report identified concerns regarding potential disparities in the training provided to police officers and Special Constables in recognising and responding to Acute Behavioural Disturbance (ABD). The report also raises concerns in relation to the clarity and operational suitability of police policy to remove all methods of restraint when an individual appears unconscious. These matters have been examined closely within Essex Police, informed by the evidence heard during the inquest and subsequent internal review. In relation to ABD, you noted that Special Constables may not have received the same depth of training as regular officers. Essex Police acknowledges the importance of ensuring that all officers, regardless of role, are equipped to identify life-threatening medical emergencies and respond consistently. As a result, all officers—regular and Special Constabulary—now receive the same level of training in relation to ABD. This change addresses the previous differences created by reduced refresher training time provided for Special Constables. Furthermore, ABD training has been moved from the First Aid Learning Programme refresher sessions into the College of Policing’s Scenario-Based Training programme, which ensures that ABD is taught in the context of practical, decision-making scenarios involving the National Decision Model, tactical considerations, personal safety, and use-of-force decision-making. This training is now fully standardised across both initial and refresher inputs, guaranteeing that all officers receive consistent information irrespective of role. These changes ensure a more robust Essex Police Headquarters PO Box 2 Chelmsford Essex

27/03/2026 HM Area Coroner Sonia Hayes HM Coroner's Office County Hall, A Block Victoria Road South, Chelmsford Essex Essex CM1 1QH

understanding of ABD across the workforce and improve the identification and management of high-risk presentations. You also expressed concern that police officers did not remove handcuffs or leg restraints when Mr Taylor appeared unconscious, and that officers did not appear clear that the relevant policy required them to do so. The policy in place at the time contained an absolute instruction to “remove all methods of restraint,” in the case of unconsciousness which, when considered against the operational realities of ABD and the unpredictable nature of such presentations, was not sufficiently aligned with safe decision-making or with the principles of the National Decision Model. Following review at the inquest and subsequent policy analysis, Essex Police has updated this guidance to provide officers with clearer, more realistic direction. The revised policy now states that officers must remove restraints where it is considered safe and appropriate to do so, and that this decision must be informed by the prevailing circumstances and assessed through the National Decision Model. This updated wording removes the absolute instruction that did not reflect the operational complexities faced by officers, and instead reinforces the requirement for a considered, risk-assessed approach that is consistent with officer training and the realities of managing individuals experiencing ABD. The updated policy has now been incorporated into both initial and regular refresher training so that all officers fully understand their responsibilities and the rationale underpinning these changes. Essex Police recognises the seriousness of the issues highlighted in your Regulation 28 Report and is grateful for the opportunity to reflect, improve, and strengthen its practices. The actions already taken will improve the recognition and management of ABD, ensure consistency in officer training, and provide clearer, more operationally realistic guidance to support officers in making safe and effective decisions in highly dynamic circumstances. If you require any further information, clarification, or supporting documentation, I would be happy to provide it.

Dear HM Coroner Sonia Hayes

I am writing further to the inquest into the death of Scott Darren Taylor, which concluded on 31 July 2025. I understand that a number of Trust witnesses gave oral evidence in respect of the call handling and triaging aspects of the 999 calls for Mr Taylor on 12 August 2022, who was exhibiting signs of Acute Behavioural Disturbance and sadly died on 13 August 2022.

Ambulance call codings are set by NHS England via a group called ECPAG (Emergency Call Prioritisation Advisory Group). However, EEAST had previously determined that patients presenting with the symptoms exhibited by Mr Taylor should be classified as a Category 1 response (a higher response than that set by the Emergency Call Prioritisation Advisory Group), as this represented the most appropriate level of urgency. At the time, internal procedures required a Clinician to review Category 2 calls and, where indicated, upgrade them to Category 1. This happened with the call for Mr Taylor and the call was upgraded by a Clinical Co-ordinator to a Category 1 in line with the procedure in place at the time.

I understand you raised the following concerns in the Regulation 28 report dated 2 February 2026:

East of England Ambulance Service NHS Trust Whiting Way Melbourn SG8 6NA

a. The police, during the 999 call, were put on hold on three occasions by the ambulance service and became increasingly concerned about Mr Taylor’s deteriorating condition over an 18 minute period. The call remained a Category 2 call despite active police restraint with suspected Acute Behavioural Disturbance. Police decided to ‘scoop and run’ and urgently convey Mr Taylor to hospital due to the severity of their concerns. The EEAST Standard Operating Procedure required escalation to Category 1 where there is active restraint, but this is not linked to Acute Behavioural Disturbance and remains unclear and may continue to cause confusion during triage by contact call handlers.

b. The East of England Ambulance NHS Trust provide ambulance services across 6 counties and that also includes police/healthcare professionals reporting Acute Behavioural Disturbance and active police restraint. There is concern that there is a different response applied and that this discrepancy between Category 1 and Category 2 responses is significant and could affect the survival of patients.

c. The EEAST updated training on Acute Behavioural Disturbance, active restraint and reports received from police and correct coding remains confusing with the policy and training handouts in December 2023 with discrepancies between those who are sectioned and those who are not.

d. The EEAST documents continue to use the term ‘Excited Delerium’ interchangeable in some of the training materials and this may lead to confusion with contact handlers triaging calls.

Following the inquest a working group was set up with the intention of revising the guidance for patients exhibiting signs of Acute Behavioural Disturbance and establishing the most appropriate way to respond to these patients within the Emergency Operations Centre.

The conclusion of this group was the implementation of Emergency Operations Centre Standard Operating Procedure 145 in January 2026, which is a standalone procedure for cases were Acute Behavioural Disturbance is suspected or confirmed by either members of the public or Police.

Specifically, the term “excited delirium” has been removed from the documentation and the signs and symptoms that could be associated with Acute Behavioural Disturbance are outlined and made much clearer.

The procedure has also been updated to reflect that a Category 1 coding is now applied to all calls where the police are actively restraining a patient; or reporting agitation/behaviour changes; or the police use the term Acute Behavioural Disturbance. The call handler will immediately escalate this to a Call Handler Team Leader who will upgrade the call to a Category 1 and the response will be dispatched on this basis. If, at this point, the Call Handler Team Leader or Dispatcher believe this may not be a Category 1 call, the call will be highlighted to a Clinical Navigator who will complete a clinical review and triage to establish if a downgrade is required.

The same process is applied where the caller is a member of the public and they state that the patient has taken illicit drugs and is being restrained; or reporting agitation/significant behaviour change.

In addition, both Emergency Operations Centre Standard Operating Procedure 044 (Patients Detained under the Mental Health Act) and the Guidance on Escalation for Emergency Operations Centre staff have been changed to reflect Emergency Operations Centre Standard Operating Procedure 145. These have also been approved and disseminated to the relevant staff.

During the inquest you requested further information in respect of the progress of introducing protected time for Emergency Operations Centre staff for 1:1 supervision and time to review procedure/policy updates.

From 3 November 2025, all call handling staff have been given 1 hour protected time each month for the purpose of reviewing emails and newly released policies/procedures; completion of mandatory training; undertaking any additional training from the International Academy of Emergency Dispatch (the organisation that provide the call handling system); and participating in 1:1s. There are plans to increase this to 2 hours protected time per month over the coming year.

Providing the same level of protected time for dispatchers has proved more challenging although we do acknowledge that the dispatch role has more flexibility in their working day and ‘downtime’ to review procedures/complete

training etc than the call handling role. It is anticipated this will be fully rolled out by 30 June 2026.

All clinical staff based in the Emergency Operations Centre are also receiving monthly 1:1s with their Clinical Workforce Manager for supervision and updates to be shared. In addition, any procedural updates are being graded to assess whether they are high priority or not. If an update is identified as high priority, the member of staff may not start shift until they have read and acknowledged this update.

Please do not hesitate to contact me should you require any further information.

Dear Ms Hayes

SCOTT DARREN TAYLOR (DECEASED)

I am writing in response to the preventing future deaths report in my capacity as managing director of the Association of Ambulance Chief Executives (AACE).

On behalf of AACE, I would like to extend our sincere condolences to the family of Mr Taylor.

AACE is a private company owned by the English and Welsh Ambulance NHS trusts. It exists to provide ambulance services with a central organisation that supports, co-ordinates and assists with the implementation of nationally agreed policy. Our primary focus is the ongoing development of the English and Welsh ambulance services and the improvement of patient care. It is a company owned by NHS organisations and possess the intellectual property rights of the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) UK ambulance service clinical practice guidelines (the “JRCALC guidelines”). AACE is not constituted to mandate or instruct ambulance services, however, it has national influence via the regular meetings of ambulance chief executives and chairs along with a network of national specialist groups.

We respond in relation to your proposed matters of concern:

It was agreed in evidence that the set of symptoms consistent with Acute Behavioural Disturbance amount to a medical emergency with a significant mortality risk. The evidence was that the Association of Ambulance Chief Executives set the Categories nationally that dictate the required classification for ambulance response to emergencies, however in some ambulance localities the required response is allocated Category 2 and in others Category 1. This means that there is not a national standard for response Acute Behavioural Disturbance with active restraint.

We agree that acute behavioural disturbance (ABD) is a medical emergency.

With regard to the required classification for ambulance response to emergencies, AACE do not set the categories nationally of ambulance response. Ambulance call codes are determined by NHS England by the Emergency Call Prioritisation Advisory Group (ECPAG). We are aware that cases of suspected ABD should be assigned a Category 2 response, which is the immediate dispatch of an emergency ambulance. However, ambulance services are advised that a senior clinician within the

control room should be made aware of patients presenting with symptoms that are potentially ABD to assist with decision-making; if necessary, this would, in certain situations, such as the use of restraint, include upgrading the incident to a Category 1 if the patient’s condition indicated that was appropriate.

With regard to the ABD, over a number of years we have developed and further revised UK ambulance service clinical practice guidelines for clinicians. This has been based on learning from ABD cases we have been involved with, some of these via coroners’ inquests and preventing future death reports. We have published guidance for patients that are agitated, have delirium and have suspected ABD. This is to ensure that the recognition, assessment and management of these patient presentations are considered by ambulance clinicians. We emphasise in the ABD guidance that the condition is a clinical emergency and that the patient may suffer sudden cardiovascular collapse or cardiac arrest or both with little or no warning. We stress that the clinician must take all reasonable actions to clinically monitor the patient throughout restraint where possible, and that patient restraint time must be kept to an absolute minimum – the degree of restraint used must be justifiable, reasonable and applied for the minimum time necessary and proportional to the situation. The attending ambulance crews should undertake a time-critical transfer and provide a hospital pre-alert for suspected ABD cases.

I hope this is helpful. Please do not hesitate to contact me should you require any further information.