Dear Ms Hunt

Subject - Regulation 28 Prevention of Future Deaths Report arising from the inquest touching on the death of Muhammad QASIM.

Thank you for your Preventing Future Deaths Report arising from the inquest into the death of Mr Muhammed Qasim. We have carefully considered its contents and set out our response below in relation to the following concern: For the IOPC: The IOPC were investigating the conduct of the police driver in this case. As a result of their investigation no full forensic collision investigation report was obtained. The IOPC need to confirm where investigative responsibilities lie when a conduct investigation is being conducted in all fatal incidents to ensure lessons are learnt from the death and adequate evidence is obtained. The lack of a full forensic collision investigation report in this case creates a risk of future deaths and action should be taken. The IOPC is committed to ensuring that whenever we carry out an independent investigation into a death or serious injury, our investigation is thorough and evidence- based with a clear focus on learning and accountability. We work to ensure we gather all relevant and available evidence and seek expert advice where it is necessary and proportionate to the circumstances of the case. Collectively, this helps to inform the investigation and our ability to reach evidence-based decisions.

With specific reference to matters involving road traffic incidents, the IOPC does not possess the technical skills or expertise to undertake collision investigation work. As such, we work with policing partners who have a duty to provide independent assistance by way of

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2 objective and unbiased opinion in relation to matters within their expertise. The reports produced by Forensic Collision Investigators are provided to the IOPC and the salient points are then included in the IOPC investigation report. Following the death of Mr Qasim in the early hours of 02 October 2023, the IOPC received a Death or Serious Injury (DSI) referral from West Midlands Police and an independent investigation was declared on 05 October 2023.

At the conclusion of the IOPC investigation, solicitors representing Mr Qasim’s family challenged the IOPC investigation and a decision was made on 24 September 2024 to reinvestigate the police contact with Mr Qasim.

The Terms of Reference for the initial IOPC investigation were agreed on 26 October 2023 and included: To investigate West Midlands Police’s contact with Mr Qasim and Male B on 2 October 2023, specifically in relation to: a) The actions and decisions of police officers and staff prior to the road traffic accident; b) whether the decisions and actions of officers and staff were in line with local and national policies and procedures. At the outset of the investigation, the Lead Investigator engaged with a Senior Collision Investigation Unit (SCIU) supervisor within West Midlands Police. The Lead Investigator met with the SCIU supervisor and the allocated Forensic Collision Investigator on multiple occasions during the investigation. The IOPC lead investigator was advised that a full forensic collision report into the crash would not ordinarily be produced because Mr Qasim’s vehicle had not collided with another vehicle– it had left the road and impacted with a tree. There was CCTV footage from nearby properties that demonstrated that the police car involved in the incident was not close to Mr Qasim when he crashed. Therefore, at an early stage, the IOPC lead investigator was satisfied that the police car had not had direct physical contact with Mr Qasim’s vehicle to cause the collision.

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3 As a consequence, the lead investigator and decision-maker were satisfied that the streamline collision investigation report would provide sufficient information for the IOPC independent investigation to fulfil its statutory obligations. During the investigation, the IOPC lead investigator was also advised by the SCIU that as a result of the damage to Mr Qasim’s vehicle, a vehicle examination would not be beneficial. However, the IOPC asked that this should go ahead, and this took place on 29 November 2023 with the IOPC in attendance. The IOPC lead investigator obtained information downloaded from the police car, documenting its speed, the use of brakes and the use of sirens/emergency warning lights during the incident. This was obtained from both the on-board system and the vehicle CAN data. The IOPC lead investigator assessed the actions relating to the driver of the police vehicle regarding his manner of driving and decision-making prior to the collision, and determined there was an indication that the officer may have breached the Standards of Professional Behaviour to such an extent that disciplinary proceedings may be warranted. The investigation therefore became a conduct investigation. The lead investigator discussed the available evidence with the IOPC decision maker and a decision was made to approach the SCIU to undertake extensive analysis and speed calculations of the period prior to Mr Qasim’s crash. This was directly relevant to the conduct matters to determine whether the officer had entered into a pursuit, prior to the collision. As a result of the contact with the WMP SCIU, two documents were produced for the investigation:
1. A Coroner’s File – Fatal Road Traffic Collision report
2. A CCTV – Speed Analysis Report Both documents are attached to this response.

Updates were provided to the Coroner throughout this investigation by the IOPC.

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4 Actions to be Taken / Organisational Learning

Following the inquest into Mr Qasim’s death, you have identified that the IOPC needs to confirm where investigative responsibilities lie when a conduct investigation is being conducted in all fatal incidents, to ensure lessons are learnt from the death and adequate evidence is obtained.

In all IOPC investigations into fatal road traffic incidents, it remains open to us to make representations for a full Forensic Collision Investigation Report to be completed, or for us to commission one from an independent source. While it was the view of the investigation team that one was not required in this instance, we recognise that we did not specifically ask the Coroner their views.

Going forward, all lead investigators will need to assess the circumstances of an incident and have early contact with the Coroner to determine whether a full Forensic Collision Investigation Report is required. If one is required, we will either request this from a police force or source an independent report if necessary. We will continue to use our internal technical leads in the IOPC to provide advice to IOPC lead investigators and your concerns have been brought to their attention as well as to the attention of our operational policy team. We will update the internal written guidance we provide to IOPC lead investigators to ensure consideration is given to securing a full Forensic Collision Investigation Report and that there is consultation with the Coroner about our approach. Our internal guidance will be updated within the next six weeks but in the meantime, our internal technical leads will liaise with investigators in the early stages of any investigations involving a road traffic fatality to ensure the correct considerations are made. In instances where we feel it is appropriate to secure a streamlined collision investigation report, we will set out the minimum standards we expect for that report, to ensure all relevant information is secured. I trust that the information provided clarifies our role and offers reassurance regarding the matters raised. We are committed to upholding the principles of impartiality and

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5 independence, which are fundamental to the integrity of our investigative processes.

Dear Ms Hunt, Muhammad Qasim - Regulation 28 Report to Prevent Future Deaths Thank you for your Regulation 28 Report dated 25 June 2025 concerning the tragic death of Muhammed Qasim. We acknowledge the concerns raised regarding the current guidance within the Police Pursuits Authorised Professional Practice (APP), and the delivery of police pursuit training to police drivers. We understand your primary concerns relate to:
• The lack of clear guidance within the Police Pursuits APP on the definition of a ‘spontaneous pursuit’, which may lead to inconsistent interpretation.
• Potential variations in the delivery of police pursuit training across different forces. The College of Policing remains committed to supporting operational excellence and public safety across all forces. In response to your report, we have taken the following actions and made the following commitments:
• We have liaised directly with ACC , NPCC National Lead for Police Pursuits, to consult on the content of your report and the concerns raised.
• We have reviewed the current Police Pursuit APP guidance. While the initial definition of a police pursuit is considered clear and appropriate, we acknowledge that the term ‘spontaneous pursuit’ may be open to interpretation. This could suggest that a pursuit might occur without first meeting the established definition.
• We will progress an amendment to the Police Pursuit APP to replace the reference to ‘spontaneous pursuit’ with clearer, more precise guidance aligned with the National Decision Model (NDM). We have reviewed the current training requirements for police pursuits:
• The Code of Practice on the Management of Police Pursuits (Home Office, 2011) states that Chief Officers should arrange the selection, training, and authorisation of officers involved in pursuits in accordance with national standards. These national standards are set out in the Police Driving National Policing Curriculum and cover the initial phase pursuit, tactical phase pursuit, and command and control. It is the responsibility of each Chief Officer to determine the operational deployment of officers trained and authorised in both the initial phase (response drivers) and tactical phase (advanced drivers).
• The Police Pursuit APP outlines the roles and responsibilities of officers during a pursuit and mandates that only those trained and authorised to College standards may be directly involved. The standardised delivery of police driver training is now a legal requirement under the

Road Traffic Act 1988 (Police Driving: Prescribed Training) (Amendment) Regulations 2025. Police Driver Training Units are subject to annual quality assurance and licensing by the College of Policing to ensure compliance. We are committed to ensuring that the learning from this case leads to meaningful and lasting improvements in policing practice and will continue to work closely with NPCC leads and police forces to ensure that national guidance and training reflect best practice and support safe operational decision- making. We aim to publish the revised guidance by December 2025, subject to consultation and governance processes. The College will continue to monitor and address any inconsistencies in training delivery through its QA framework and feedback mechanisms. We will also ensure that learning from this case is disseminated nationally through our operational learning channels, including bulletins and updates to training materials. We extend our sincere condolences to Muhammed Qasim’s family and thank you for bringing this matter to our attention. We remain committed to ensuring that police pursuits are conducted safely, lawfully, and in a manner that maintains public confidence.