28A recommendation and response record To Head of Professional Standards - British Transport Police (BTP) Copied to British Transport Police Authority HM Coroner Mary Hassell Date sent 13 August 2024 Deadline for response 56 days after the date above – 8 October 2024 Case name Euston Railway Station DSI Case type Independent Case reference 2023/198295 Recommendation from Operations Manager Police case reference

We have identified organisational learning for BTP and make the recommendation below under Paragraph 28A of Schedule 3 to the Police Reform Act 2002. You are required by law to respond, in writing to us by the deadline specified above (56 days from the date this recommendation has been sent to you) and should do so using this form. Paragraph 28B of Schedule 3 of the Police Reform Act sets out the requirements in relation to the response.

OFFICIAL

To be completed by IOPC To be completed by recipient Reference Recommendation Previously sent as a S10 recommendation? Do you accept? Details, to include a) action to be taken, b) reason for no action, or c) reason not accepted

Date sent 2023/198295/1 The IOPC recommends that the British Transport Police (BTP) should explore opportunities to raise awareness of the Vulnerability Assessment Framework (VAF), outside of the Public Protection and Vulnerability training programme, to ensure that officers are made aware, and regularly reminded, of how and when this should be used in respect of safeguarding vulnerable individuals.

This follows an IOPC investigation whereby a member of the public contacted police to report a concern for a man’s welfare outside Euston Railway Station. The call Yes No

Yes No

OFFICIAL

was graded as requiring an emergency response and several officers attended. As a result of decisions made at the scene, no further action was taken and sadly the man later died. Evidence obtained during the investigation indicated that despite the officers having attended the training programme, they appeared unaware of the application of the VAF to help them assess the man and gather the appropriate information to inform their decision- making. Spreading further awareness of the VAF, will help officers make better decisions about safeguarding when attending welfare incidents. In using the VAF in this instance, the officers would have likely recognised that the man was vulnerable, and action could have been taken to appropriately safeguard him.

OFFICIAL

On receipt of your response, we are required to publish it within 21 days and send a copy to any person who was sent the original recommendation (as listed above). If you have any representations why this response should not be published, e.g. if it may prejudice ongoing proceedings, please let us know.

When completed please return this form to:

Dear HMC Hassell, Inquest into the death of Mohammed Akramuzzaman – PFD Response This is a response prepared by British Transport Police (‘BTP’) following a Regulation 28: Prevention of Future Deaths Report issued in the inquest of Mohammed Akramuzzaman. The Prevention of Future Death report identified 5 areas of concern for BTP as outlined below.
1. The officers left Mr Akramuzzaman after he had simply nodded that he was alright and shaken his head that he did not want medical treatment. They never actually heard him speak. They did not attempt to stand him up to see if he was able to support himself. I appreciate that if Mr Akramuzzaman had mental capacity then he could not be forced to go to hospital, but it is difficult to see how he could have been assessed properly following just a nod and a shake of the head.
2. The three station officers (one PC and two PCSOs) who attended Mr Akramuzzaman told me that they had placed great reliance on hearing a BTP response officer (one of three who had arrived just moments before the station officers) give an opinion over the radio that Mr Akramuzzaman was “coming round” after having taken drugs or alcohol. However, the station officers were themselves very experienced, and should have formed their own view.
3. The officers also eventually accepted at inquest that it was impossible to decide so quickly that this was a drug comedown.
4. It must have been a very cold night (it was minus 4⁰C when he was found in the morning), but nobody went back to check on Mr Akramuzzaman later. I appreciate that a decision had to be made about what action to take there and then. But when I asked, BTP witnesses agreed that it would have been an easy matter for an officer on patrol later to check on a person in that situation. No consideration was given to that

British Transport Police West Gate House, Grace Street, Leeds LS1 2RP

by either of the PCSOs, by the PC, or by the sergeant who then took the decision to cancel the ambulance called earlier.
5. I was told that the BTP officers had reflected a lot about this incident in the time since, and had learnt a lot. However, when giving their evidence they struck me as defensive, and they were unable to point to any specific learning or any changes in their procedures following Mr Akramuzzaman’s death. Whilst I readily accepted that the officers had talked about Mr Akramuzzaman since his death, I did not gain the impression of a culture of learning. The sergeant told me that before the inquest, he had not known about the existence of ketoacidosis. The officers reminded me that they are not healthcare professionals. However, as I explained in court, I was not suggesting that they should have a particular understanding of ketoacidosis. Mr Akramuzzaman could have been suffering from any number of medical conditions. He could have sustained a subtle head injury. He could have had diabetes (which, as it happens, can also result in ketoacidosis). He could have had epilepsy. The list goes on. Mr Akramuzzaman did not need the BTP officers to be doctors in order to survive this episode, but he was probably already confused when officers dealt with him, and he needed them to make an appropriate assessment and to take appropriate action as BTP officers. The sergeant told me that he thought learning should be undertaken by BTP at an organisational level.

Following the death of Mr Akramuzzaman, BTP referred themselves to the IOPC. A decision was made that the IOPC would investigate the actions of the officers and the officers were still under investigation when the inquest was taking place. This may have been a factor in why the officers appeared to be defensive when giving evidence before you.

The IOPC report provided the following recommendations for BTP. The IOPC recommends that the British Transport Police (BTP) should explore opportunities to raise awareness of the Vulnerability Assessment Framework (VAF), outside of the Public Protection and Vulnerability training programme, to ensure that officers are made aware, and

British Transport Police West Gate House, Grace Street, Leeds LS1 2RP

regularly reminded, of how and when this should be used in respect of safeguarding vulnerable individuals.

In response to the IOPC recommendations, a force wide bulletin was circulated on 19 July 2024 to highlight the learnings identified as a result of this incident. This bulletin is exhibited to this response [EXHBIT 1].

The safeguarding of the vulnerable is a key objective for BTP and we have opted out of the national programme ‘Right Care, right person’ due to the increased vulnerability of people on the rail network. We are currently promoting our own ‘Mental Health Crisis to Care’ programme in force and have eleven regional single points of contact pulling this activity together. A force wide update was circulated on 7 August 2024 to provide an update on Mental Health Crisis to Care. This update is exhibited to this response [EXHIBIT 2].

Reflective practice has been provided to the officers involved in the incident. The officers have reviewed their understanding of BTP's safeguarding policy and legal powers under the Mental Capacity Act and Mental Health Act, and they have reflected on the comments made by the Coroner around making further checks on the male's welfare, which in hindsight would have required the ControlWorks log to have been left open. They have also reflected on their use of BWV and the importance of capturing everything. They have commented that they would look to be more persuasive in convincing subjects to get medical attention in future incidents.

The reflective practice was also provided to the IOPC who gave feedback as follows. I would just like to feedback that the RPRP process here appears to have been very positive, with both individuals demonstrating genuine reflection and positive steps to develop their understanding of issues that were relevant in this case, as well as things that would be done differently if faced with a similar situation to help prevent another tragic outcome.

British Transport Police West Gate House, Grace Street, Leeds LS1 2RP

BTP trusts that this addresses the concerns of the coroner but if there is anything further that can assist, please do not hesitate to let us know.