Lamont Roper

PFD Report All Responded Ref: 2023-0381
Date of Report 7 September 2023
Coroner Andrew Walker
Coroner Area North London
Response Deadline est. 25 December 2023
All 1 response received · Deadline: 25 Dec 2023
Coroner's Concerns (AI summary)
Concerns include insufficient and cumbersome water rescue equipment for police, inadequate training for cycle patrols near water, and limited awareness of dive team availability and capacity.
View full coroner's concerns
1. The Coroner recommends to the MPS that they consider whether there is any alternative and less cumbersome water rescue equipment [to throw lines] that could be issued to officers on patrol near bodies of water, for example some sort of device which could be inflated quickly and thrown to the person in the water to assist them in floating until a throw line is available.
2. If this not possible to source alternative water rescue equipment that can be carried by officers on cycle patrol, then the family considers that the risks of cycle patrols near to bodies of water outweighs the benefits. The Coroner a recommends in the alternative that the MPS amends their policies and training to reflect the fact that cycle patrols alongside bodies of water are potentially very dangerous more so in the absence of water rescue equipment and that in these circumstances careful consideration to continuing the patrol will need to be undertaken at a senior level .

3. The coroner recommends for the MPS to implement a requirement for officers conducting pre-planned operations along stretches of a canal or other bodies of water to make themselves aware of the availability (or non-availability) of water rescue equipment in order for this to be factored into their ongoing dynamic risk assessment whilst on patrol”
4. The Coroner makes a recommendation to the MPS to ensure that its officers are made aware the MPS dive team can attend a critical incident involving someone submerged in water even when the team are not on call and / or at night, and that this possibility should therefore be explored at an early stage. This may be achieved by special training and the publication of an operational notice.
5. The Coroner recommends that that [throw lines] must be available and issued to all MPS marked emergency vehicles.
6. The Coroner makes a recommendation that steps should be taken to increase the number of qualified divers available to the police to assist with the respond to an incident.
7. The Coroner recommends to the MPS that they provide specific training about cycling, whether during a pursuit or otherwise, near to the bodies of water in particular as there is a serious risk of future deaths occurring as a result of MPS cycle patrols and pursuits at up to 15mph [on electric bicycles] near bodies of water. The Coroner recommends that specific policies and training are put in place to ensure that such pursuits are undertaken safely and in a manner such as to mitigate risks of accidents or injury.
Responses
Metropolitan Police Service Police / Law Enforcement
25 Oct 2023
Action Taken
The MPS reviewed and refreshed its cycle training at the beginning of 2022 and now maintains training and resourcing records, for the deployment of officers and staff who have received this training. (AI summary)
View full response
Dear Mr Walker Iam the Deputy Assistant €Omissioner for Professionalism in the Metropolitan Police Service (~MPS" ) On behalf of the Commissioner of Police of the Metropolis; Wite t0 provide the response to the matters of concer addressed to the MPS in your Report to Prevent Future Deaths dated September 2023 On behalf of the MPS may I irst of all express Iy condolences t0 the family aud fiieuds o Lamout Roper Ou thoughts and sympathies are much with them The MPS has acknowledged and reviewed all the matters of concern raised in YOur Regulation 28 Report and responds as follows Matter e Couceru L ~The Coroner recomends to tle MPS that thev consider whether there is Gny: alternative and less cumbersome water rescue equipment [to throw lines] that could be issues to officers on patrols near bodies of water, for example some sort of device that could be inflated quickly and thrown to the person in Ihe water I0 assist them in floating util a throw line is available MPS Respouse The MPS Marine Policing Unit ("MPU" ) are responsible for policing 47 miles of the River Thames in London between Dartford and Hampton Court: They also provide response t0 over 250 miles of waterways and other bodies of water across the rest of London such as lakes reservoirs and canals. ven]

METROPOLITAN Police As a 24/7 frontline policing Ulit; officers in tle MPU will face Iany of the samle situations as their landside colleagues such as crime and anti-social behaviour: COIUnity issues and security. They proactively patrol the river to derecr and prevent crime, maintain order and help keep London safe. Tley also respond to calls across Loudon where wate hazard exists: The MPU work closely with other agencies such as the Royal National Lifeboat Institutio RNLI ) London Fire Brigade (~LFB" ) Port of London Authority (PLA) UK Coastguard_ London Ambulance Service (LAS") Canal & River Trst and the Environment Agency (EA) If someone is in difficulty in the rivet, the LFB. RNLI o Coastguard will attend. The role Of the MPS dive team is t0 seareh and recove . it is defined by the following IWO areas: Searching: This is either searching underwater as of proactive deployment Or in a reactive capacity looking for discarded property Or evidence (for example Weapons) Recovery- An incident that has been declared as no longer rescue but body recovely. In response to the Coroner'$ matter of concer, whilst it is not the responsibility of the MPS Marine Policing Uuit t0 rescue perSons who are in difficulty in water. officers Will seek t0 identify Water rescue equipment which is easily accessible when such spontaneous incidents arise Or when patrolling near bodies of water. This includes throw which are retained in every MPS marked emergency vehicle Iu addition: the MPS Public and Personal Safety Uuit (~PPSU" ) has scoped the CuTent marketplace to ascertaill if there are ay viable alternatives that would offer caliage Of water rescue equipment O1 the person. No product has currently been identified which would overcome the issues previously outlined. i.e; tle cumbersone product design weight that would have t0 be additionally faetored The PPSU will continue tO work- with stakeholders with responsibilities in water rescile, consider the viability il the Use of future (echuologies for Use by police officers i such ciCUIstances. Matter_ef Coucern 2 ~Ifthis HOt possible 1o source alternative water rescue equipment that can be carried by officers 0n cycle patrol, then the family considers that the risks of patrols near bodies %f water outweighs the benefits: Tle Coroner a recommends the alternative that the MPS amends their policies and training t0 reflect the fact that patrols near bodies of water are potentially very dangerous more public pant lines. aId key ccle Gcle

METROPOLITAN POLICE s0 in the absence of water rescue equipment in these circumstances careful consideration to cOntinuing tle patrol will need to be undertaken at a senior level" . MPS Respouse The MPS Water Intervention Risk Assessment was Teviewed and updated at the end of 2021 to outline the risk water aud water ently pose. Additional measures iclude: Basic €Oland Units are t0 review their geographic areas iL Order t0 identify any Kown water related ass participation events activities With local risk assessments t0 be in place for identified events. Basic Command Units are to establish system management for the deployment; use and maintenance of thow Basic Command Units are to ensure officers are aware of locations of rescule aids life-saving equipeut whilst eusuring local brieling packages ate in place aud disseqinated tluoughout the Basic Command Unit, The circumstances of cycle patrol are the salle as those Of geleral patrol duties in that are hol planned taskings or operations Throw lines are now available in all marked emergency vehicles which Iitigates the risk of officers O foot O cycle patrols having ready access t0 this provision Officers either specifically tasked with patrols by bodies of water. Or part of planned operations. ale required to have throw line available to them This may extend to access fiOm a nearby vehicle Mutter_el Coucern z "The Coroner recommends for the MPS to implement a requirement for officers conducting pre- planned operations along stretches of a canal or other bodies of water to make themselves aware of the availability (or HOn-availability) of water rescue equipment in order for this to be factored into theiv ongoing dynamic assessment whilst on patrol MPS Response As above officers conducting pre-planned operations along bodies of water. are nOw required to have access [0 throw lines which is coVered in the MPS Water InterVention Risk Assessment Furthermore. in the most recent Public and Personal Safety Training (PPST' delivered t0 over 21,500 oflicers between April 2023 and October 2023. olficers Were required t0 view mandatory and thar ad lines: they nsk

METROPOLITAN POLICE video 0n the use of throw lines This video states that attendees must access and digest the infomation i1l Teadiness to be practically assessed at tleir *il person' PPST session PPST is assessed O1 a1 Oflicer'$ competence and ability to Ileet the leanling objectives tlerefore il a lealler failed to display comprehension of how to use throw lines. they would fail the session and then receive Teqedial training Which could include Leviewing the mandated footage again: Mater ef Concern ! ~The Coroner makes recomendation to the MPS to ensure that its officers are made aware the MPS dive team Can attend a critical incident involving someone submerged in water even when the ream are nol Ou call andor at night; and that this possibility should therefore be explored at an early stage. This mav be achieved by training (nd the publication of &n operational notice MPS Response The role of the MPS Dive Team is to search and recover. To support this the MPS has carried out a uuber of actions t0 upskill slaff in the Dive Team capacity aud provide awareness of the call out procedure In June 2022. au e-Iail was sent t0 all MPU oflicers conlining the Dive Team' $ capability and availability. An Open Water Rescue Recovery Guide has been produced and was sent t0 all MPU officers in December 2022 and published On1 the same date via the MPS Intranet (internal website) . This highlights the differeuce betweell Iescue aud recovely aud outliues the process for calling the Dive Teal It also provides tlle 24/7 telephone Huber O the Marine Unit Officer for advice_ All incidents involving people in a body of water is nOW brought to the attention of tle 24/7 Marine Unit Officer by the Incident Room The Marine Unit Duty Officer will review the incident and assess if there is possibility of a Dive Team call out during out of hours_ Discussions Will be had with the incident €Olander around the tactical options and implement any call out if required All current and new Met Grip Chief Inspectors (pan London Control supervisors) are briefed by the Dive Teal O1 theit capacity and call out procedure . The last course took place at the begilling of Septenber 2023 special Dury Duty Room

METROPOLITAN POLICE Until recently. all police inspectors' promotion training courses had Dive Team input to upskill new and current inspectors around capacity and call out procedure. From 2024. this mnput be incorporated into the new MPS Leader Programme Coverage of these areas furishes those in command of an incident involving any person in body of water. With knowledge of the MPS Dive Teams' capabilities and the process of call out: Matter_eL Couceru i "Tlie Coroner recowmends that [throw lines] must be available and issued to all MPS marked emergency vehicles MPS Response The MPS procured 4.000 tlow By June 2023 they were distributed to all Basic € Omand Units and placed in all MPS marked emergency vehicles. There is a requirement for front line vehicles to be inspeeted by local suppoit teams t0 ensure theit Suitability for Operatioual use as Well as expectations O the police driver to ensure the vehicle is Suitable for use and contains all mandatory equipment for patrol, ineluding a throw line: Mater ef Couceru 6 Tlie Coroner makes recowmendation that steps should be taken to increase the nbers 0f qualified divers available to _ I0 assist With the respond t0 an incident MPS Response Other agencies. such &s the RNLL LFB ald the UK Coastguard have the relevant expertise aud responsibilities in water rescue. The MPS Dive are all MPU officers who have received more general MPU training then chosen to specialise as police divers. The team are commercially endorsed divers. licensed search officers and are trained t0 i confined spaces and hazardous enviroments. Their responsibilities range ffOm crime searches t0 body recovery. The MPS Taskforce Command constantly review and assess team sizes based On the threat, harm and risk balanced With the demand At this tille, the assesSment is that there iS sufficient police dive Team capaclty t0 meet Its demand Will alat lines safe police Team and operate

METROPOLITAN Us POLICE Malter_eL Couce - "Tle Covoner recowmends I0 the MPS thar provide specific raining about cycling; whether during a pursuit O1" otherwise, near to bodies 0f water in paiticular as there is & serious risk of funure deaths OccuTing aS @ result of MPS cycle patrols and pursuits "p to HJmph [on electrIc cycles] near bodies 0f water: Ihe Coroner recommends that spectfic_ polcies are tramg are place t0 ensure that such pursuits are undertaken safely and in & manner such &S f0 mitigate r7skS 0f accidents o1" injut)' MPS Response Following this incident; at the beginning f 2022 the MPS reviewed and refreshed irs cycle taining and now maintains training and resourcing records, for the deployment of otticers and staff who hare Teceived this training. From April 2023 , officers and staff are nor permitted to cycle operationally without this cuTent training Traing 15 delivered locally by trainers who have attended Central Tramler ; Course OH each Basic Command Unit Operational Command Unir who in MIm) Will train their officers and statf, The training incldes specific input abont pursulits and an Inderstanding of the MPS Pursuits Srandard Operating Procedures is covered as part of the cycle - tnining: Advice t0 officers and staff near t0 bodies of water IS covered in the MPS patrolling risk assessments. Please do nor hesitare ro conract me shonld you require fither information from the MPS Yours silCerely Tke put using cycles
Sent To
  • Metropolitan Police Service
Response Status
Linked responses 1 of 1
56-Day Deadline 25 Dec 2023
All responses received
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Source: Courts and Tribunals Judiciary

Report Sections
Investigation and Inquest
On 8th October 2020 I commenced an investigation into the death of Lamont Ashley Roper. The investigation concluded at the end of the inquest held on the 22nd November 2021. The medical cause of death was 1(a) consistent with drowning. The conclusion of the Jury at the inquest was:-
1. Non compliance with stop and search request.
2. Inadequate recourses for water rescue along the canal and Lock 19.
3. Lack of sufficient police resources.
4. Lack of specialised on call rescue team (ie Divers).
Circumstances of the Death
Mr Roper was found dead at the bottom of Lock 17 after entering the water the previous night. Mr Roper entered the water after an initial cycling pursuit along the tow path between Marksfield Park and Lock 17. Mr Roper was issued with a stop and search request which was ignored. Mr Roper then had a struggle with a police officer after falling off his bicycle adjacent to Lock 17. The Struggle continued at the railings closest to the canal, and after a brief time the police officer shouted “GO GO” and released Mr Roper who shortly afterwards fell into the canal.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.