Dear Ms Hassell I am the Deputy Assistant Commissioner for the Directorate of Professional Standards in the Metropolitan Police Service (“MPS”). On behalf of the Commissioner of Police of the Metropolis, I write to provide the response to the matters of concern addressed to the MPS following the inquest into the death of Mr Emmanuel Seisay and your Report to Prevent Future Deaths dated 5 July 2023. On behalf of the MPS may I express my sincere condolences to the family and friends of Mr Emmanuel Seisay, our thoughts and sympathies are very much with them. The Coroner’s “Matters of Concern” The Prevention of Future Deaths report dated 5 July 2023 records:- “There were two other aspects of the resuscitation that I want to bring to your attention to help with organisational learning.

1. What was particularly challenging for the officers was knowing when to move Mr Seisay to the floor and when to commence CPR.

Mr Seisay was in peri arrest/arrest for probably around three and a half minutes before CPR was commenced. Although earlier CPR would not have changed the outcome for him, it might for another casualty. The intensive care consultant giving evidence at inquest articulated his view of the point at which Mr Seisay was in peri arrest. He recognised that this was a difficult call to make, but told me that if in doubt about such an arrest situation, first aiders should move straight to CPR.

I am aware of the work the MPS has undertaken to improve the first aid training of its front line officers. The recognition of the deteriorating patient is notoriously difficult, sometimes even in a hospital setting. However, given that it is a difficulty I have seen recur for the MPS, it seems to me that it would benefit from further consideration.

MPS Response

Since this incident in March 2021, the MPS has introduced the following changes to the MPS Emergency Life Support (ELS) training, which will assist in reducing any delays in administering CPR.

• The introduction of the trapezius muscle squeeze when checking for a response in order to ensure an accurate response level is established. Additionally the changing of the term unresponsive to unconscious to ensure there is no confusion when informing the London Ambulance Service of the response level.

• Since June 2021, it is mandatory for all officers to complete an agonal breathing digital package which assists in identifying breathing that is not normal and to commence CPR more quickly.

• The introduction of the jaw thrust manoeuvre as standard to open an airway when breathing is noisy, and for a casualty to be maintained on their back with a jaw thrust manoeuvre applied until medical help arrives. The recovery position is only to be used to clear fluid from the airway. Where a jaw thrust manoeuvre does not clear noisy breathing, CPR is commenced immediately.

2. Whilst the officers worked well as a team in many respects, it seemed to me that there could have been more focus on pro-active support from those not directly monitoring Mr Seisay’s vital signs. I heard at inquest about the MPS training to speak up, speak out in such a situation.

I know that the MPS trains on the value of a helicopter view from a secondary safety officer. However, it seemed to me that this was not completely embedded within the frame of reference of the officers attending. It is not about criticism of one’s colleagues, it is about remaining active in the resuscitation. I am wary of recommending a counsel of perfection but, as this is an issue I have observed on previous occasions, I feel I would be failing in my duty if I did not raise it with you.

MPS Response

In April 2024, the MPS will be introducing the “first aid safety officer” as part of the annual first aid training cycle, which all officers are required to attend. This role is for when there are a number of officers dealing with a casualty, one officer steps back and takes an overview of the first aid delivery and requirement and ensures that all checks and monitoring are completed.

In May 2023, the National Police Chief Council endorsed recommendations from its First Aid Forum’s review following the Manchester Arena public inquiry. This increased ELS Module 2 training from 9-12 hours (and increased refresher training by 2 hours). This training will introduce techniques such as the ‘jaw thrust’ and also provide more practical scenario-based drills with the aim of improving officers’ confidence in dealing with casualty situations. The MPS will start to deliver this additional training from April 2024.

Please do not hesitate to contact me should you have any queries.