Dear Mrs Louise Hunt (HM Senior Coroner), Regulation 28 Report – Mr Trevor Smith I write on behalf of the College of Policing (the College) in relation to paragraph 7, Schedule 5 of the Coroners and Justice Act 2009, and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, prevention of future death report to the College dated the 17th November
2021. The report sets out two primary concerns that arose from the information received during the inquest into the death of Mr Trevor Smith. I was very sorry to read of the circumstances of Mr Smith’s death. My sympathies are with his family and friends and I share your commitment to addressing the concerns that you raise. The College is the independent professional body supporting everyone working in policing to reduce crime and keep people safe. The College has three complimentary functions;
• Sharing knowledge and good practice: creating and maintaining easy access to knowledge, disseminating good practice, and facilitating the sharing of what works
• Setting standards: setting standards for key areas of policing which help forces and individuals provide consistency and better service for the public

• Supporting professional development: setting requirements, accrediting, quality assuring and delivering learning and professional development, promoting diversity and wellbeing, and helping to nurture and select leaders at all levels.

The first concern raised in the report relates to the MARAC process undertaken by West Midlands police, and specifically that potentially significant information disclosed at a meeting to discuss Mr Smith was not effectively cascaded to the SIO or firearms team prior to the policing operation to arrest him. I understand that West Midlands police has provided a response to your concern. Police forces implement localised policies and practice in terms of the recording and dissemination of information and intelligence. The College Authorised Professional Practice for Armed Policing (APP-AP) Armed policing (college.police.uk) provides guidance to firearms commanders in respect of information and intelligence gathering, and the importance of considering the potential that the subject of an operation may be emotionally or mentally distressed. I consider the relevant APP-AP content to be appropriate. My Armed Policing Team has, however, agreed with the National Police Chiefs’ Council (NPCC) portfolio lead for armed policing (Chief Constable Simon Chesterman), to publish a national circular for dissemination to chief officers. The intention is that the circular, which will be sent out imminently, will raise awareness of both of your concerns and will recommend that forces consider local policy and practice in respect of recording and sharing information disclosed during the MARAC process.

Your second concern relates to the provision of CPR to Mr Smith and your report states: The evidence at the inquest confirmed that officers appeared confused about the need for rescue breaths to be given to Mr Smith during resuscitation. The inquest also heard how appointing one person to coordinate the resuscitation (if there are sufficient personnel) would have been of benefit. Consideration should be given to amending policies, procedures and training to ensure one person is allocated to coordinate CPR if it is required. The College licences the First Aid Learning Programme (FALP) used by Home Office Forces, including West Midlands Police. The programme is endorsed by the NPCC and the Health and Safety Executive (HSE). The College is responsible for ensuring appropriate quality assurance processes are in place to guide forces in the implementation of the HSE guidelines relating to the provision of first aid. The requirement in respect of first aid training provided to armed officers is included in the National Police Firearms Training Curriculum (NPFTC). Armed officers receive an enhanced level of training to deal with ballistic injuries and other first aid interventions that may be required during an armed deployment, or indeed any other incident.

While the College sets the required learning standards to be achieved by armed officers, the training to support these outcomes is developed and delivered under local ‘clinical governance’ arrangements. This ensures the appropriate clinical expertise, and the currency and credibility of the first aid interventions that are included. The first aid training delivered to armed officers also has to be delivered within the context of armed operations to ensure its relevance to operational situations. Armed officers must receive first aid refresher training every year, during which they are assessed for their continued competence. The national training and policy do not currently include or mandate the appointment of a CPR or first aid coordinator. Depending on their role and deployment profile, armed officers may deploy in pairs or relatively small numbers. During any incident that involves the use of force, and particularly the discharge of a police firearm, there may be a variety of tasks required of officers (e.g. to mitigate continued threat to the public or the preserve evidence at the scene). First aid provision will always be a primary consideration, however the number of officers, and/or other responsibilities, may impact the ability for a dedicated first aid or CPR coordinator to be identified. That said, I accept that it would be good practice, and there will be instances when it would be either necessary or achievable for a coordinator to be appointed. The APP-AP is regularly reviewed often in response to recommendation and investigation findings, and includes a requirement to prioritise medical assistance and some of the associated considerations for commanders. It was revised in May 2021, and the revised version contains additional guidance in respect of ensuring the prompt attendance of ambulance service staff in the event of police firearms discharge. This amendment was made in response to findings identified by the Independent Office for Police Conduct (IOPC) in their investigation into the fatal shooting of Mr Smith. I consider that the APP-AP already provides appropriate operational guidance. However I do feel that amendments to training could be considered. As a matter of course all coroner reports and inquests related to the provision of first aid by police officers is reviewed by the NPCC First Aid Forum as a standing agenda item. At the NPCC First Aid Forum meeting on the 9th December 2021 the chair raised the issue of establishing a ‘safety officer’ where, if possible, an officer at the scene might provide oversight for colleagues administering first aid. These discussions were not related to the inquest in question but in reflection of possible organisational learning from a similar role being considered for officer personal safety training, specifically when conducting restraint. There was broad support for the idea, and further discussions will take place at the next meeting on 25th March. As a result of your report, the issue of establishing a first aid (CPR) coordinator will also be raised formally as a substantive issue at this meeting. The concept of a coordinator for first aid provision has potentially wider application than armed policing and that wider application, and the policy and training considerations will be progressed by the NPCC First Aid Forum to ensure that national standards and consistency are achieved.

The introduction of a new role will require clear guidance on the responsibilities to be discharged by an officer performing the role and consideration of any additional training requirements. As I have previously indicated the national circular will however raise awareness of your concerns so that forces can consider a coordinator role in appropriate circumstances while the associated national guidance and training is considered. The College works proactively with forces, the NPCC and other agencies to raise standards of practice in the care of people who come to police attention. We would like to thank you for bringing the circumstances of Mr Smith’s death to our attention so that we can ensure that our immediate and future work is informed by the events that culminated in his death.

Dear Mrs Louise Hunt (HM Senior Coroner), Regulation 28 Report to Prevent Future Deaths. I am writing in relation to the above report that the Coroner's Office commissioned on the 17th November 2021. This report was commissioned as a result of the investigation and inquest into the death of Mr Trevor Alton Smith. Outlined within the report is matters of concerns raised by the Coroner's Office, which has been noted as a risk that future deaths will occur unless action is taken. This letter addresses the concerns highlighted detailing the action taken, or proposed to be taken, setting out the timetable for action. Recommendation one: MARAC Information With regard to concerns raised on MARAC, our response is detailed below. It should be noted that at the time that this MARAC meeting took place on 12th March 2019, WMP had no role in the coordination or administration of Solihull's MARAC meetings. The agency responsible for minute-taking and coordination in this case was Coventry Haven, who were commissioned to perform this duty up until the 31 st March 2019, two weeks after the MARAC meeting in question took place. It was after this time that WMP took responsibility for the coordination and administration of all seven local authority areas, including Solihull, from 1 st April 2019. At the time that the meeting involving Mr Smith was taking place, in an unrelated but extremely timely and relevant piece of work, the regional MARAC process was being revised ready for WMP to take over as one regional function. The centralisation of the MARAC function in this way, along with the introduction of trained minute takers, MARAC Coordinators and one regional lead, meant that many of the issues identified in this case were coincidentally already beginning to be addressed before Mr Smith was killed. Sadly, there was no possibility these improvements could have impacted this particular MARAC case.

With regard to the specific concerns raised by H.M Coroner our responses are as follows: Concern: It was likely that the mental health agency in question shared specific information at the MARAC meeting which was not then recorded. Response: All MARAC agencies are encouraged to submit written copies of their intended MARAC updates in advance. Whilst the primary reason for this is to improve the pace of the meeting from a minuting perspective, there is a natural benefit in that a record of submission is available alongside a record of the conversation itself. Further, all MARAC agencies are offered guidance and support from their local MARAC Coordinator around how best to engage with and prepare for the MARAC process. Whilst we cannot govern every single piece of data which comes into the process, we do seek to ensure that partners researching cases have the best understanding possible to ensure the information is relevant and appropriate. Partner agencies must take responsibility thereafter for what is submitted and how it is presented in the meeting. Concern: Information shared at the meeting was not properly minuted, or not minuted at all. Response: Since taking over responsibility for minuting MARAC meetings from 1st April 2019, WMP has recruited and trained a team of six dedicated minute takers who are experienced in the role and well-supported by supervision. As of summer 2021, MARAC minutes have been subject to regular dip samples and audits to ensure the continued improvement of staff involved in the recording process. In addition to this, partner engagement with the MARAC process has improved significantly, with open communication channels for any challenge regarding the quality of minutes. Further, WMP is committed to the continued improvement and development of staff in the minute-taking role, including ongoing auditing and dip-sampling around quality of recording. Concern: The information shared at the MARAC meeting was not shared with the S10 of the Firearms Team. Response: All MARAC Chairs are aware that there may be a need to share MARAC information more widely than via the MARAC minutes alone. They are encouraged to set specific actions around this if a risk has been identified whereby the MARAC minutes being shared alone will not suffice. However, as all MARAC information is recorded on a system separate to Connect, which is where the vast majority of Police information is stored, this impacts upon transparency and speed of information sharing. Further, at the current time WMP is reviewing how existing links between the MARAC system and wider WMP systems and departments can be improved in order to more promptly, and confidently, capture and record key information around warning markers and significant MARAC information. Concern: There is no clear process for ensuring relevant information is cascaded to officers involved in MARAC cases. Response: In cases where there is an Officer in the Case (OIC), MARAC staff are set actions to share documents with them in order that information relevant to triggers, risks, warning markers etc may be properly recorded by the officer. In cases with there is no allocated OIC, the same steps are taken directly with the relevant supervision.

Concern: There is no clear guidance or process for accurately recording information at MARAC by WMP. Response: There is a regional MARAC Operating Protocol which has been in place since 1 st April 2019. It governs WMP and wider agency engagement with the MARAC process and offers clear guidance on what is expected of them and what they can expect of Information Sharing within the process. Further, the MARAC Coordination team are responsible for ongoing MARAC training across the region which ensures that partners engaging with the process have staff trained and prepared to do so. In addition all MARAC minute takers are intensively trained when in role and are not permitted to take minutes alone until training is complete to the satisfaction of the local MARAC Coordinator. Recommendation two: CPR Coordinator With regard to concerns raised on D13 co-ordinator, our response is detailed below. D13 is the module in the National Police Firearms Training Curriculum (NPFTC) that focuses on the first aid procedures to be adopted by Authorised Firearms Officers (AFOs) and those that deliver firearms training. Enhanced training is provided to officers identified in a forces armed policing strategic threat and risk assessment. The module covers first aid and enhanced first aid. The Chief Firearms Instructor (CFI) and Head of Firearms Unit have reviewed the recommendation and the following actions have been carried out:
1. The CFI has contacted the College of Policing (Armed Policing Lead). is reviewing the recommendation and will review the National Police Firearms Training Curriculum (NPFTC) (as role is currently not included in Authorised Professional Practice - Armed Policing or the NPFTC) with consideration regarding the Operational Firearms Commander (OFC) role profile, and whether to include a recommendation for providing a D13 coordinator where operational circumstances allow. In the meantime West Midlands Police:
2. Have ensured that all Strategic and Tactical Firearms Commanders (S&TFCs), Operational Firearms Commanders (OFCs), Firearms Tactical Advisers (FTAs) and all Authorised Firearms Officers (AFOs) are aware of this recommendation. All officers have been reminded of the importance of nominating a CPR coordinator where resources allow. There may be circumstances where the operational need and level of resourcing at an incident do not allow an officer to perform the role of coordinator. This will be a dynamic assessment for the officers at the scene. All team briefing sheets have been updated and version controlled and now include reference to the coordinator role. These briefing sheets are used as a template in firearms briefings which are recorded. Medical Plan The Medical Plan details actions to be completed when medical care is required, and the location of available equipment and now includes the following direction regarding the co­ ordination of care. Nominated Medics are all D13 trained and can assist.

Medical equipment will be stored at the most tactical advantageous position having considered the tactical ground assessment. Where deployments require officers to be away from their support vehicle, medical equipment should be taken to the most appropriate location i.e. in a high rise block this maybe on the landing of the subject address. In instances where tactical medical care is being delivered, officers are reminded of the benefit of a co-ordinator being identified to oversee the effective delivery of care. Where resources allow, one person should take on the role of co-ordinating the response. This may not always be possible due to numbers of officers deployed/engaged in an incident. Where a co-ordinator has been identified, they would normally fall under the direction of the OFC, but it is accepted that the OFC may be otherwise engaged elsewhere in the incident. Any co-ordinator will act in accordance with their D13 training. Chief Constable