Derriford Park, Derriford Business Park; Plymouth, PL6 5QZ Tel 01752 204636 Fax 99, Ilion end daling May May

Ambulance Doors When ambulances are stationary ambulance doors cannot be locked to prevent egress from inside the vehicle_ This may affect police containment preparations when police officers are escorting individuals for the purposes of Section 136 of the Mental Health Act ACTION SHOULD BE TAKEN In my opinion action should be taken t0 prevent future deaths and believe you have the power to take such action; Please review how best that information at paragraph 5 of this Report may be shared and appropriate awareness andlor training provided Your RESPONSE You are under a duty t0 respond to this report within 56 days of the date of Ihis report, namely by 11 December 2018. !, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION have sent a copy of my report to the Chief Coroner and t0 the following Interested Persons: all interested parties at the Inquest, Tamar Bridge Aulhority. have also sent it to the Home Secretary and Secretary of State for Health; who may find it useful or of interest; am also under a duty to send the Chief Coroner a copy of your response The Chief Coroner may publish either or both in a complele or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations t0 me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner; Dated 19 October 2018 Signature Senior Coroner for Plymnouth; Torbay and South Devon Derriford Purk Derriford Busincss Park; Plymouth, PL6 5Q2 Tel 01752 204636 Fax