Dear Ms. Hassell, Re: Inquest touching the death of Rashan Charles Response_to Prevention of_Future Deaths Report am the Deputy Assistant Commissioner for Professionalism in the Metropolitan Police Service (MPS): write in response to your Regulation 28 Report to Prevent Future Deaths dated 29th June 2018_ Your report was initially sent to Deputy Assistant Commissioner Matt Twist following the conclusion of the inquest into the death of Mr Rashan Charles note that the medical cause of Mr Charles' death was recorded on 20th June 2018 as: Ia) cardiac arrest; 1b) upper airway obstruction by a foreign body during a period of restraint; In your Report, you made raised the following matters of concern: An apparent struggle to resist search or arrest; might in fact be a struggle to breathe, or might become that;
2. Choking is not always accompanied by classic signs such as clutching the throat; coughing, red face or bulging eyes, but can be silent and very quick;
3. It can be extremely difficult to assess whether breathing is present and normal, particularly in a stressful andlor noisy situation: (I heard evidence that; for training purposes; abnormal breathing could possibly in future be simulated by a virtual reality programme:)

Members of the public can sometimes give vital assistance, but this assistance might need to be managed: You further stated that "analysis of a situation by a member of the public might give helpful insight; but on the other hand might not be accurate. Even a single member of the public might unwittingly distract an officer, especially in fast-paced environment: heard evidence that; at present; MPS training does not include specific advice about how best to utilise members of the public who are willing and able to assist police officers". In drafting our response we have consulted with the relevant subject matter experts: MPS Medical Director, HQ Strategic Health & Safety; Inspector Officer Safety and the College of Policing: The College of Policing set the First Aid Learning programme (Appendix A) for police forces of England and Wales: This has the approval of the National Police Chiefs Council (NPCC) and the Health and Safety Executive (HSE): Response_to Matters of Concern respond to your Report as follows: An apparent struggle to resist search or arrest; might in fact be a struggle to breathe, or might become that: The possibility that an apparent struggle or resistance might mask medical emergency is firmly established within the MPS' Emergency Life Support (ELS) training: It is central to training concerning positional asphyxia and Acute Behavioural Disturbance. It has also informed the MPS' review of guidelines associated with restraint positions. Current work is focusing upon tilting the subject's head forward to help reduce the risk of concealed objects falling into the airway and causing choking_ The revised guidance is currently being peer-reviewed prior to adoption by the MPS The findings will be shared with the College of Policing to help ensure best practice across England and Wales_ The careful assessment of a subject's breathing features in one of the training scenarios within the 2018 2019 ELS training package_ The scenario requires an assessment of a subjects breathing, and them being re-positioned to assist breathing: The scenario then develops to breathing and onto the delivery of cardiopulmonary resuscitation (CPR): Choking is not always accompanied by classic signs such as clutching the throat; coughing, red face or bulging eyes, but can be silent and very quick The MPS ELS training is delivered in accordance with the College of Policing First Aid Programme Specification ("the Programme Specification'): This mandates the content 2 noisy

of the first aid programme and the frequency with which elements of the curriculum should be delivered by police forces of England & Wales. The Programme Specification states in respect of choking: "An airway obstruction can be recognised by difficulty speaking, attempts to breathe or cough, increasing signs of asphyxia (blueness discolouration to face) and eventual loss of consciousness: Therefore, it is therefore made clear that individuals who are choking may not be able to breathe or cough: Training on the signs and symptoms and the treatment of choking is included in the initial training delivered to new recruits. It is then included in refresher training in a three yearly cycle: It will next be covered in the 2019/ 2020 training cycle. Where the subject is not showing any of these classic signs the fact that they are not breathing, or are experiencing difficulty breathing should be identified by the breathing check. This aspect of first aid training is covered below_ 3_ It can be extremely difficult to assess whether breathing is present and normal, particularly in a stressful andlor noisy situation_ The importance of completing a thorough breathing check and regularly monitoring subject's breathing is central to ELS training: The training states that if breathing cannot be established because subject is in the recovery position, they should be turned onto their back to facilitate a full breathing check: It further states that CPR should be commenced if there is any doubt_ Under current training; when completing an initial assessment of a subjects breathing, the check includes: Not breathing Not breathing normally, and Not sure_ The ELS training advises the following depending on the outcome of the breathing check: snoring may not be normal breathing, especially if drugs and alcohol are involved i.e. it may be due to partial airway obstruction. When subject appears to be snoring, officers are to attempt to rouse them. If the snoring is because the subject is asleep, will rouse. If the subject is roused, their snoring stops and appear to be breathing normally, then their breathing should continue be monitored_ b If the subject is roused but the snoring continues their breathing should be checked carefully: If the subject does not respond, their airway should be opened. If still do not respond, are not breathing normally, or the first aider is unsure, then CPR should be commenced. they they they they

Members of the public can sometimes give vital assistance , but this assistance might need to be managed. The potential value of bystanders in dealing with casualties is recognised within the training given to officers and is explored with various scenarios_ These include assisting in placing a subject into the spinal recovery position , crash helmet removal and the delivery of CPR However, due to the variety of potential situations combined with differences in their background, training and skills, it is not possible to be prescriptive about how bystanders may be best utilised. Instead, officers are expected make informed decisions based on the continual assessment & review of the specific circumstances of the incident through the application of the National Decision Model (Figure 1) "Gather nlo:ton and Inlelligenee Nake#dtiona Assess threat and andnvewen Tisk and develop # happened Code working stralegy 0f Ethics Docn yoplonsand Consider powersand conngendies polly Figure 1: College of Policing: National Decision Model Itis emphasised that bystanders should only be given tasks appropriate to any training or skills they might have and that cannot take responsibility for casualties unless are medical professionals with the training for such events_ Conclusion The MPS has recommended changes to the Personal Safety Manual;, Module 12 'Management of Persons Suspected of Concealing Items in Mouth', now requires that where they they

possible the subjects head should be tilted forward thereby reducing the risk of any objects falling into the airway and causing choking: The MPS recognises the importance of effective first aid training to support its officers who may be required to administer first aid. First aid training of MPS officers is the remit of MPS Senior First Aid Advisor, s also Chair of the National Police First Aid Forum. The MPS continues to have leading role in ther review and refinement of existing techniques and practices and acknowledges that this remains a continual learning process.