In the Matter of the Death of Mr Jason Basalat Response of the Chief Constable of Northamptonshire Police pursuant to Regulation 29 of the Coroners (Investigations) Rules 2013 1 Preamble
1.1 The Chief Constable makes this response to the Coroner'$ Report dated the 27th November 2017 and issued under the provisions of Regulation 28 of the Coroners (Investigations) Rules
2013.
1.2 The original date for providing a response was the 22nd January 2018,but this date was extended by HM Coroner to the 6th April 2018 to allow the Chief Constable to receive copies of the documents and evidence considered by the Inquest and also recordings of the Inquest proceedings, no transcript being available:
1.3 The Chief Constable in making this response notwithstanding:
1.3.1 the surprising decision of the Coroner, in the context of an Article 2 inquest into the death of Mr Basalat while in the custody of the State and two after he had been in the custody of the police, not to give formal notice to the Chief Constable as properly interested person as required by Regulation 20 (2) (h) of the Coroners Rules 1984 at the commencement of the Coroner' $ investigations; or
1.3.2 thereafter, not to give such notice when the issue of events in and flowing from police custody were raised at the Pre Inquest Review on the 20th June 2017 by Counsel for the family; or
1.3.3 thereafter, when the issue was specifically raised by Counsel for the Prison Service on the first of the Inquest hearing; or
1.3.4 thereafter, when the Coroner himself identified, during questioning of the only police witness called by the Coroner to give evidence on the first of the Inquest hearing that he was not competent to deal with all the areas of questioning posed by Counsel for the family, specifically as to police custody practice and procedure; or
1.3.5 in any event at the point when the Coroner decided that the inquest jury should be specifically asked to consider whether the actions or omissions of Northamptonshire Police had caused or contributed to the cause of death:
1.4 The Chief Constable has considered his position and taken the view that he will not challenge the findings of the inquest on the basis that this would, in all likelihood, result in a requirement for a further inquest to be held and that this would be unfair to the family of Mr Basalat: days day day

1.5 Accordingly, the Chief Constable responds to the report as follows, but has also, where necessary, makes reference to matters which do not appear to have been made known to or considered by the Inquest hearing: 2 Terms of Response Required
2.1 In accordance with the terms of the Report issued by the Coroner, this response addresses the following areas of concern:
2.1.1 "(1) deceased had been arrested for Dangerous Driving when, on the 9th December 2016, he tried to grab the steering wheel of bus travelling on the M1 motorway forcing it to collide with the barriers in the roadworks. Whilst in police custody the deceased was behaving in a bizarre manner and was assessed by a medical practitioner at the custody centre. When eventually transferred to Woodhill Prison after appearing on a Saturday Morning at Wellingborough Magistrates Court the warrant simply stated that the offence was "Dangerous Driving" Which did not in way give a true picture of the offence and very little information was provided to the prison as to his behaviour or his mental state. The prison informed me that it would have been helpful for them to receive a copy of the deceased' $ custody record that gave the full picture_
2.1.2 Point (2) appears to relate solely to the procedure before the Magistrates' Court and is not addressed in this response_
2.1.3 "(3) There needs to be an urgent review by both the Northamptonshire Police and the Northamptonshire Magistrates' Court as to their procedures for sharing information with the prison when it is known in advance that the prison will receive a vulnerable prisoner. 3 Background
3.1 Arrest
3.1.1 Mr Basalat was arrested on the 9th December 2016, following a report to the police that a coach had crashed on the M1 motorway: Officers attended and were told that Mr Basalat had seized the steering wheel of the coach and turned it towards a temporary barrier, causing it to collide
3.1.2 Witnesses on the coach told the police that, prior to the incident; Mr Basalat had been talking to himself:
3.1.3 Mr Basalat was arrested on suspicion of having committed an offence of common assault on the coach driver. The any

3.1.4 Mr Basalat was conveyed to the custody suite at the Northampton Criminal Justice Centre.
3.2 Detention
3.2.1 Mr Basalat arrived at the custody suite at 06.35 hours on the 9th December 2016_
3.2.2 His detention was authorised at 07.07 by Sergeant The circumstances of arrest given to Sergeant] are stated as: 'DP [i.e Detained Person] was travelling on a National Express Coach on the M1 when he approached the driver, grabbed hold of the steering wheel, pushed it to the left forcing the coach to collide with the barrier bringing the coach to a stop' Detention was authorised for the purposes of securing and preserving evidence by questioning:
3.2.3 Sergeant kconducted a risk assessment of Mr Basalat at 07.13. risk assessment involved firstly asking Mr Basalat a set of pre-determined questions (the Inquest had before it a copy of the custody questions and they are not repeated here): In answer to the questions, Mr Basalat confirmed the following:
3.2.3.1 he hit his head hard in the accident that morning;
3.2.3.2 he was prescribed alanzapine and diloxatine but had none with him;
3.2.2.3 he suffered from paranoid schizophrenia and was supposed to be medicated, that he came out of hospital yesterday Edinburgh main hospital for mental health;
3.2.3.4 he had tried to harm himself lots of times, the last occasion a year ag0 when he head butted a wall and that he did not feel good at the moment;
3.2.3.5 he was alcohol dependent and hallucinates when he had not had a drink, the last occasion being 5 previously;
3.2.3.6 he needed to see a doctor and that it had been difficult for him to get out of the hospital and he had not told them the truth:
3.2.4 As a result of that process, Sergeant Pateman arranged for a Healthcare Professional to examine Mr Basalat:
3.2.5 At 07.24, Sergeant as a result of the risk assessment, determined that Mr Basalat' s risk to himself should be viewed as medium He was placed in a CCTV monitored cell and was to be visited 30 minutes and roused, because of concerns about his head injury: This regime was to remain in place until he was seen by a Healthcare Professional:
3.2.6 At 07.25, Mr Basalat'$ property and any item of clothing which might be used to self harm was removed from him
3.2.7 At 07.50, Sergeanth Ispoke to the Healthcare Professional; in relation to Mr Basalat. The days every

3.2.8 At 09.07, Community Psychiatric Nurset (Day examined Mr Basalt in a consultation which lasted 28 minutes She noted the following: "Alert, able to mobilise, speech spontaneous, coherent; normal rate; tone and volume_ Engaged well in conversation, thought process was fluid and easy to follow, content remained within context. No evidence of distracted by or responding to unknown stimuli: No psychomotor agitation or impairment Reported hearing and speaking to people but no evidence of this. Denied alcohol/substance use, denied taking medication_
3.2.9 Community Psychiatric Nurset [Day also made contact with the practice in Edinburgh where Mr Basalat had been treated the following day and noted the following at 11.29: "Discussed with Edinburgh Access Practice and the CPN attached to the homeless team who the DP is open to Diagnosed with dissocial personality disorder. Assessed under MHA assessment last night, no psychotic features, no suicidal tendencies, deemed fit to return to hostel and engage with CPN: Diagnosis of Pulmonary Embolism confirmed.
3.2.10 Nurse confirmed that Mr Basalat was fit to detain and fit to be interviewed.
3.2.11 Mr Basalat was interviewed under caution by Mr Basalat was represented by a solicitor and an appropriate adult_ Mr Basalat was additionally arrested for the offences of Criminal Damage with intent to endanger life and Dangerous Driving: Mr Basalat gave a pre-prepared statement: At 17.35 Mr Basalat returned from interview:
3.2.12 submitted a request to the Crown Prosecution Service for charging advice and the charge of Dangerous Driving was authorised. Mr Basalat was charged with the offence at 21.50. The form of the wording is prescribed.
3.2.13 Mr Basalat'$ further detention was authorised for him to appear before a remand court_
3.2.14 Throughout the period of his police detention, the detention was appropriately reviewed under the provisions of the Police and Criminal Evidence Act 1984 and Code of Practice C for the detention, treatment and questioning persons by police officers.
3.3 Transfer
3.3.1 Mr Basalat was released in to the custody of Geo Amey at 08.38 on the 10th December 2016.
3.3.2 In accordance with the Authorised Professional Practice promulgated by the College of Policing, a Person Escort Form was completed by
22.17 on the 9th December 2016.
3.3.3 The section of the form headed 'Current and Relevant Risk' was not completed: being Day charge

3.3.4 The section of the form headed 'Health Risks' contained the following information under heading of 'Details of Current & Relevant Risk' :
3.3.4.1 "Medication _ Alanzapine and Diloxatine"
3.3.4.2 "Hit Head in Accident 09/12/2016"
3.3.4.3 "Alcoholic" =
3.3.4.4 "Paranoid Schizophrenia and
3.3.4.5 "S/Harms"
3.4 Police National Computer A check of the Police National Computer has shown that there were no warning markers to indicate that he had previously been considered to be at risk of self harm Response
4.1 As to: "(1) The deceased had been arrested for Dangerous Driving when, on the 9th December 2016, he tried to the steering wheel of bus travelling on the MI motorway forcing it to collide with the barriers in the roadworks. Whilst in police custody the deceased was behaving in a bizarre manner and was assessed by a medical practitioner at the custody centre. When eventually transferred to Woodhill Prison after appearing on a Saturday Morning at Wellingborough Magistrates Court the warrant simply stated that the offence was "Dangerous Driving" Which did not in any way give a true picture of the offence and very little information was provided to the prison as to his behaviour or his mental state. prison informed me that it would have been helpful for them to receive a copy of the deceased'$ custody record that gave the full picture
4.2 As this particular concern appears to be made up of a number of discrete issues, have been dealt with as separate matters as follows below, to avoid confusion:
4.3 The format of the charge of Dangerous Driving is prescribed by a national code to ensure a consistency of approach. The purpose of a charge is to provide an accused person with sufficient information about the nature of the charge laid against them to enable them to determine whether or not to admit or It will not contain a narrative or summary of the evidence supporting the charge; that information falls to be disclosed in the course of any subsequent proceedings
4.4 The standard offence wording for an offence of Dangerous Driving is as follows: On **(.SPECIFY DATE: ) at **(_SPECIFY TOWNSHIP ) drove a mechanically propelled vehicle, namely **(_SPECIFY VEHICLE MAKE AND INDEX NUMBER.) dangerously on (A)_[a road,]_ (B)_[roads,]_ grab The they deny guilt:

(C)_[a public place;]_ namely **(.SPECIFY ROAD/ROADS/PLACE/PLACES_)
4.5 Accordingly, the terms of the charge laid in Mr Basalat'$ case was in accordance with the national standard.
4.6 The format of the Warrant of Remand is not a matter for the police and the Chief Constable makes no comment on that
4.7 The Custody Record is a document which the police are required to maintain to record certain decisions made pursuant to section 37 of the Police and Criminal Evidence Act 1984 and paragraph 2.1 of Code of Practice C referred to above_
4.8 Paragraph 2.3 of the Code of Practice states as follows: "2.3 The custody officer is responsible for the custody record's accuracy and completeness and for making sure the record or copy of the record accompanies a detainee if are transferred to another police station: The record shall show the: time and reason for transfer; time a person is released from detention. (emphasis addedl
4.9 The purpose of a Custody Record is not to record information in relation to the course of a criminal investigation or the evidence gathered; it is a record of the treatment ofa detained person while in police custody: It will not; therefore, give a 'full' picture_
4.10 Custody records are electronic documents. are not ordinarily printed out to accompany a detained person on transfer to court: This is SO even when there is to be an application for a remand into custody: However, see below at paragraphs 4.14 et seq in relation to the guidance set out in the College of Policing's Authorised Professional Practice
4.11 As to: "(3) There needs to be an urgent review by both the Northamptonshire Police and the Northamptonshire Magistrates Court as to their procedures for sharing information with the prison when it is known in advance that the prison will receive a vulnerable prisoner:
4.12 Following receipt of the Coroner's Report, a review of the circumstances of Mr Basalat'$ case was conducted and considered against existing procedures. Following the provision of the witness and documentary evidence referred to in the Inquest Hearing, that review was revisited to ascertain whether any additional matters required scrutiny:
4.13 Northamptonshire Police adopts the College of Policing Authorised Professional Practice for Detention and Custody: All custody staff are trained in accordance with it and are able to access it online in the event of query: A copy of the section on Risk Assessment is appended to this response.
4.14 Within the section on Risk Assessment; guidance is given in relation to the use of the Person Escort Form as follows: issue. they They

"Person escort record form The PER form provides staff transporting and receiving detainees with all necessary information. This includes any risks or vulnerabilities that the person may present: Officers must complete a PER form whenever a detainee is escorted police station to another location: This includes movement or transfer between separate custody suites (police stations) and other custody accommodation (courts, prisons and immigration detention facilities) and from custody to hospital. Identifying a risk of suicide or self-harm is one of the prime purposes of the form. Staff must indicate both a current risk and any known past risks. PER form requirements Where the detainee is to be transferred from a station, the responsibility for the PER form lies with the first custody officer who becomes aware of the transfer. The form may be completed by a trained and competent custody detention officer, but responsibility for the form content and sign off remains with the custody officer: This reduces the risk of important information lost during any subsequent handovers between custody officers: It is the responsibility of the custody officer who transfers the detainee the police station to the escort to ensure that the PER is up to date and contains details of any additional post-charge or other care requirements_ Custody officers must provide supporting information when ticking a warning marker box Officers should attach copies of risk assessment forms and medical examination records that are not confidential to the PER. should also enter relevant information onto the PER in case any of the attached information is lost. Confidential medical information must be attached in a sealed envelope: Information relating to self-harm or suicide cannot be deemed confidential and should always be on the PER form: Staff should add a direct contact telephone number for the custody suite to the PER so that escort, court; probation or prison staff can make prompt contact with the custody officer should they need to clarify any information: The escorting staff are responsible for maintaining a record of the detainee'$ movements and any occurrences during transit
4.15 In this case, the content of the PER form is brief; but nonetheless lists the significant risk factors which had been identified during Mr Basalat'$ time in police custody. Medical examination and information from treating practice had not raised concerns of self harm_ Although no direct telephone number was provided for the custody suite, it was one of only two in Northamptonshire and Northamptonshire Police operates a 24 hour, 7 per week switchboard through which any enquiries could have been directed: from police being from They his day

4.16 However; the Chief Constable confirms that Custody officers and staff have been reminded of the guidance in relation to the completion of PER forms and in respect of ensuring any relevant additional documentation accompanies them:
4.17 Further, contact will be made with the national police lead on Custody to suggest a review of the PER form to ensure it reflects the guidance in the Authorised Professional Practice.

NORTHAMPTONSHIRE MAGISTRATES' COURTS RESPONSE TO HM CORONER'S REGULATION 28 REPORT TO PREVENT FUTURE DEATHS RE: MR JASON BASALAT INTRODUCTION On 27th November, 2017 Mr Osbourne, HM Senior Coroner for Milton Keynes, requested response from the Clerk to the Northamptonshire Magistrates' Court to his report to prevent future deaths made under paragraph 7 , Schedule 5,of the Coroners and Justice Act 2009 (the Act) and regulations 28 and 29ofthe Coroners (Investigations) Regulations 2013 arising from the death of Mr Jason Basalat: Her Majesty' $ Courts and Tribunals Service wish to place on record its concern that it was not identified as an interested party in accordance with Section 47 (1) (2) (f) or (m) of the Act or required to give or submit any evidence to the inquest into the death of Mr Basalat; in accordance with Section 32 and Paragraph 1 of Schedule 5 ofthe Act: This concern relates particularly to the first question put to the inquest jury that the courts service had failed to pass on information regarding the offence and concerns relating to Mr Basalat to the prison authorities and that that failure caused or contributed to his death_ BACKGROUND
3. Mr Basalat appeared in custody before the Northamptonshire Magistrates' Court sitting at Wellingborough on 10th December, 2016,a Saturday morning, charged with an allegation that on 9th December, 2016 he had driven a National Express coach on the M1 dangerously contrary to section 2 of the Road Traffic Act 1988. appeared on behalf of the Crown Prosecution Service and Nobles Solicitors, represented Mr Basalat: The legal adviser to the magistrates was Brief details of the offence were outlined to the court; who were also advised that, in respect of Mr Basalat's mental health, the all clear had been given by the police's doctor/mental health team: There were no concerns about Mr Basalat from the Community Psychiatric Nurse who had assessed him in custody the previous evening so a CPNI was not completed: The court determined that the matter was too serious to be heard in the magistrates' court and sent the matter to Northampton Crown Court for trial; Mr Basalat not having indicated a plea.

6. There was no application for bail and Mr Basalat was remanded in custody to appear before the Crown Court: The exceptions stated for refusing bail were that, Mr Basalat may failure to surrender to custody and may commit further offences on the grounds of the nature and seriousness of the charge, not for his own protection as stated in the Coroner's report (see copy record of bail decision appendix A): not knowing that Mr Basalat had been seen the previous evening by a CPN, tried to contact the CPN service but was not successful: remand warrant authorising Mr Basalat' s detention was issued to GeoAmey, the prisoner escort service a marker on the warrant indicating the prosecution's and defence'$ representations regarding Mr Basalat' $ mental health
8. A Person Escort Record form had been completed by the and have accompanied Mr Basalat. Subsequently, Mr Basalat was taken to HMP Woodhill where on 11th December, 2016 he was found hanging from his bed frame; he was taken to Milton Keynes hospital where his death was confirmed_
10. CORONER'S CONCERNS
11. Matters of Concern
12. "The warrant simply stated that the offence was "Dangerous Driving" . Which did not in any way give a true picture of the offence and very little information was provided to the prison as to his behaviour or mental state_
13. On a normal working day, any remand warrant would generally be generated by the court's computer system when the result is entered. This would state the full charge which would detail the date, place etc: of the offence; however, it would not outline how the offence was alleged to have been committed. At present, on a Saturday, as there are no support staff, the legal adviser manually generates the warrant and records only a brief description of the offence. This is normal practice; full details of the charge, in ay event as stated above, would not indicate the circumstances of the offence or any behaviour or mental health issues_ 14_ HMCTS is implementing an 'in-court' computer system which requires the legal adviser, rather than support staff; to enter the court result: This will generate a warrant with the full charge but will not include the circumstances of the offence. The put would police

15 did place marker on the warrant in relation to Mr Basalat' 5 mental health, unfortunately, although the legal adviser' $ contemporaneous notes, state; 'marker put on remand warrant for GeoAmy re: pros & def rep's re m health" unable, given the passage of time, to recall the details of that note: A copy ofthe warrant has been requested the Coroner's office but this has not been forthcoming: 16_ again as evidenced by her notes, did try and call in the Community Psychiatric Nurse Service to no avail. If she had been successful then the CPN's assessment, recorded on form CPNI would have been available to forward to the prison with the warrant: In any event a CPN had assessed Mr Basalat the previous evening and had not completed a CPNI because they had no concerns
17. The court did have in its possession a physical copy of the police form MGS which includes an outline of the circumstances of the offence by way of a summary of the evidence supported by the statements. It is not normal practice for this to be forwarded to the prison, consideration will be given at to whether it should be in the future see below
18. "The prison informed me that it would have been helpful for them to receive a copy of the deceased'$ custody record that gave the full picture =
19. This was not in the possession of the court and would not normally be police had completed a PER form.
20. "When the deceased appeared before the magistrates his solicitor was informed that it was not possible on a Saturday morning for a mental health assessment to be conducted, 21_ The court does have in place a process to provide it with information when vulnerable adults are detained in custody: This is initiated by the police when they have concerns that such an adult is detained; will request a CPN to attend the custody suite and carry out an assessment_ The assessment is then recorded on form CPNI and this is then forwarded to the court when the defendant appears before them in custody,orata later date ifthe defendant is released to appear on a subsequent occasion: from key The being they

22. If the court believes a vulnerable adult is appearing before them without such an assessment having been carried out then there is a call-in scheme for a CPN to attend and complete an assessment and submit a report; again on a CPNI_
23. On this occasion, even though a Saturday morning, it should have been possible to contact a CPN to attend and carry out an assessment_ Unfortunately, as stated above Ms Mehan was unsuccessful in her attempts to do so. 24_ In any event; on this occasion, the court was advised that Mr Basalat had been given the all clear by the police doctor/mental health team to attend court. There were no concerns about Mr Basalat from the Community Psychiatric Nurse who had assessed him in custody.
25. Ms Mehan does not recall that Mr Basalat'$ solicitor requested that a CPN attend:
26. "The court did not attempt to contact the prison to inform the prison of the problems being experienced by him due to his mental illness:
27. Ms Mehan did place a marker on the warrant indicating that Mr Basalat had mental health issues_ Without sight of the warrant it is not possible to comment o the details of that marker.
28. It is not normal practice for a legal adviser to directly contact any prison establishment: Unlike any custodian of a detained person the court does not undertake a risk assessment of a prisoner. The police had completed a Person Escort Record form and this would have accompanied Mr Basalat_
29. "Consideration should have been given as to the most appropriate place for the deceased to be held or to receive a mental health assessment:
30. No representations were made from either party that Mr Basalat should be remanded to any establishment other than a penalone. The court had been specifically advised that Mr Basalat had been given the all clear to appear before the court by the police doctor/mental health team
31. The court does have power, under certain circumstances, to remand a defendant to a hospital or custodial establishment for a mental health assessment ifit is satisfied that the defendant did the act or omission alleged,however; in this case the defendant had not indicated a plea and had been

SUMMARY AND WAY FORWARD
38. HMCTS is concerned that it was not identified as an interested party or requested to submit any evidence or make representations to the inquest the death of Mr Basalat
39. There has been a review of Mr Basalat'$ appearance before the court on 10th December 2016. This concluded that: a) Mr Basalat was sent to the Crown Court for trial and he was remanded in custody on the grounds that he would fail to surrender to custody and commit further offences b) Mr Basalat had been cleared to attend court by the police's doctor/mental health team: A CPN had assessed Mr Basalat the previous evening: c) There was no CPNI available and attempt to call in CPN was unsuccessful. d) warrant issued by_ was endorsed indicating that Mr Basalat had mental health difficulties: The warrant only detailed the offence as 'dangerous and no further information was provided; the court did have in its possession an MGS_ e) No representations were made to the court that Mr Basalat should be remanded to any other establishment other that the usual remand prison: 40_ The court does have in place procedures to ensure vulnerable adults are identified and assessments undertaken:
41. Liaison has taken place with Northamptonshire Consta bulary and Northamptonshire PCC'$ office and this has established; a) The police are undertaking their own review and further Iiaison will take place following its conclusion. b) The Pcc'$ office is re-negotiating a new contract for the provision of healthcare in custody.
42. The court will liaise with the Criminal Justice Liaison and Diversion Team, to review the robustness of present CPN procedures and consider what further information should be forwarded to a prison should a vulnerable adult be remanded to it;
43. Legal advisers have been issued with the above Team' $ information leaflet and reminded of the need to forward the CPNI form to relevant custodial establishment if a vulnerable adult is remanded into custody. this, to endorse the warrant and forward the MGS, if available _
44. If a report on the outcomes of future liaison with the police/Pcc/Criminal Justice Liaison and Diversion Team are required, then the court respectively requests an extension of the period allowed for this response: (It is understood that Northamptonshire Constabulary will be requesting an extension of six weeks and if granted a similar time-period is likewise requested:) any into The driving' the the Failing

sent to the Crown Court for trial. Additionally, the court was not in a position to conduct such an enquiry and had not been invited to do so by either party: 32 A copy of the record of the proceedings, including Ms Mehan'$ notes, see appendix B and statement made by Ms Mehan, see appendix C are attached_ PROCEDURES IN PLACE, ACTION TAKEN AND TO BE TAKEN
33. As outline above the court does have procedures in place to ensure that vulnerable defendants are identified to the court; see appendix D and E Magistrates have been made aware of these procedures, see appendix F and training has been delivered to magistrates and evaluated, see appendix G.
34. Following receipt of the Coroner's report liaison has taken place with the relevant criminal justice agencies The court is aware that Northampton Constabularyare conducting its own review, which will include the CPN response. Following its conclusion there will be further liaison to share outcomes and ensure that the necessary information is shared with the when a vulnerui le adult is remanded into their care_
35. The court is also aware that the Northamptonshire Police and Crime Commissioner' $ office is re- negotiating a new contract for the provision of healthcare in custody. Again, there will be further Iiaison following this review:
36. The court facilitates 'custody meeting' attended by numerous criminal justice agencies. This has in the past overseen the CPN procedure: The court will liaise with the Criminal Justice group Liaison and Diversion Team; Northamptonshire Healthcare NHS Foundation Trust to review the robustness of the present procedures and to consider what further information should be forwarded to a prison should a vulnerable adult be remanded to it: 37 In the interim, legal advisers have been issued with the above Team's information leaflet, see H, and reminded of the need to forward the CPNI form to the relevant custodial appendix establishment if a vulnerable adult is remanded into custody: They have also been advised that if CPNI form is not available then they should ensure that any warrant is suitably endorsed and if available the MGS should accompany the warrant: prison

Znce Deputy Clerk to the Justices