Philmore Mills
PFD Report
Partially Responded
Ref: 2016-0110
Coroner's Concerns (AI summary)
Police training for subjects with suspected excited delirium lacks instruction on containment tactics and fails to inform officers that restraint take-down procedures can carry a risk of death, only focusing on minor injuries.
View full coroner's concerns
(1) In the course of the evidence, the Jury heard from two independent experts on restraint techniques and Police training. They both had the opportunity to review the existing Thames Valley Police and ACPO Training in place at the time of Mr Mills’ death. This included training for Police Officers when dealing with a subject who may be suffering from excited delirium. Both Officers highlighted the fact that there is no reference to the option of containment as a tactic taught to Police Officers as part of their training in dealing with subjects with suspected excited delirium. In the evidence, containment was identified as one of the tactical options that Officers should carefully consider in any situation.
(2) The Jury heard from one of the two expert witnesses, that, while Police Officers are trained as to the medical consequences of the take down procedure in restraining a subject, those consequences do not include reference to the risk of death. While they described the risk of bruising, broken bones etc, they do not suggest that such a manoeuvre could, in certain circumstances, prove fatal to the subject involved.
(3) The evidence surrounding the circumstances of the death of Philmore Mills suggests that this is a potential outcome of which Officers should be made aware.
(2) The Jury heard from one of the two expert witnesses, that, while Police Officers are trained as to the medical consequences of the take down procedure in restraining a subject, those consequences do not include reference to the risk of death. While they described the risk of bruising, broken bones etc, they do not suggest that such a manoeuvre could, in certain circumstances, prove fatal to the subject involved.
(3) The evidence surrounding the circumstances of the death of Philmore Mills suggests that this is a potential outcome of which Officers should be made aware.
Responses
Action Planned
The College of Policing will add specific reference to 'containment' to the ABD/PA chapter of the National Personal Safety Manual and clarify that, in certain circumstances, prone restraint carries a risk of death, within the next scheduled update. (AI summary)
The College of Policing will add specific reference to 'containment' to the ABD/PA chapter of the National Personal Safety Manual and clarify that, in certain circumstances, prone restraint carries a risk of death, within the next scheduled update. (AI summary)
View full response
Dear Mr Bedford REF: PJB MILLS am writing in response to your letter of 17 March 2016 and Regulation 28 Report into the death of Mr Philmore Mills at Wexham Park Hospital, Slough on 27 December 2011. The role of the College of Policing is to develop knowledge, education and standards within policing to improving the service provided to the public_ To support this the College sets standards for the learning, delivery and assessment of personal safety training: The College keeps this guidance under continual review and has updated and amended it in line with learning that has arisen from operational incidents legal and coronial findings A suite of standards and learning products are available designed to safeguard the safety of police personnel and members of public. The products are focused on avoiding conflict situations where possible. However, guidance on they include guidance on how to restrain people in the most effective and safest way is also included. Chief constables will use these standards and products to train their staff. The College is a permanent representative of national Self Defence & Restraint (SDAR) Working Group and together with the National Police Chiefs Council Lead continues to engage with partners_ including leading healthcare professionals, to help ensure the latest medical, legal and tactical developments are considered. The risks associated with the conditions know as Acute Behavioural Disorder (ABD) and Positional Asphyxia (PA) are embedded in wider police training, and remain central tenets of mandatory Personal Safety Training_ Your specific matters of concern and our response are outlined below: National training products in use at the time made no reference to the tactic of containment as an option for managing a subject who is displaying signs of excited delirium. It is important to note that concept of 'containment' affects many strands of policing (tactical communication, hostage negotiation, Public Order, Firearms etc ) and is not limited to Personal Safety Training: The common factor to each of these strands is the National Decision Model (NDM) , which helps to ensure timely and consistent 'use of force' decisions often in complex and fast-moving events The NDM also helps to ensure that officers' actions are proportionate, lawful, accountable and necessary in the circumstances_ Colegjeef dsucing Limted colrpan} registered in Englnd an #vaies. #th (e"JS{ar-J (imber 8285 93 ard VAT {egistete } nuinber 152023949. Our rex Jeteter #frce College &f Policirg Limiited _ ezmington Roud, Rytorton Dunsinore Covertry Cve 3EN college May the the firmly the
These important wider issues, which include concepts such as containment, are central to the National Personal Safety Manual, training and guidance. The delivery of Personal Safety Training, including the risks associated with ABD and PA, were subject of a recent national quality assurance programme; led by the College. This piece of work was commissioned by the National Policing Lead to help enhance the policing response and ensure compliance with the National Personal Safety Manual. This undertaking has led to the production of a national training video, which reinforces the medical implications of restraint and good practice elements including the tactic of 'containment' This video is scheduled to form part of the national Personal Safety Training Programme for 2016/17 Having reviewed your observations and for completeness, specific reference to 'containment' will be added to the ABDIPA chapter of the National Personal Safety Manual to make explicit what is currently implicit:
2. National training products in use at the time did not provide information that the medical consequences of the use of the take down procedure as a means of restraining subject could, in certain circumstances, include the risk of death as well as the risk of injury: The focus of the College in situations where confrontation between the police and the public is a realistic proposition is the safety of all. The use of a prone restraint remains an option for police officers, and although the technique presents challenges, it still represents a necessary tactical option in this type of situation Whilst the medical implications contained within National Personal Safety Manual contain the inherent risks of harm to subjects who are restrained in a prone position further clarity will be added to reinforce that; in certain circumstances, there is a risk of death. shall ensure that these are included within the next scheduled update_ that this letter provides reassurance that the concerns raised in this report are addressed, would like to thank you for drawing this matter to our attention
These important wider issues, which include concepts such as containment, are central to the National Personal Safety Manual, training and guidance. The delivery of Personal Safety Training, including the risks associated with ABD and PA, were subject of a recent national quality assurance programme; led by the College. This piece of work was commissioned by the National Policing Lead to help enhance the policing response and ensure compliance with the National Personal Safety Manual. This undertaking has led to the production of a national training video, which reinforces the medical implications of restraint and good practice elements including the tactic of 'containment' This video is scheduled to form part of the national Personal Safety Training Programme for 2016/17 Having reviewed your observations and for completeness, specific reference to 'containment' will be added to the ABDIPA chapter of the National Personal Safety Manual to make explicit what is currently implicit:
2. National training products in use at the time did not provide information that the medical consequences of the use of the take down procedure as a means of restraining subject could, in certain circumstances, include the risk of death as well as the risk of injury: The focus of the College in situations where confrontation between the police and the public is a realistic proposition is the safety of all. The use of a prone restraint remains an option for police officers, and although the technique presents challenges, it still represents a necessary tactical option in this type of situation Whilst the medical implications contained within National Personal Safety Manual contain the inherent risks of harm to subjects who are restrained in a prone position further clarity will be added to reinforce that; in certain circumstances, there is a risk of death. shall ensure that these are included within the next scheduled update_ that this letter provides reassurance that the concerns raised in this report are addressed, would like to thank you for drawing this matter to our attention
Sent To
- College of Policing
- National Police Chiefs’ Council
Response Status
Linked responses
1 of 2
56-Day Deadline
12 May 2016
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
I conducted an Inquest into the death of Mr Philmore Leonard Mills that was heard at Reading Town Hall between the 8th February 2016 and 8th March 2016. The conclusion of the Inquest was in the terms of a Narrative Conclusion attached to this report.
Circumstances of the Death
Mr Mills was a 55 year old gentleman who was a patient on the Respiratory Ward at Wexham Park Hospital, Slough with significant comorbidities including terminal Lung Cancer, Chronic Obstructive Pulmonary Disease, Pneumonia, Pulmonary Emboli and Ischaemic Heart Disease. As a result of Hypoxia he became confused and aggressive and, after nursing and security staff were unable to control him, Police Officers attended and in the course of restraining him, Mr
-1-
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
Mills collapsed and died. This occurred on 27th December 2011. Evidence from three Pathologists described Mr Mills as being at risk of Death at any time but they were unable to exclude the temporal association of restraint and death.
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REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
Mills collapsed and died. This occurred on 27th December 2011. Evidence from three Pathologists described Mr Mills as being at risk of Death at any time but they were unable to exclude the temporal association of restraint and death.
Copies Sent To
17th March 2016
Peter J. Bedford Senior Coroner for Berkshire
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.