Hywel Hughes
PFD Report
Partially Responded
Ref: 2014-0311
Coroner's Concerns (AI summary)
Police training on positional asphyxia is inadequate, and vehicle designs hinder monitoring detainees. The SIA also fails to review restraint-related deaths by door supervisors.
View full coroner's concerns
In the circumstances it is my statutory to report to (1) The training on positional asphyxia presently provided to police officers by the North Wales Police Force does not include guidance on the significance of 'snoring' and in particular that it is not inconsistent with deep unconsciousness and obstruction to breathing: (2) The design of the 'bubble cars' in existence at the time of Mr Hughes' death and apparently still in use pending their phasing out, is such that the condition of a detainee held in the rear of the vehicle may not be easily monitored (because of the presence of a Perspex screen that may affect the ability to see and hear detainee): (3) The design of the new 'bubble cars' may impede an officers ability to hear a detainee (and thus identify irregularities or difficulties in breathing) because of the presence of (albeit smaller) Perspex screen: (4) Twenty deaths apparently related to andlor following restraint by door supervisors have occurred since the introduction in 2004 of (rolled out) compulsory licensing of door supervisors, by the Security Industry Authority ("SIA (established by the Private Security Act 2001, in 2003). There have been four restraint related deaths involving twelve supervisors (all of whom have been charged with either murder or manslaughter) since April 2013, that following the introduction (in February 2013) of mandatory training as a condition for the awarding (or renewal) of a licence to work as a door supervisor anywhere in the UK (5) The SIA does not undertake any review or inquiry into those deaths indicated by Inquest or criminal findings to be related to restraint by door supervisors to determine whether there are any lessons to be leamt in
Responses
Action Taken
North Wales Police amended their training materials on positional asphyxia to include snoring as a symptom and added an exercise to demonstrate the dangers of medical emergencies. They also designed and are testing a single cell compartment bubble car and considering auditory improvements. (AI summary)
North Wales Police amended their training materials on positional asphyxia to include snoring as a symptom and added an exercise to demonstrate the dangers of medical emergencies. They also designed and are testing a single cell compartment bubble car and considering auditory improvements. (AI summary)
View full response
Dear Madam
Hywel Llewelyn Hughes
We refer to your Schedule 5, Regulation 28 report to prevent future deaths dated 2 July 2014 and in particular the parts addressed to North Wales Police (“NWP”).
We reply as follows:-
a) Snoring
NWP agree that in the light of the evidence/findings arising from this inquest that snoring should be including in the training on positional asphyxia.
Therefore, NWP have:-
• Amended their first aid, personal safety and tasar training materials and training package to add snoring as a symptom of positional asphyxia.
• Added an exercise in which a violent person stops breathing after being dealt with by officers to the tasar and personal safety training to demonstrate the dangers of such medical emergencies.
The NWP amendments on snoring have been recommended to the organisations below to bring about improvement to material/training at a national level for police forces.
o College of Policing o The National Secretary and Regional Representative for the Self Defence Arrest and Restraint section of the Association of Chief Police Officers (“ACPO”) o The North West Regional Firearms Group Gareth Pritchard MA Dirprwy Brif Gwnstabl / Deputy Chief Constable
Our ref: DCC/ND/HHCorInqFinal14
21st August 2014
b) Bubble Cars
NWP consider that police officers can effectively monitor detainees irrespective of the issues highlighted over sight and hearing connected to the protective screens in the existing double compartment bubble car or proposed single compartment bubble car when transporting detainees. Monitoring is achievable to acceptable levels if officers pay sufficient attention to the task and abide by their detainee risk assessments and force policies when transporting detainees. However, NWP are considering improvements to assist with monitoring as set out below.
Bubble cars are general purpose police vehicles lawfully modified to utilise a containment cell for prisoners within the vehicle. The protective screen in bubble cars’ containment cells (between the detainee and the driver/passenger police officer) are made of polycarbonate not perspex. The protective screens were designed as part of the containment cell arrangement to achieve a sensible balance between health and safety concerns for the police officers and the detainees whilst providing an acceptable capacity for monitoring detainees.
NWP operate in a large rural area, utilising three designated custody suites in convenient locations within their force area. NWP consider bubble cars as a preferable alternative to police vans for transporting detainees for a number of reasons. The force are presently evaluating changing the containment cell from a double one to a single cell, however, a final decision on whether this goes ahead will be dealt with after testing and further consideration is concluded. It is not correct to suggest that the double cell bubble cars are being “phased out”.
The screen is not scratch resistant but a sharp instrument would be needed to scratch it. Bubble cars are the subject of a vehicle user check for each day by the police officer utilising the vehicle and a weekly check by a supervising sergeant. The user check includes the protective screen. Defects are reported to fleet services which result in repairs being undertaken in a timely fashion, which include scratches on the protective screen. NWP have assessed the protective screen as adequate to hear a detainee within the containment cell.
The bubble cars used over the years have altered because of fleet services procurement requirements. The latest vehicle being utilised was the Ford Focus, which due to manufacturer redesigns resulted in less cabin space due to the area occupied by the compartment cell. This lack of space resulted in complaints from taller officers that there was insufficient room for the front seats to be put back sufficiently. There was also concern about a number of incidents in which violent detainees had kicked out the rear nearside and offside windows and with drunken detainees slumping across the rear seats, making monitoring more problematical. Accordingly, to assist with these problems, NWP have designed a single cell compartment bubble car in conjunction with the manufacturer and are testing the single cell compartment, which appears so far to present significant improvements to the existing double cell compartment arrangement. It allows better monitoring as the police officer is closer to the detainee from visual and auditory perspectives.
Proposed auditory Improvements NWP are considering the following:-
• Scoping an automated intercom solution with a view to identifying an appropriate product to be tested on a demonstrator vehicle for use in the bubble containment cell;
• Undertaking enquiries as to the possibility of having a hole in the protective screen to see if that improves ability to monitor detainees (and does not compromise the integrity of the protective screen or provide health and safety implications for the police officers/detainees).
Finally, the Police and Crime Commissioner (“PCC”), Winston Roddick QC wishes to make it clear that he will scrutinise NWP’s response to your report by examining its revised training programme to satisfy himself that the revisions have been adopted and the training is being carried out in accordance with those revisions. He proposes to make unannounced visits to force training sessions to verify their adequacy.
Similarly, the PCC will satisfy himself that NWP’s use of the bubble car, whether in a double or single compartment, including any improvements to the polycarbonate screen and/or intercom arrangements, are adequate.
Hywel Llewelyn Hughes
We refer to your Schedule 5, Regulation 28 report to prevent future deaths dated 2 July 2014 and in particular the parts addressed to North Wales Police (“NWP”).
We reply as follows:-
a) Snoring
NWP agree that in the light of the evidence/findings arising from this inquest that snoring should be including in the training on positional asphyxia.
Therefore, NWP have:-
• Amended their first aid, personal safety and tasar training materials and training package to add snoring as a symptom of positional asphyxia.
• Added an exercise in which a violent person stops breathing after being dealt with by officers to the tasar and personal safety training to demonstrate the dangers of such medical emergencies.
The NWP amendments on snoring have been recommended to the organisations below to bring about improvement to material/training at a national level for police forces.
o College of Policing o The National Secretary and Regional Representative for the Self Defence Arrest and Restraint section of the Association of Chief Police Officers (“ACPO”) o The North West Regional Firearms Group Gareth Pritchard MA Dirprwy Brif Gwnstabl / Deputy Chief Constable
Our ref: DCC/ND/HHCorInqFinal14
21st August 2014
b) Bubble Cars
NWP consider that police officers can effectively monitor detainees irrespective of the issues highlighted over sight and hearing connected to the protective screens in the existing double compartment bubble car or proposed single compartment bubble car when transporting detainees. Monitoring is achievable to acceptable levels if officers pay sufficient attention to the task and abide by their detainee risk assessments and force policies when transporting detainees. However, NWP are considering improvements to assist with monitoring as set out below.
Bubble cars are general purpose police vehicles lawfully modified to utilise a containment cell for prisoners within the vehicle. The protective screen in bubble cars’ containment cells (between the detainee and the driver/passenger police officer) are made of polycarbonate not perspex. The protective screens were designed as part of the containment cell arrangement to achieve a sensible balance between health and safety concerns for the police officers and the detainees whilst providing an acceptable capacity for monitoring detainees.
NWP operate in a large rural area, utilising three designated custody suites in convenient locations within their force area. NWP consider bubble cars as a preferable alternative to police vans for transporting detainees for a number of reasons. The force are presently evaluating changing the containment cell from a double one to a single cell, however, a final decision on whether this goes ahead will be dealt with after testing and further consideration is concluded. It is not correct to suggest that the double cell bubble cars are being “phased out”.
The screen is not scratch resistant but a sharp instrument would be needed to scratch it. Bubble cars are the subject of a vehicle user check for each day by the police officer utilising the vehicle and a weekly check by a supervising sergeant. The user check includes the protective screen. Defects are reported to fleet services which result in repairs being undertaken in a timely fashion, which include scratches on the protective screen. NWP have assessed the protective screen as adequate to hear a detainee within the containment cell.
The bubble cars used over the years have altered because of fleet services procurement requirements. The latest vehicle being utilised was the Ford Focus, which due to manufacturer redesigns resulted in less cabin space due to the area occupied by the compartment cell. This lack of space resulted in complaints from taller officers that there was insufficient room for the front seats to be put back sufficiently. There was also concern about a number of incidents in which violent detainees had kicked out the rear nearside and offside windows and with drunken detainees slumping across the rear seats, making monitoring more problematical. Accordingly, to assist with these problems, NWP have designed a single cell compartment bubble car in conjunction with the manufacturer and are testing the single cell compartment, which appears so far to present significant improvements to the existing double cell compartment arrangement. It allows better monitoring as the police officer is closer to the detainee from visual and auditory perspectives.
Proposed auditory Improvements NWP are considering the following:-
• Scoping an automated intercom solution with a view to identifying an appropriate product to be tested on a demonstrator vehicle for use in the bubble containment cell;
• Undertaking enquiries as to the possibility of having a hole in the protective screen to see if that improves ability to monitor detainees (and does not compromise the integrity of the protective screen or provide health and safety implications for the police officers/detainees).
Finally, the Police and Crime Commissioner (“PCC”), Winston Roddick QC wishes to make it clear that he will scrutinise NWP’s response to your report by examining its revised training programme to satisfy himself that the revisions have been adopted and the training is being carried out in accordance with those revisions. He proposes to make unannounced visits to force training sessions to verify their adequacy.
Similarly, the PCC will satisfy himself that NWP’s use of the bubble car, whether in a double or single compartment, including any improvements to the polycarbonate screen and/or intercom arrangements, are adequate.
Sent To
- Home Office
- Security Industry Authority
Response Status
Linked responses
1 of 3
56-Day Deadline
27 Aug 2014
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
An investigation into the death of Mr Hywel LLewelyn Hughes (date of birth 11 January 1971) concluded at the end of the Inquest on 26 June 2014. The conclusion of the inquest was that: () the medical cause of death was traumatic asphyxia; (ii) the actions of police officers attached to the North Wales police force on coming upon Mr Hughes were not appropriate and (iii) it is more probable than not that the actions of the police officers more than minimally contributed to the death of Mr Hughes:
Circumstances of the Death
On 2 2003, Mr Hywel LLewelyn Hughes was forcibly removed from Joops nightclub, Bangor; by employed members of the door staff at about 23.10. After struggle with two members of the door staff between approximately 23.10 and 23.18, he was restrained by them in face down position on the road_ During the period of this restraint; he was unable to breathe and suffered injuries which ultimately caused his death. Two police officers attached to the North Wales police force arrived on the scene at approximately 23.18 and transported Mr Hughes to Caernarfon police station from where he was conveyed to Ysbyty Gwynedd,_arriving_at_approximately_00.30. Mr_Hughes was declared May deceased at Ysbyty Gwynedd at 19.30 hours on 3
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action_
Copies Sent To
5. have also sent it to HM Coroner for North West Wales and to the British Security Industry Association
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.