GREATER MANCHESTER Wan POLICE E"R POLICS Sir Peter Fahy Q.P.M;, MA Chief Constable RECEIVED Mrs Jennifer Leeming MAY 2014 Coroner's Office Greater Manchester West Ground Floor Paderborn House Howell Croft North Bolton Our ref: IWILC BL1 1JW Your Ref: 28th April 2014 &or dcs RE: REGULATION 28 REPORT CAROLINE LOUISE PILKINGTON Thank you for copying me into the report you have submitted in respect of the above case. share your concerns about the involvement of police officers in such situations, and am grateful for your support in highlighting the risks All too often, such incidents have led to demands for police officers to be better trained, an approach which fails to recognise the underlying issue here_ As you know, have been concerned for some time about the increasing demand that is falling on police from gaps in health services_ This is evident in many forms, from 'concern for welfare' reports through to police involvement in mental health and accident and emergency situations. The common theme is tendency for health professionals to call police to deal with situations where health professionals already have the appropriate powers and medical skills, but appear to lack the confidence, will; and particular skills around incident resolution which should obviate the need for police involvement note in this case that there were sufficient paramedics present to manage the incident safely without the need for police involvement, and understand that the restraint equipment used is carried by ambulances crews for such purposes: Unfortunately we have been called to similar incidents at mental health settings, including secure units, where mental health nurses have also not been trained in control and restraint. fully endorse the need for police involvement when health professionals are assaulted or threatened with violence by those who need dealing with through the criminal justice system: Clearly we good operational and professional relationships with our colleagues across the emergency services, and we have always supported requests for assistance without question in the past. However, am increasingly concerned that we are becoming a default option if the correct medical response is not available, and are drawn into high risk medical emergencies It is difficult to justify involvement of police officers in situations which are clearly medical emergencies, whether physical health or mental health; Our newly revised officer safety training programme has emphasised the need for officers to recognise the medical risks in situations such as those in Miss Force Command, Central Park, Northampton Road, Manchester M4O SBP Tel: 0161 856 2010, Fax: 0161 856 2036, Minicom: 0161 872 6633 Loam ~S / enjoy being the

Pilkington's case, and to treat those as medical emergencies While police officers are trained in restraint; would suggest that medical emergencies are different, and consequently require different considerations and approaches. Calling police to deal with such emergency situations will cause delay, abstract officers from their core duties, and potentially endanger the patient through failure to take action andlor inappropriate techniques used: In respect of training for the ambulance service, my understanding is that paramedic staff must receive training in personal safety, which is a requirement through NHS Protect; and an obligation under health and safety at work responsibilities However; the content of that training is not stipulated, and it is down to each service to determine the content and frequency of that training am unclear as to the extent to which their of care responsibilities are understood in relation to controlling and restraining patients. We find knowledge of the Mental Capacity Act and Mental Health Act is variable, and that some policies within the ambulance service and hospitals automatically refer incidents to police when could take action themselves; concur with your recommendations, and would be happy to offer our support to NWAS in respect of any training initiatives they may undertake in response to your report. Juns Ancey, Sir Peter Fahy Chief Constable being duty they

Dear Mrs Leeming CAROLINE PILKINGTON (DECEASED) We write further to your letter of 25 March 2014, enclosing Regulation 28 Report to Prevent Future Deaths in relation to the inquest examining the death of Caroline Pilkington. Please accept this as our response in accordance with Regulation 29(4). We note that vou raise concerns regarding the fact that North West Ambulance Service (NWAS) personnel are not trained in control and restraint techniques and call upon the police service to assist them in dealing with patients who are unwell; but require control or restraint_ NWAS are acutely aware of the importance of delivering safe patient care and are constantly striving to improve our procedures In March 2012 joint protocol was developed, following consultation between the North West Region Police Forces and NWAS, which provides framework to support inter-agency working and the appropriate use of resources to deliver the best possible care for patients who lack capacity: The aim of this protocol is to ensure patients who lack capacity and are refusing advice or treatment, receive care that is in their best interests the least restrictive means necessary: The protocol takes into account the Mental Capacity Act 2005 (MCA); Code of Practice 2007 and the National Policing Improvement Agency (NPIA) Briefing Note on Applying the Mental Capacity Act 2010. All 5 police forces in the North West have formally agreed to the protocol. Protocol for ambulance service requesting police assistance In accordance with the protocol, ambulance staff may request police assistance for patients who lack capacity under the following circumstances:
1. Patients in need of emergency treatment who require restraint due to their threatening or violent behaviour; Headquarters: Ladybrdge Hall 399 Chorley New Road, Bolton. BL1 SDD Chalrman: INVESTORS Chief Executive: Mr B Williams IN PEOPLE | Champion Delivering the right care, at the right time, in the right place RECEIVED 2 8 using Osaet

2 Patients refusing emergency treatment and/or transport in their best interests, where it has been identified that minimal restraint will be neither effective nor safe to be undertaken by ambulance staff;
3. Patients who are at risk of causing further harm to themselves or others;
4. Where there are other significant risk factors identified at the scene of the incident that prevent the patient from receiving treatment or transport to hospital that is in their best interests. The police will respond to the incident as a emergency and the ambulance staff and police officer(s) will then work together and agree plan on how to manage the patient in the safest, timeliest and least restrictive means possible_ Ambulance staff will have responsibility for all decisions relating to the clinical treatment of the patient and will agree with police the appropriate level and type of restraint to be used, taking into account the patient' $ condition/injuries and assessment or treatment required: Use of restraint by ambulance service staff Ambulance staff are legally authorised and obliged under the MCA to act in the best interests of, and provide treatment for, patients who are lacking capacity, even where the patients refuse treatment or are abusive, threatening or violent: The MCA also supports the use of reasonable force to ensure that patients lacking capacity receive care that is in their best interests or are protected from further harm: However, ambulance staff are neither trained nor expected to restrain patients who are acting in threatening or violent manner. Ambulance staff are trained to provide minimal restraint in cases where patients lack capacity and there is no perceived risk of harm to them or the patient. NWAS believes that ambulance staff should focus on the treatment of the presenting condition of their patients. Advanced control and restraint is an extremely specialised skill; which, due to the risks involved, requires extensive training and regular practice. It would not be feasible for our staff to be trained in such techniques since situations where control and restraint is required arise very rarely: Consequently, ambulance staff would not be able to maintain the skills at the necessary level to ensure appropriate patient care: We believe this has the potential to compromise, rather than improve, the safety of patients. NWAS recognises the importance of multi-agency work in the care of patients. Both the police and ambulance service employ highly skilled, well trained and specialised staff who each have a vital role to play in the care and safety of the public We believe that working together is the best way to achieve consistency and guarantee safety for patients. We that the content of this letter has satisfactorily addressed vour concerns If you require any further information please do not hesitate to contact us. Alternatively, Head of Clinical Governance; has offered to meet with you to discuss the contents of this letter further.

syeivcu 15 MAY 2014 From the Rt Hon Jeremy Hunt MP Secretary of State for Health Department of Health Richmond House 79 Whitehall London POCI 851396 SWIA 2NS Tel: 020 7210 3000 Ms M J Leeming Mb-sofs@dh-gsi-govuk Senior Coroner HM Coroner's Court Paderborn House Howell Croft North Bolton BL] 1QY 2 May 2014 DM, 6m Thank you for your letter following the inquest into the death of Caroline Louise Pilkington. In your report you conclude that the medical cause of death was accidental, caused by Propranalol toxicity: On 25 April 2013, Miss Pilkington was found suffering from & fit in an upstairs bedroom at her home address: The North West Ambulance Service (NWAS) was called and three paramedics attended. Due to the violence of Miss Pilkington'$ movements in the course of her fit it was necessary to restrain her limbs in order to remove her safely from her home. NWAS personnel called the police service to assist them: Officers of Greater Manchester Police attended, applied restraints to Miss Pilkington and assisted in removing her safely from her home Miss Pilkington died on 26 April 2013 at Royal Bolton Hospital. She had taken an accidental overdose of Propranolol which had been prescribed some time before for relief: You raise the following concerns: NWAS personnel are not trained in control and restraint techniques This results in them having to call the police service to assist them when dealing with ill patients who require control and restraint This is So despite the fact that other clinical personnel, for example Mental Health nurses, are trained in such techniques In this case the three paramedics had to call for assistance from the police service. The police, although trained in control and restraint techniques, are not clinically trained to deal with such patients. ;J, pain

The involvement of the police service in these cases not only potentially results in inappropriate removal of police officers from their core policing duties, but also potentially results in harm to patients being caused by delaying their removal to hospital. You have found that these matters did not cause or contribute to Miss Pilkington'$ death However; you believe there is a risk that future deaths would occur while ambulance personnel remain untrained in control and restraint techniques, partly because police staff are not clinically trained and partly due to delays in patients to hospital whilst awaiting the arrival ofthe police. Inote that you sent a copy of your report to NWAS and I am aware of the contents of their reply. They have advised you that: A joint protocol was developed between the North West Region Police Forces and NWAS in March 2012 which supports inter-agency working and the appropriate use of shared resources to deliver the best possible care for patients who lack capacity. All five forces in the North West have agreed to the protocol. The protocol means that NWAS staff may request assistance for patients in need of emergency treatment who lack capacity and who require restraint due to threatening Or violent behaviour towards themselves or others. The police will respond to the incident as an emergency and the ambulance staff and officer(s) will then work together and agree a plan on how to manage the patient in the safest; timeliest and least restrictive means possible Both the police and ambulance service employ highly skilled, well trained and specialised staff who each have a vital role to play in the care and safety of the public. NWAS believe that this model of collaborative multi-agency working is the best way to achieve consistency and guarantee safety for patients. The use of restraint and reasonable force is supported under the Mental Capacity Act 2005 (MCA), to ensure that patients lacking capacity receive appropriate care. Although NWAS staff are trained to provide minimal restraint in cases where patients lack capacity and there is no perceived risk ofharm to them or the patient; are not trained or expected to restrain patients who are acting in a threatening or violent manner. Advanced control and restraint is an extremely specialised skill, which, due to the risks involved, requires extensive training and regular practice. As ambulance staff are not commonly tasked with situations which require taking ~ police police police they

Department of Health advanced control and restraint; it would not be possible for them to maintain the skills at the necessary level to ensure the safety of patients. My officials have discussed this case with the Association of Ambulance Chief Executives (AACE): AACE considers that it is neither appropriate nor beneficial to train all ambulance staff in control and restraint; for the same reasons given above by NWAS: [ fully support the collaborative approach taken by NWAS As the control and restraint of patients is highly specialised area I believe NWAS personnel rightly rely on the North West police forces to provide this facility as and when necessary. I hope that this response is helpful and [ am grateful to you for bringing the circumstances of Miss Pilkington s death to my attention k ;ess JEREMY HUNT

From the Rt Hon the Earl Howe P.C Parliamentary Under Secrelary of Slate for Quality (Lords) Department of Health 0 9 SEP 2014 Richmond House 79 Whitehall Ms M J Leeming London SWIA 2NS Senior Coroner HM Coroner's Court Tel: 020 7210 4850 Paderborn House Howell Croft North Bolton BLI 1QY Lez~= 3 Thank you for your further letter 0f 28 2014 and the responses you enclosed from the North West Ambulance Service (NWAS) and Sir Peter Fahy of Greater Manchester Police. Your letter follows our response of 12 2014 to your Regulation 28 report concerning the death of Caroline Pilkington: You acknowledge that NWAS staff are trained to provide minimal restraint in cases where patients lack capacity and there is no perceived risk ofharm to them or the patient; but are not trained O1 expected to restrain patients who are acting in a threatening O violent manner However; you raise the following concerns: that the deceased, Caroline Pilkington, was not acting in either a threatening O1' violent manner and infer that this was a case that could have been handled with the application of minimal restraint; without the need of Police involvement; that there is a training need for ambulance to correctly identify those cases that can be dealt with by minimal restraint and those which need Police involvement because health arc assaulted 01 threatened with violence. that a failure to distinguish between patients behaving in a manner" due to their illness and those who are being threatening O1 violent could delay the removal of a physically unwell patient to hospital, potentially leading to future deaths_ That the increasing demand for Police involvement in situations such as in Miss Pilkington 's case potentially endangers the by removing Police Officers from their core duties. M^ May ' May staff staff public

You ask US therefore to consider: Whether ambulance personnel should receive further training in making the distinction described. Firstly, it needs to be understood that the training of ambulance in control and restraint techniques is not a matter for which the Department of Health (DH) is responsible. Ambulance staff; for example emergency care assistants, emergency care practitioners and paramedics, are health professionals and are trained as such: The actual training that ambulance staff require and receive in control and restraint is a matter for the NHS Trust concerncd, and not DH. We have however consulted NWAS and the Association of Ambulance Chief Executives (AACE) about the further issues you raise. NWAS has confirmed that a regional protocol is in place that all police forces it works with; including Greater Manchester Police; have agreed to_ This protocol is under review. However; at the most recent North West Police Regional Mental Health Forum; NWAS presented and discussed the findings from your inquest concerning the death of Caroline Pilkington. None of the police forces believed there was a need to change the current policy 01 reduce the involvement of the police-in managing those patients who required more than minimal restraint NWAS confirm that ambulance staff should only request assistance fiom the police for patients who elicit a "pathfinder red" outcome (i.e. those patients who require transfer to an Emergency Department). This in itself reduces the number of requests for police assistance_ As the need for ambulance personnel to use restraint techniques is comparatively rare, NWAS believes that the need t0 train all ambulance staff in more advanced 01 specialised restraint techniques is not demonstrated, Even if all staff were to be trained, it would be difficult to maintain their skills sufficiently (because of the low incidence of use) to safely restrain these types of patients when the skills were called for: The risk is that poorly 01 inappropriately restraint techniques could cause harm to the patient O1 to staff: staff applied

Department of Health In addition; AACE have confirmed that it; as a national organisation, fully supports the NWAS position. AACE does not feel that the issues You raise represent a general problem and considers that ambulance arc sufficiently trained in restraint techniques to deal with almost all ill 0r injured patients and those resisting help. Ambulance staff are trained to seek assistance from police only when and where believe it appropriate and are best placed to make the decision on a case by case basis as t0 when intervention is required. I that this further response is helpful EARL HOWE staff they police hope (e~ sccUl-