Douglas Oak
24 Oct 2019 · Coroner Rachael Griffin · Dorset
This report repeats 1 earlier warning, and was raised again 3 times later. See the linked reports.
The coroner's concerns
1. severe acute behavioural disturbance
“Acute Behavioural Disturbance (ABD) is a term used to describe the presentation of a spectrum of behaviours, signs and symptoms which create an immediate risk to life, especially at the severe end of the spectrum”
2. lack of awareness of acute behavioural disturbance
“There is a lack of awareness generally with ABD.”
3. untrained police control room staff
“College of Policing issued a training package at the end of 2016 to all Police Forces on ABD.”
Linked reports
Identical hazardConfidence 0.86 · high
Earlier report
“it was clear from the inquest that there was a lack of understanding of how to treat someone with an acute behavioural disturbance.”
This report
“During the iInquest evidence was heard that: i. Acute Behavioural Disturbance (ABD) is a term used to describe the presentation of a spectrum of behaviours, signs and symptoms which create an immediate risk to life, especially at the severe end of the spectrum.”
Closely relatedConfidence 0.85 · high
This report
“College of Policing issued a training package at the end of 2016 to all Police Forces on ABD.”
Later report
“insufficient or inadequate instruction of both police and ambulance crew about the critical issues of recognising and responding to a medical emergency and the effects of restraint including positional asphyxia.”
Identical hazardConfidence 0.96 · high
This report
“Acute Behavioural Disturbance (ABD) is a term used to describe the presentation of a spectrum of behaviours, signs and symptoms which create an immediate risk to life, especially at the severe end of the spectrum”
Later report
“Acute Behavioural Disturbance (ABD) is an umbrella term to describe a presentation which usually includes abnormal physiology and/or behaviour. ABD is not a diagnosis or a recognised syndrome, but rather a term used to describe a combination of signs and symptoms of aggression and agitation with physiological abnormalities”
Identical hazardConfidence 0.90 · high
This report
“College of Policing issued a training package at the end of 2016 to all Police Forces on ABD.”
Later report
“During the course of the Inquest, evidence was heard about the understanding and training in relation to Acute Behaviour Disturbance (ABD). All of the officers who had received their College of Policing Personal Safety Training had been trained on the ABD module within that package.”
Responses
2019-0352-Response-by-Association-of-Ambulance-Chief-Executives.pdf ↗· Association of Ambulance Chief Executives
Stated action
“We will address each of your concerns, insofar as we are able.”
2019-0352-Response-by-College-of-Policing.pdf ↗· College of Policing
Stated action · 2020
“the College will work with police stakeholders through the NPCC First Aid Forum and the national clinical governance panel to reflect this learning outcome in Module 2, the refresher training module for front line staff. This will ensure that this training is given to all front line officers. This amendment will be made as part of the wider scheduled review of the FALP following the release of updated guidance by the UK Resuscitation Council in 2020.”
2019-0352-Response-by-Department-of-Health-and-Social-Care.pdf ↗· Department of Health and Social Care
2019-0352-Response-by-St-Johns-Ambulance.pdf ↗· Dorset Police
Stated action
“providing additional Continuous Professional Development training around Acute Behavioural Disturbance”