Recommendations - National Police Chiefs' Council, December 2024
We identified organisational learning following an IOPC investigation where a man was arrested and taken to hospital after swallowing a large quantity of tablets. After being discharged from hospital, he was physically restrained by police officers in the prone position, handcuffed and placed in limb restraints. The man’s condition deteriorated over the following days and the man sadly died.
IOPC reference
Recommendations
The IOPC recommends that the National Police Chiefs’ Council (NPCC) should review the processes through which the Flexible Lift and Carry System (FLACS) and other operational equipment are introduced and reviewed and ensure these are aligned with the most recent medical and professional guidance.
This follows an IOPC investigation where a man, who had been arrested by Thames Valley Police (TVP) officers, was taken to hospital after he had swallowed a large quantity of tablets and appeared unwell. The man remained under police guard while in hospital.
When he was discharged from hospital, he appeared non-compliant and was physically restrained by two officers. Handcuffs and limb restraints were applied. Hospital staff assisted in the restraint at various intervals.
The officers called for support and an additional three officers arrived at the hospital with a police van. The man was restrained in the prone position by police for a prolonged period before the FLACS was applied to the man. This equipment is designed as a soft stretcher and aids the removal or evacuation of a subject.
The man was transported using the FLACS to a police van. Upon being placed into the van, officers noticed that the man was unresponsive. The man was removed from the van, and officers administered cardiopulmonary resuscitation (CPR). The man was taken back to the hospital where he was resuscitated and placed in an induced coma. The man’s condition deteriorated over the following days and the man sadly died.
During our investigation, we identified that the process through which the FLACS was introduced was not robust. The medical opinion obtained in relation to the FLACS appears to have been commissioned by the company which produces FLACS.
Accepted
On the 6 February 2023, the NPCC Self Defence and Restraint (SDAR) strategic group agreed a new Equipment and Tactics Governance Regime. This sets out a robust and documented process for the adoption of new equipment.
Once a capability gap has been identified through an evidence-based approach, potential options are presented to the SDAR chair and preferred option(s) agreed. Medical and/or scientific testing is to be undertaken prior to any pilot and final adoption of new equipment.
The IOPC recommends that the National Police Chiefs’ Council (NPCC) should undertake medical testing of the Flexible Lift and Carry System (FLACS) independent of the manufacturer. This should include testing of whether the FLACS can be safely used after a period of restraint and/or prone restraint and whether the person’s neck/windpipe can be suitably supported during transportation.
This follows an IOPC investigation where a man, who had been arrested by Thames Valley Police (TVP) officers, was taken to hospital after he had swallowed a large quantity of tablets and appeared unwell. The man remained under police guard while in hospital. When he was discharged from hospital, he appeared non-compliant and was physically restrained by two officers. Handcuffs and limb restraints were applied. Hospital staff assisted in the restraint at various intervals.
The officers called for support and an additional three officers arrived at the hospital with a police van. The man was restrained in the prone position by police for a prolonged period before the FLACS was applied to the man. This equipment is designed as a soft stretcher and aids the removal or evacuation of a subject.
The man was transported using the FLACS to a police van. Upon being placed into the van, officers noticed that the man was unresponsive. The man was removed from the van, and officers administered cardiopulmonary resuscitation (CPR). The man was taken back to the hospital where he was resuscitated and placed in an induced coma. The man’s condition deteriorated over the following days and the man sadly died.
During our investigation, the NPCC highlighted medical opinion that FLACS posed no risk to a subject’s neck/windpipe. However, medical opinion appears to have been commissioned by the company which produces FLACS.
Accepted
The NPCC will ensure that medical testing of the FLACS is independent of the manufacturer and will be undertaken prior to the reintroduction of FLACS.
The IOPC recommends that the National Police Chiefs’ Council (NPCC) and College of Policing work together to review and update guidance on the use of the Flexible Lift and Carry System (FLACS) following completion of the medical testing recommended in 2021/148339/003.
The updated guidance should also highlight that any individual to be moved in the FLACS will have been briefly in the prone position prior to its application.
This follows an IOPC investigation where a man, who had been arrested by Thames Valley Police (TVP) officers, was taken to hospital after he had swallowed a large quantity of tablets and appeared unwell. The man remained under police guard while in hospital. When he was discharged from hospital, he appeared non-compliant and was physically restrained by two officers. Handcuffs and limb restraints were applied. Hospital staff assisted in the restraint at various intervals.
The officers called for support and an additional three officers arrived at the hospital with a police van. The man was restrained in the prone position by police for a prolonged period before the FLACS was applied to him. This equipment is designed as a soft stretcher and aids the removal or evacuation of a subject.
The man was transported using the FLACS to a police van. Upon being placed into the van, officers noticed that the man was unresponsive. The man was removed from the van, and officers administered cardiopulmonary resuscitation (CPR). The man was taken back to the hospital where he was resuscitated and placed in an induced coma. The man’s condition deteriorated over the following days and the man sadly died.
The IOPC has recommended in 2021/148339/003 that the NPCC undertake medical testing of the FLACS independent of the manufacturer. Following completion of this medical testing, the IOPC is of the opinion that the guidance should be updated to reflect the findings. In addition, guidance on the use of FLACS should highlight that any individual to be moved in the FLACS will have been briefly in the prone position and that, although not intended as restraint equipment, the risks associated with restraint are still present.
Accepted
On the 22 September 2023, the NPCC National Tactical Advisory Group (NTAG) reviewed the training and tactics employed when utilising the FLACS.
The NTAG is the recognised lead body for the police service in all Public and Personal Safety Training (PPST) issues. The NTAG is comprised of a national cohort of experienced PPST instructors who support and advise chief officers.
The NPCC will engage positively with the College of Policing so that their guidance included within the National Personal Safety Manual is update
The IOPC recommends that the National Police Chiefs’ Council (NPCC) requires all forces to ensure they have mechanisms for recording the use of Flexible Lift and Carry Systems (FLACS), and similar manual handling devices, thereby providing a clear auditable process which forces can use to monitor the effectiveness of this equipment.
This follows an IOPC investigation where a man, who had been arrested by Thames Valley Police (TVP) officers, was taken to hospital after he had swallowed a large quantity of tablets and appeared unwell. The man remained under police guard while in hospital. When he was discharged from hospital, he appeared non-compliant and was physically restrained by two officers. Handcuffs and limb restraints were applied. Hospital staff assisted in the restraint at various intervals.
The officers called for support and an additional three officers arrived at the hospital with a police van. The man was restrained in the prone position by police for a prolonged period before a FLACS was applied to the man. This equipment is designed as a soft stretcher and aids the removal or evacuation of a subject.
The man was transported using the FLACS to a police van. Upon being placed into the van, officers noticed that the man was unresponsive. The man was removed from the van, and officers administered cardiopulmonary resuscitation (CPR). The man was taken back to the hospital where he was resuscitated and placed in an induced coma. The man’s condition deteriorated over the following days and the man sadly died.
The IOPC investigation identified that two of four police forces using the FLACS had no means of recording its use or effectiveness. It is recognised that other police forces may use similar devices that serve the same purpose as the FLACS, and the use of these devices and their effectiveness should also be recorded.
Accepted
The NPCC Self Defence and Restraint (SDAR) strategic group will contact forces to emphasise the need for accurate recording where force has been used and outline the requirement for accurate records to be kept when FLACS is used. The responsibility for recording the use of the FLACS, or any other equipment, will remain the responsibility of individual forces.
The NPCC wish to express our sincere condolences to the family and friends of the man who sadly died.