Independent Investigation Final Report
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- Bu səhifədəki naviqasiya:
- Introduction ..................................................................................................................................3
- Subjects to the investigation ......................................................................................................4
- Policies and Procedures ........................................................................................................... 40
- Learning Report ......................................................................................................................... 58
- Subjects to the investigation
- Chronological summary of events
- Previous contact with the police
- 20 May 2011 – prior to arrest
- The search for Mr Edwards
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Independent Investigation Final Report Mr Robert Edwards (Deceased) Death in custody – Suffolk Constabulary
IPCC Final Report Mr Robert Edwards
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Terms of Reference......................................................................................................................3
Background ................................................................................................................... 6 Previous contact with the police .................................................................................... 7
20 May 2011 – prior to arrest ......................................................................................... 7
The search for Mr Edwards ........................................................................................... 8 The Arrest of Mr Edwards ............................................................................................ 11
Events at the police station .......................................................................................... 13 First aid ........................................................................................................................ 35
Hospital ........................................................................................................................ 38 Post Mortem ................................................................................................................ 39
Events pre-arrest ......................................................................................................... 46 Arrest ........................................................................................................................... 47
Healthcare professional assessment ........................................................................... 49 Mark Trask ................................................................................................................... 50
PC Alison Huntley ........................................................................................................ 51 Barry Brackenborough ................................................................................................. 52
PS Jason Francis......................................................................................................... 55 PS Mark Whitehead ..................................................................................................... 56
PS Matt Gilbert ............................................................................................................ 57 Learning Report ......................................................................................................................... 58
Table of contents IPCC Final Report Mr Robert Edwards
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Introduction
1. On Friday 20 May 2011 at approximately 9.20pm Mr Edwards was arrested for an assault occasioning Actual Bodily Harm against his estranged wife Susan Edwards. Mr Edwards was taken to Bury St Edmunds police station where he was accepted into custody but placed on 30 minute rousing checks due to his intoxicated state. He was also seen by a healthcare professional. At approximately 1am on 21 May 2011 it was noticed that Mr Edwards could not be roused in his cell. He was seen by a doctor and an ambulance was called. First aid was provided, and he was then taken to West Suffolk Hospital where he was placed in a medically induced coma. 2. The IPCC were notified about this incident on 21 May 2011 by Suffolk constabulary. At the time of notifying the IPCC, Suffolk constabulary also raised concerns about Mr Edwards ’ s care whilst in police custody. 3. Due to the serious nature of Mr Edwards ’ s condition, it was decided on 25 May 2011 that the circumstances of Mr Edwards ’s detention would be independently investigated by the IPCC. At 9.30pm that night Mr Edwards died at West Suffolk Hospital.
D20 4.
The Terms of Reference for this investigation were finalised and agreed by IPCC Commissioner Sarah Green on 11 June 2011. They were to investigate: A. Whether officers involved in the search for Mr Edwards were provided with specific information that could have impacted on his care in custody, and if so, whether that information was passed onto the custody sergeant. B. T
he circumstances surrounding Mr Edward’s arrest and transportation to Bury St Edmunds Police Station. C. The initial risk assessment when Mr Edwards was first brought
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into custody. D. The care given to Mr Edwards whilst in custody.
5. To assist in fulfilling the state’s investigative obligation arising under the European Convention of Human Rights (ECHR) by ensuring as far as possible that: A. the investigation is independent on a practical as well as an institutional level; B. the full facts are brought to light and any lessons are learned.
6. To identify whether any subject of the investigation may have committed a criminal offence and if appropriate make early contact with the relevant prosecuting body.
7. To identify whether any subject of the investigation may have breached their standards of professional behaviour. If such a breach may have occurred, to determine whether that breach amounts to misconduct or gross misconduct and whether there is a case to answer.
8. To consider and report on whether there is organisational learning for the appropriate authority, including:
recurrence of the event, incident or conduct investigated.
Whether the incident highlights any good practice that should be disseminated.
9. There were three custody sergeants and four detention officers on duty at Bury St Edmunds Police custody suite during Mr Edwards ’s period of detention. The sergeants were Matt Gilbert, Jason Francis, and Mark Whitehead. The detention officers were Mark Trask, Sharon Giles, PC Alison Huntley, and Barry Brackenborough. IPCC Final Report Mr Robert Edwards
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There were concerns about the quality of the cell checks carried out on Mr Edwards during his detention by Mark Trask, PC Alison Huntley, and Barry Brackenborough. It was considered that these checks may not have been in accordance with the guidance and instructions given to them, and that consequently their conduct may have fallen short of either the Police Standards of Professional Behaviour (PC Huntley) or the Police Staff ‘Responsibilities And Obligations - General Rules on Behaviour and Conduct’ (Mr Trask and Mr Brackenborough) . Due to the serious potential consequences of their conduct, all three were served with Gross Misconduct Notices. The notices set out the allegations under investigation, and that the allegations, if proven could lead to a disciplinary hearing. All three subsequently provided detailed accounts of their actions during interview.
11. The custody sergeants are ultimately responsible for the welfare of the detainees. However, initially it was not clear which of the three sergeants on duty were responsible for Mr Edwards, and therefore all three were served with Gross Misconduct Notices. It then transpired, through correspondence from PS Gilbert’s Federation representative, that he was in a different charge room at Bury St Edmunds, booking in his own detainees, and he was not asked to perform any actions in relation to Mr Edwards. It was therefore decided that he was not one of the sergeants directly responsible for Mr Edwards. As a result, his Gross Misconduct Notice was withdrawn. The remaining sergeants subsequently provided detailed accounts of their actions during interview, and PS Gilbert provided a detailed statement.
12.
During the course of the investigation it was established that some of the officers who had been involved in searching for Mr Edwards, prior to his arrest, may have been provided with important information about a medical condition he suffered from when heavily intoxicated. It was believed that this information was not then passed onto the custody sergeants at Bury St Edmunds police station when Mr Edwards was taken there. The officers who it was believed this may have applied to
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were; PC Bell, PC McNee, PC Nailard, PS Aylott, and PC Peachy. 13.
It was decided that these officers would not be served with notices for misconduct. The basis of this decision was that, although if proven this would have amounted to an omission and potentially a breach of the Standards of Professional Behaviour, a more proportionate way to deal with any omission, in accordance with the Taylor principle enshrined in the new misconduct system, would be through learning or Management Action. Accordingly, these officers provided witness statements.
S5b S5a
S6 S8
S18 14.
Some background information about Mr Edwards has been obtained from his estranged wife Susan Edwards, his sister Belinda Edwards, and his partner Michelle Harrison.
15. It is relevant to note that prior to the events on 20 May 2011 Mr Edwards was known to have a history of problems related to the use of alcohol and drugs, which commenced during his youth in South Africa before he emigrated to the UK in the late 1980s.
16.
Despite some lengthy periods of abstinence Mr Edwards continued to experience problems with alcohol and in more recent years was also known to have problems with the use of prescription drugs, and occasional use of recreational drugs. Mr Edwards’s marriage to Susan Edwards deteriorated at the start of 2010, after she discovered he had been having an affair with Michelle Harrison. Mr Edwards moved out of the family home to an address in Bury St Edmunds. His alcohol and drug use notably increased, and included the use of heroin.
17. In August 2010 Mr Edwards was prescribed methadone in an attempt to manage his drug addiction. At this point he was a habitual alcohol user, but there is no evidence that he continued to use heroin.
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D19
18. Mr Edwards spent subsequent periods living at the family home, but in March 2011 Mr Edwards was convicted of assaulting his wife. He then moved to live with his sister, Belinda Edwards, in Bury St Edmunds. Belinda Edwards has described Mr Edwards as being very rarely sober between March 2011 and May 2011; he would take his methadone in the morning and then use alcohol through the day and night. As of 12 April 2011 Mr Edwards was subject of a restraining order which prohibited him from making contact with Susan Edwards or visiting the family address.
D51
19. It was established through previous custody records for Mr Edwards that, prior to his arrest on 20 May 2011, he had been in custody at Bury St Edmunds Police Station several times, and some officers and police staff involved in this investigation had had previous dealings with him.
20.
Mr Edwards was accepted into police custody at Bury St Edmunds Police Station on 5 March 2011, 10 March 2011, and 18 March 2011. On each occasion it was identified that he was dependent on methadone and alcohol. On each occasion he was placed on a minimum of 30 minute checks and seen by a healthcare professional. On all three of these occasions, after a period of time in custody, Mr Edwards started to suffer from the effects of withdrawal from either alcohol or methadone. Notably when Mr Edward was in custody on 10 March 2011, after a long period of time in custody he suffered from acute alcohol withdrawal symptoms, including fitting, and was taken to West Suffolk Hospital.
21. The custody records show that PS Francis, PS Gilbert, PS Whitehead, and Mr Trask had each been on duty at least once during Mr Edwards’s previous periods of detention .
20 May 2011 – prior to arrest IPCC Final Report Mr Robert Edwards
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S18
22. In her statement Belinda Edwards said that on the morning of 20 May 2011 after 7.00am she found that Mr Edwards had been drinking during the night and he was drunk. Sometime later Mr Edwards left to get his methadone prescription. S8
23. In her statement Michelle Harrison stated that she last saw Mr Edwards at 12.30pm on 20 May 2011. She stated that she was aware that Mr Edwards had taken his methadone prescription and had consumed half a bottle of vodka.
24. Belinda Edwards stated that after Mr Edwards returned to her house he consumed four cans of cider and a half bottle of vodka. By the time she left at 1.50pm she saw that Mr Edwards had consumed a further four cans of cider and another half bottle of vodka.
25.
She said she returned home at 3.10pm and found Mr Edwards was still there. She explained that they went together to her new house where Mr Edwards offered to do some decorating. She said that on their return to Belinda Edwards’s old house Mr Edwards stopped to buy another half bottle of vodka and four cans of cider, which he then consumed at her house. S5
Belinda Edwards has also said that Mr Edwards wanted to borrow tools from his estranged wife Susan Edwards and spoke to her on the phone. In her statement Susan Edwards explained that she told him not to come over, but he said he would do so. Belinda Edwards then drove Mr Edwards to Susan Edwards’s house in Bury St Edmunds .
27. Susan Edwards has described how she opened the door to Mr Edwards and told him that he should not be there, but he entered against her wishes. An altercation between Mr Edwards and Susan Edwards took place inside the house, which Susan Edwards was to later report to the police as an assault.
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D16
S6 28.
Suffolk Police were called at 8.14pm by one of Mrs Edwards ’ s neighbours, whose name is known to the IPCC, to report that Robert Edwards was at Mrs Edwards ’ s address in breach of his restraining order. The neighbour reported that Mr Edwards had threatened her husband then left the scene in a car. From this call Suffolk Police created an ‘Event Chronology’ . This is an electronic record on which details of a police response to an incident are recorded, including who is deployed, updates from the people deployed, and times of events.
29.
A number of officers were deployed to deal with this incident. Their actions involved tracing Mr Edwards, seeing Susan Edwards, Belinda Edwards, and Michelle Harrison, and also ensuring Mr Edwards’ s children were located and safe. S18 30.
Belinda Edwards explained she left the scene with Mr Edwards before the police arrived, and she drove Mr Edwards to a Co-operative shop where he bought a large bottle of vodka. She then left him there and drove home. D16 31.
The Event Chronology showed that at 8.48pm a taser authority was given by Inspector Hill due to information the police had obtained that Mr Edwards may have been in possession of a knife which it was thought he had taken from Mrs Edwards’s house, and may be violent. His grounds, as recorded on the Event Chronology, were that he had reason to suppose that officers attending this incident may have to protect themselves, other officers or members of the public from violence or threats of violence of such severity that they may need to use force. S30
S32 S33
S4a 32.
Officers involved in searching for Mr Edwards explained that they passed Belinda Edwards ’ s home address at around 9pm. Outside the address they saw the car Mr Edwards had been seen in earlier. They explained that they therefore searched Belinda Edwards ’ s home, but Mr Edwards was not there. They said Belinda Edwards provided them with keys to her new home where she said she thought Mr Edwards IPCC Final Report Mr Robert Edwards
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may have gone, and told them Mr Edwards had got out of her car at the Three Kings Public House in Fornham.
33.
Belinda Edwards has stated that during this visit by officers she informed one of them that they needed to watch Mr Edwards when he was arrested because he could vomit in his sleep, and potentially he could choke. She said she had seen Mr Edwards do this on a number of occasions and was worried this would happen due to the amount he had drunk.
34.
None of the officers who went to see Belinda Edwards remember her saying this. S1a
At around the same time PC Nailard has explained that she and PC Harper went to see Michelle Harrison at her home address where they thought Mr Edwards may have gone, and he had previously been arrested for making threats towards her. However, the officer explained that Ms Harrison said she had not seen or heard from Mr Edwards that evening. PC Nailard and PC Harper stayed with Ms Harrison at her home until Mr Edwards was later detained. S8
36. Ms Harrison has explained that whilst these officers were with her, she told PC ‘Naitland’ , who she knew from a previous incident, that Mr Edwards was taking Methadone and had drunk alcohol that day. She explained that she was worried that at times when Mr Edwards was asleep he would vomit and not wake up, or be aware that he had vomited. She asked PC ‘Naitland’ that they ke ep an eye on him in custody because of this. Ms Harrison explained that she told PC ‘Naitland’ this whilst the two of them were outside. Ms Harrison has also explained that the following day she told Belinda Edwards that she had told the officers this.
37.
PC Nailard has said that she did not remember being told this by Ms Harrison.
IPCC Final Report Mr Robert Edwards
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