Independent Investigation Final Report
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- Bu səhifədəki naviqasiya:
- Hospital
- Post Mortem
- Policies and Procedures
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First aid 129. The CCTV showed at 1.01am that PS Francis went to Mr Edwards ’ s
kneeled down by his head. He explained in interview he tried various different techniques to try and rouse Mr Edwards including calling his name and shaking his shoulder but did not get a response. The CCTV showed that PS Francis and Mr Brackenborough pulled Mr Edwards back further onto the mattress and away from the vomit he was lying in. PS Francis then rolled him onto his left hand side in the recovery position. PS Francis tried further measures to rouse Mr Edwards including applying pressure to his finger with a pen, and rubbing his chest, but has explained he was still not able to rouse him. S14
130. At 1.06am the CCTV showed that Mr Brackenborough left the cell to get Dr Dorsett who was in the su rgeon’s room , a few meters away from the cell. Mr Brackenborough explained they needed to know whether Mr Edwards had to go to hospital.
131. The CCTV showed at 1.07am that Dr Dorsett entered Mr Edwards’ s cell with Mr Brackenborough. Dr Dorsett explained that he performed a ‘ rib rub ’ on Mr Edwards but did not get a response, so advised that an ambulance should be called immediately. He recorded that Mr Edwards
’ s pulse was about 86 and regular, his breathing had no added sounds, he was not rapid or slow breathing, and his eyes were unremarkable. Dr Dorsett said he instructed PS Francis to continue to keep him in the recovery position and to call if there was further deterioration. PS Francis explained he requested Mr Brackenborough to call an ambulance and the Duty Inspector, Inspector Benham.
132. The CCTV showed Dr Dorsett and Mr Brackenborough then left the cell. Dr Dorsett explained he went to resume the blood procedure he had been conducting. Mr Brackenborough said he went to the custody room and got PC Huntley to call the ambulance, whilst he called Inspector Benham and explained about Mr Edwards ’ s condition. IPCC Final Report Mr Robert Edwards
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133. PC Huntley said that she phoned for an ambulance and explained they had a detainee who was unconscious and breathing. This was recorded on the East of England Ambulance Service call records at 1.09am.
134. The CCTV showed at 1.10am Mr Brackenborough briefly went back to the cell, then left to go and get a blue blanket which he brought back in and put around Mr Edwards. Very soon after this PC Huntley brought a defibrillator into Mr Edwards ’ s cell and placed it on the bed. 135. In interview PC Huntley explained that she brought the defibrillator into the cell as a precautionary measure, and that it was something she knew about from her first aid training. S12
Edwards ’ s cell. She has explained that she asked where the doctor was, and was informed he was in the middle of a blood procedure. Inspector Benham then went to see Doctor Dorset and explained he was needed back in the cell.
137. The CCTV showed that at 1.15am PS Francis turned Mr Edwards over onto his back. He has explained that was to be in a better position to check his breathing, as he thought it may have stopped. Just after doing so Dr Dorsett and Inspector Benham arrived back in the cell. Dr Dorset checked Mr Edwards ’ s pulse, then ripped his shirt open. PS Francis prepared and attached the defibrillator, and Mr Brackenborough prepared his breathing mask. Dr Dorsett has explained Mr Edwards ’ s blood pressure and pulse were unrecordable and his pupils were measured as 3.5mm.
138. The CCTV showed at 1.18am that PS Francis commenced chest compressions and Mr Brackenborough provided Mr Edwards with air through a breathing mask.
139. At 1.19 Inspector Benham provided an update, via her radio, for the ambulance on route that Mr Edwards had stopped breathing and IPCC Final Report Mr Robert Edwards
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cardiac massage had commenced. This was shown on the CCTV and ambulance call records. S10
S15 140. The CCTV showed at 1.23am paramedics Andrew Sprake and Andrew Mascall entered Mr Edwards ’ s cell and have explained the following: Mr Mascall took responsibility for Mr Edwards ’ s airways. Mr Sprake set up the defibrillator they had brought with them which was to replace the police defibrillator, because their machine had a monitor that allowed them t o view the patient’s cardiac rhythm and also to manually shock. Mr Edwards ’ s cardiac rhythm was in asystole, meaning there was no electrical output from his heart. Mr Sprake then took responsibility for canulation for IV treatment, and PS Francis continued with chest compressions.
141. Mr Mascall explained that he assembled his equipment to attempt an intubation which means to insert a breathing tube into somebody’s airways. He explained the advantages of intubation would have been to have allowed good access for air directly into Mr Edwards ’ s lungs and also to prevent any vomit going into his lungs. He explained that as fast as he was suctioning Mr Edwards to clear the vomit, more vomit was coming up. This was making it impossible to see where to insert the tube. After a couple of attempts at the intubation, he explained he decided that the best airway to insert was a shorter oro- pharyngeal airway which extends to the back of the tongue. He inserted this, and then used the bag and mask to provide Mr Edwards with air.
142. Mr Sprake explained that during the CPR he provided Mr Edwards with drugs in the following order; adrenalin (1mg at 1.30am), naloxone (400mg at 1.34am), adrenaline (1mg at 1.35am), naloxone (400mg at 1.37am), and then adrenaline (1mg at 1.41am).
143. Mr Sprake and Mr Mascall have explained that following the third dose of adrenaline, and in conjunction with the chest compressions and bagging, there was a change in Mr Edwards ’ s heart rhythm. His IPCC Final Report Mr Robert Edwards
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rhythm had changed to ventricular fibrillation (VF) meaning there was chaotic electrical activity in the heart, and therefore they could administer a shock with their defibrillator. Following the shock, they carried on with CPR until a beep was heard from the defibrillator at approximately 1.43am. Mr Edwards ’ pulse was checked and it was present, and the defibrillator showed that Mr Edwards had a heart rate compatible with life. Mr Mascall explained he then continued to ventilate Mr Edwards as he was still not breathing independently. The CCTV shows that Mr Edwards was then placed on a stretcher, carried to the ambulance, and taken to West Suffolk Hospital.
144. It could be seen on the CCTV that at 1.59am Mr Brackenborough was in the custody room with PC Huntley, and was asking her whether she had printed off the medical form for Mr Edwards, and said: ..because that was what we were saying, if he becomes difficult to rouse….. that’s why I said to Jason, at what point is difficult difficult? When I went up there that last time he actually told me to fuck off (laughs) which is not on there because I came and got Jason straight away.
D145 145. Dr Michael Palmer, a consultant at West Suffolk Hospital, has provided details of Mr Edwards’s treatment there. He was not present when Mr Edwards was first brought in, but did have involvement in Mr Edwards’s care. He has explained the following: at 2.05am Mr Edwards arrived at West Suffolk Hospital. He was deeply unconscious, still required assisted breathing and it was noted there was a large amount of vomit around his mouth and in his throat. After attempts to reduce his body temperature to prevent brain damage due to oxygen depravation, he was taken to the intensive care unit for continued support as per the hospital unit’s protocols for out of hospital cardiac arrest.
146. Mr Edwards remained in intensive care until 25 May 2011 when he IPCC Final Report Mr Robert Edwards
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was reviewed by Dr Paul Molyneux, a neurology consultant at West Suffolk Hospital. Dr Molyneux reported that the clinical findings supported significant hypoxic brain injury and that he had never seen a patient with such damage make a recovery. Dr N Levy, the on call ICU consultant then had a discussion with Mr Edwards ’ s family and all agreed continued invasive management was inappropriate. Ventilatory support was then reduced from 5pm that day, and Mr Edwards died at 9.30pm.
D27 147. On Friday 27 May 2011 a post mortem for Mr Edwards was carried out by Home Office Approved Pathologist Dr Nat Cary at West Suffolk Hospital Mortuary. Prior to the post mortem Dr Cary was provided with a briefing prepared by the IPCC, based on the information known about Mr Edwards’ s arrest and detention at that time. Dr Cary also had sight of Mr Edwards’ s medical records, and was asked specifically to look for any evidence of choking, head injury, and restraint. A number of samples were taken at the Post Mortem which were sent for analysis. S9a S19
148. Dr Cary concluded in his post mortem report that Mr Edwards ’ s death was the result of severe hypoxic brain injury, itself a consequence of cardiac arrest. Examination of Mr Edwards ’ s brain identified evidence consistent with cardiac arrest and chronic alcohol abuse, and there was no evidence of any traumatic brain injury. The circumstances leading up to cardiac arrest would suggest that there was respiratory arrest associated with a large aspiration of gastric contents. This and the inability to rouse would be in keeping with loss of consciousness as a result of the combined effects of alcohol and drugs. The back- calculated blood alcohol level for the time at which Mr Edwards was unrousable was 272-302mg%, which would equate to severe drunkenness with the potential to cause unconsciousness. When combined with the presence of methadone also detected in Mr Edwards ’
blood, in Dr Cary’s opinion, the combined effects would IPCC Final Report Mr Robert Edwards
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account for cardiac arrest and ultimate death. 149. Dr Cary also explained there was no evidence of any injuries of assault or restraint, and the fact that cardiac output ultimately returned would suggest that the cardiac arrest was promptly dealt with. There was nothing present to suggest there had been a prolonged period of cardiac arrest before resuscitation was instigated.
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150. Section 3(1) of the Criminal Law Act 1967 states that a person may use such force as is reasonable in the circumstances in the prevention of crime, or in affecting or assisting in the lawful arrest of offenders or suspected offenders or of persons unlawfully at large. D192 151. Section 24 of the Police and Criminal Evidence Act 1984 states that if a constable has reasonable grounds for suspecting that an offence has been committed, he may arrest without a warrant anyone whom he has reasonable grounds to suspect of being guilty of it. Conditions must apply which includes the arrest is necessary for a prompt an effective investigation.
152. Section 28 of the Police and Criminal Evidence Act 1984 states where a person is arrested, otherwise than by being informed that he is under arrest, the arrest is not lawful unless the person arrested is informed that he is under arrest as soon as is practicable after his arrest.
153. Section 32 of the Police and Criminal Evidence Act 1984 states that a constable may search an arrested person, in any case where the person to be searched has been arrested at a place other than a police station, if the constable has reasonable grounds for believing that the arrested person may present a danger to himself or others.
154. Section 117 of the Police and Criminal Evidence Act 1984 provides that officers may use reasonable force, if necessary, in exercising their powers. IPCC Final Report Mr Robert Edwards
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155. The PACE Codes of Practice provides the core framework of police powers and safeguards around stop and search, arrest, detention, investigation, identification and interviewing detainees. Code C of the Code of Practice relates to people who enter into police custody.
156. Paragraphs 3.6 to 3.10 of Code C relates to risk assessments that must be conducted of detainees when they are brought into custody. It states that the custody officer is responsible for the initiation of an assessment to consider whether the detainee is likely to present specific risks to custody staff or themselves. The assessment should always include a check on PNC.
157. Paragraph 9.3 states that those suspected of being intoxicated through drink or drugs must, subject to any clinical directions given by the appropriate healthcare professional; Be visited and roused at least every half an hour Have their condition assessed as in Annex H And clinical treatment arranged if appropriate 158. Annex H, referred to above, sets out an observation list for rousing detainees. It states that if a detainee fails to meet any of the criteria then a healthcare professional or ambulance should be called. The criteria set out was:
– can they be woken? Go into the cell Call their name Shake gently Response to questions – can they give appropriate responses to questions such as:
What’s your name?
Where do you live? IPCC Final Report Mr Robert Edwards
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Response to commands – Can they respond appropriately to commands such as: Open you eyes! Lift one arm, now the other arm! D193 159. The ACPO Guidance on the Safer Detention and Handling of Persons in Police Custody 2006 provides national guidance to police forces about the treatment of people in custody. It sets out to provide a definitive guide on how police forces should put in place strategic and operational policies to help raise the standards of custodial care for those that come into contact with the police.
160. Section 3.3.2 provides guidance to officers about whether to take someone to hospital instead of taking them into police custody. It states that a detainee should be taken directly to hospital if they: Have suffered a head injury; Are, or have been, unconscious; Have suffered serious injury; Are drunk and incapable and treatment centres are not available; Are believed to have swallowed or packed drugs; Are believed to have taken a drugs overdose; Are suffering from any other medical condition requiring urgent attention; Are suffering any condition that the arresting officer or transporting staff believes requires treatment prior to detention in custody.
161. Section 2.4.1 provides guidance on the handling of detainees believed to be intoxicated through alcohol. It states that a person found to be IPCC Final Report Mr Robert Edwards
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drunk and incapable should be treated as being in need of medical assistance and an ambulance called, and as a last resort taken into custody at a police station. It also states that there are particular concerns to look out for when rousing and checking intoxicated detainees: Where a person becomes harder to rouse the change may be due to a serious unidentified medical condition such as a stroke. Where they are quiet or snoring, which can be a significant indicator of risk, they should be roused and checked at least every thirty minutes until they are talking coherently. General guidance is given in PACE Codes of Practice Code C, Annex H.
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162. In addition to the above, Suffolk Constabulary also have local policies and procedures in place to ensure compliance with all relevant legislation and guidance. There were a number of these in place at the time of Mr Edwards ’ s detention, although they have now been replaced by a single policy for Suffolk and Norfolk Constabularies. This single policy was designed to be implemented in the new Prisoner Investigation Centres, a collaborative initiative between the two forces. However, the policies and procedures relevant to this investigation, when assessing the actions and decisions of people involved in this incident, will be those that were in operation at Bury St Edmunds at the time of Mr Edwards ’ s detention. D101 163.
Suffolk Constabulary’s
‘Custody - Observation and Engagement (Protecting Detainees) Procedure’ echoed the instructions for rousing procedures as set out in PACE Code C and The ACPO Guidance on the Safer Detention and Handling of Persons in Police Custody 2006. It also stated that custody officers commencing their shift must visit every detainee; review the risk assessment and control measures, and
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that this must be recorded on the custody record. D99 164.
Suffolk Constabulary’s ‘Custody - Handover of Responsibilities ’
about to commence duty, they would decide on the appropriate division of duties and detainees and sign for those detainees respectively. The division of work/detainees did not mean exclusive responsibility for the particular detainees. Where the sergeant was busy and an issue arose, the other sergeant was required to undertake any actions necessary and record all such actions in the custody record.
165. The procedure stated that the incoming officer would visit each detainee and observe them, carrying out rousal visits if required, checking on the detainee’s welfare and verifying the observation routines in place for each detainee. The incoming custody sergeant, after each visit to a detainee, would state on the custody record that they had observed/visited the detainee and have now taken responsibility for that detainee.
166. The procedure stated that once a custody sergeant had taken responsibility for a detainee they retained their responsibility until such time as another custody sergeant signed the custody record to state that they were then responsible. They were responsible for briefing the detention officers on all the relevant issues for each detainee and ensuring compliance with the Custody - Observation and Engagement (Protecting Detainees) Procedure. Where two or more custody sergeants were on duty they were all equally responsible for ensuring the safety and welfare of all detainees and would carry out any necessary actions required if the sergeant who signed the custody record was busy or otherwise occupied.
167. The incoming custody sergeant was responsible for ensuring that the outgoing detention officer provided a full briefing to the incoming detention officer, including any on-going issues or outstanding tasks IPCC Final Report Mr Robert Edwards
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related to the care and welfare of the detainees. D179 168. Inspector Zoe Finn a custody inspector at Bury St Edmunds Police Station has explained the protocol in place in Bury St Edmunds at the time of this incident was not so prescriptive as to definitively say which sergeant should do what, and which sergeant would be responsible for each detainee. She explained that the "norm" depended on the number of sergeants on duty at the time. In this instance, given that there were three sergeants on duty, PS Francis would handover to PS Whitehead. PS Francis would then become a detention officer for the remaining three hours of his duty, leaving PS Whitehead and PS Gilbert in charge of detainees that they each individually book in. She also explained that if there were three custody sergeants on duty, the oncoming sergeant would take over responsibility for the detainees booked in by the outgoing sergeant.
169. Inspector Finn also explained that the situation would always be fluid depending on how busy the custody suite was, one sergeant may step in and assist booking in for another for instance. She acknowledged that this was a grey area at the time. The uncertainty, which had been identified during the planning and implementation of the Prisoner Investigation Centres, led to the design of the new "suite supervisor" role.
D190 170. The IPCC publishes a Learning the Lessons bulletin every few months which contains case studies of IPCC investigations where learning has been identified. These bulletins are disseminated to police forces nationally with the intention of helping police forces improve by learning from these cases. Bulletin 3, which was published in February 2008, focused on the detention of people in police custody. It contained learning from a death in custody which had some very similar to themes to this case. A detainee who had consumed alcohol and methadone had been placed on 30 minute rousing checks. During the checks the detention officer found that sometimes the only response was ju st an audible groan or ‘I’m fine’. One of the key
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lessons in this case was that staff should be informed of PACE code updates/legislation, this referred specifically to the observation list set out in Annex H as some of the responses received during the checks did not comply with this. S22
D78- D82 171. The officers subject to this investigation had all been trained on PACE Code C, and specifically on rousing as defined in Annex H.
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