Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0499, written 14 Nov 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Nov 2014 |
|---|---|
| Reference | 2014-0499 |
| Deceased | Kirk Williams |
| Coroner | Sam Faulks |
| Coroner area | Teesside |
| Category | Police related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
1 2 3 4 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. 2. 3. 4. 5. 6. 7. Legal representatives of the Interested Persons (see Box 8) 8. IPCC CORONER I am Sam Faulks, assistant coroner, for the coroner area of Teesside CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. INVESTIGATION and INQUEST On 13.10.14 I resumed an inquest into the death of Kirk William Williams, aged 26. The investigation concluded at the end of the inquest on 06.11.14. The conclusion of the inquest was the cause of death was Ia Excited Delirium and II Coronary Artery Atheroma and Left Ventricular Hypertrophy. The narrative conclusions of the jury were elicited via a questionnaire. In summary it was found that it had been inappropriate for police officers to have taken Kirk Williams to a police station when he was detained. He should have been taken to hospital instead. The jury considered that Kirk Williams would have been accepted and treated in accident and emergency. However, the jury were unsure as to whether such treatment would have saved his life. CIRCUMSTANCES OF THE DEATH On 17.04.11 Kirk Williams was seen running around fields adjacent to the Moorhouse Estate, Stockton- on-Tees. He had ingested a number of drugs including, alcohol, cocaine, ‘M-cat’, MEC and PVP. He had divested himself of all of his clothing and was exhibiting bizarre, aberrant and very agitated behaviour. It took 4 police officers to restrain Mr Williams, apply handcuffs, leg restraints and secure him in a police van. A total of 6 police officers were in attendance in the field. One officer, it is accepted, stated that Mr Williams should be taken to hospital. The dilated pupils, agitated state, intense heat and aberrant behaviour caused that officer to consider that Mr Williams may be suffering from a condition known as ‘Excited Delirium’. The other 5 officers did not accept that the local hospital (University Hospital North Tees) would accept such an unpredictable and aggressive patient. Because those officers were content that there would be medical staff at the local police station (Middlehaven or Middlesbrough police station,) they decided that Mr Williams should be taken there. Having been taken into Middlehaven at 12:04pm, custody officers were advised by the locum forensic medical examiner at 12:19pm to have Mr Williams taken to hospital. Paramedics arrived at 12:29pm and following a cardiac arrest at 12:49pm Mr Williams was taken to James Cook University Hospital at 13:13 hours. Following extensive treatment, Mr Williams died at 14:32 hours. The pathology evidence was that Mr Williams died of Ia Excited Delirium and II Coronary Artery Atheroma and Left Ventricular Hypertrophy. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. 1 The MATTERS OF CONCERN are as follows. – (1) Police officers in Cleveland doubtless receive training about Excited Delirium and now understand in a way that they perhaps previously did not that the condition should be treated as a ‘medical emergency’ which thereby requires the detainee’s attendance at a hospital. (2) Some police officers still consider that notwithstanding that they may be faced with a medical emergency, A&E departments will not treat violent or aggressive patients. (3) The various consultants that gave evidence are clear that they will treat violent patients provided that (a) treatment is warranted and (b) they are provided with sufficient assistance from either or both the police or security staff. (4) It therefore follows that there is a mismatch in perception and expectations between Cleveland police officers and local A&E staff. (5) There did not appear to be a sufficiency of understanding within Cleveland Constabulary about how and whether detainees may be treated at A&E departments. (6) Further or alternatively, the insufficiency in understanding lies with A&E consultants and their perception of what type of patients will be accepted and allowed to be treated in their departments. (7) There does not appear to be a dialogue between Cleveland Constabulary and local A&E departments to address these particular misunderstandings or misconceptions. (8) There does not appear to be any memorandum of understanding or guideline to cover aggressive detainees in police custody being taken to A&E departments. (9) Without a fuller understanding of the true position, police officers will continue to be faced with the perennial dichotomy of whether to take an aggressive medical emergency detainee to an A&E department for treatment or to a police station to prevent self harm or harm to others. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 09.01.15. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons’ representatives, namely those acting for the family, Cleveland Constabulary, former NEAS, JCUH and Tascor (formerly Reliance). I have also sent it to the IPCC who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 6 7 8 2 9 14.11.14 3
3 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Jacqui Cheer, QPM, BA(Hons), MBA, Dip(Cantab) Chief Constable 07 JAN 2015 Postal Reply to: CRIME & JUSTICE COMMAND Shared Service Centre Ash House TI Acres Princeton Drive Thornaby Stockton on Tees Your Ref: TS17 6A) Our Ref: PM/PC Telephone: P| Direct Line Fo 5" January 2015 Dear Mr Faulks Inquest into the Death of Kirk Williams Further to your letter dated 14th November 2014 and the issuing of the Regulation 28 Report to prevent future deaths, | am writing to you on behalf of Cleveland Police to update you on the progress made by the Force against the actions you identified in your report: At point 1 in your report you note that “Police Officers in Cleveland doubtless receive training in excited delirium” that is correct, all front line officers are required to undertake Personal Safety Training on an annual basis, during that training they receive an input on “excited delirium’. At point 8 in your report you identified that there did not appear to be a Memorandum of Understanding or guidance to cover aggressive detainees in Custody being taken to A&E Departments. In order that this could be addressed a meeting was held at North Tees General Hospital on 9th December 2014. Amongst those present were Medical Director and A&E Consultant at North Tees and Hartlepool Trust , Clinical Director, A&E Consultant i j ospital North Tees, Clinica! Director, A&E Consultant Hospital, | represented Cleveland Police. Mr S. Faulks Assistant Coroner for Teesside Teesside Coroners Service Town Hall Albert Road CRIMESTOPPERS Middlesbrough TS1 2QJ 0800.555:441 We ae an equal opportunities employer The following actions were agreed and they wil! now form the basis of guidance which will be issued to staff by both Trusts and Cleveland Police, If a detainee has a known past mental health history they should be taken to the 136 unit at Roseberry Park. if there are serious concerns regarding physical health, detainees should be presented to an A & E department where they will be assessed. If the detainee is violent and aggressive a joint decision by senior A & E staff and the police will be taken as where best to provide treatment ie. if the department is full and there is a risk to other patients, assessment may even take place outside of the department possibly in police vehicles. If there is the suggestion that a detainee is ill or injured and the ingestion of drugs is causing problems, treatment with restraints may be appropriate be it physical or medical restraints. Depending on the circumstances this may include assistance from anaesthetic colleagues. If the medical assessment concludes that the detainee is not in need of treatment they will be returned to police custody. If, following any necessary treatment, the detainee is returned to police custody, a copy of the A & E notes will be given on discharge detailing treatment given. If there are any further concerns following return to police custody, the police doctor should contact the A & E department for further advice. All staff both NHS and Police to be informed of the guidelines agreed for future reference. The Force is in the process of briefing staff about the new guidelines, staff working in the Custody environment (including medical staff) and all front line officers will be briefed, Due to the holiday period this has been delayed, but it is expected that all relevant staff will have been briefed by 12th January 2015. It is my intention to review the effectiveness of the guidance in six months’ time and to take any appropriate action where necessary, whether that is amendments to the guidance in conjunction with the two Trusts, or further training to ensure staff are aware of and are implementing the guidance. Yours sincerely Temporary Detective Chief Superintendent Head of Crime and Justice Command Template Revised 08/2007 CP(.SAPERSONAL ASSISTANT TEAM:CRIME & JUSTICE COMMAND\MCPHILLIPS\LETTERSWOL S\LETT PM -
Lala 4 England Medical Directorate Skipton House 80 London Road London SE1 6LH 28 January 2015 Mr S Faulks The Coroners Service Town Hall Albert Road. Middlesbrough TS1 2QJ Dear Mr Faulks Inquest into the death of Kirk Williams Further to your letter dated 14 November 2014 and the issue of the Regulation 28 report to prevent future deaths, | would like'to offer my sincere condolences to the family of Kirk Williams regarding his death. From our review and consideration, we note that the issues concerning substance misuse and possible mental health issues have been addressed in the responses from the local health care Commissioners and Trusts. However, in view of the serious nature of this case, | will be considering it further with NHS England's Northern Regional Medical Director, | with a view to determining whether changes need to be made to relevant current policies and guidance. This will also include liaison with colleagues in Public Health England, with regard to commissioning and provision of substance misuse services. Furthermore, it is acknowledged that South Tees Hospitals NHS Foundation Trust, North Tees and Hartlepool NHS Foundation Trust, Esk and Wear Valleys NHS Trust, the CCGs and North East ambulance Service, County Durham and Darlington NHS Foundation Trust have all signed up to the Crisis Care Concordat, to support people in crisis. The Crisis Care Concordat is a national commitment between all services and agencies that come into contact with people in crisis. It sets out how they will work together and be involved in the care and support of people in crisis, and how they ensure people get High quality care for all, now and for future generations the support they need, when they need it. This commitment addresses the improvement in the commissioning and provision of services for those with co-existing mental health and substance misuse issues. One of the aims of the Crisis Care Concordat is that people in health care crisis should be taken to health care facilities, rather than police cells. The key ambition of the Concordat is for every local area to commit to, agree and deliver their own Mental Health Crisis Declaration and Action Plan. As one of the signatories to the Crisis Care Concordat, NHS England is committed to working alongside other agencies to improve the system of care and support for people in crisis, to work together to identify the causes of crises, and put in place prevention and early intervention plans whenever possible. | am grateful to you for bringing this case to my attention. Yours sincerely Sir Bruce Keogh "Bruce Keogh, KBE, MD, DSc, FRCS, FRCP National Medical Director NHS England High quality care for all, now and for future generations
South Tees Clinical Commissioning Group North Ormesby Health Village 1° Floor 11 Trinity Mews North Ormesby Middlesbrough TS3 6AL Fax: Website: www.southteesceg.nhs.uk 7 January 2015 Mr S Faulks Assistant Coroner for Teesside The Coroner's Service Town Hall Albert Road Middlesbrough TS1 2QJ Dear Mr Faulks Inquest into the death of the late Kirk William WILLIAMS Regulation 28 Report Further to your tetter of 24 November 2014 and subsequent email correspondence relating to the above, | am now in a position to respond to the issues raised in the Regulation 28 Report. As agreed, this response constitutes a combined reply on behalf of NHS South Tees CCG, NHS Hartlepool and Stockton on Tees CCG, NHS Durham Dales, Easington and Sedgefield CCG and NHS North Durham CCG. As the health economy covered by the above CCGs covers two police forces, | have provided the response based on those boundaries: NHS South Tees CCG and NHS Hartlepool! and Stockton on Tees CCG — Cleveland Police A meeting was held between the Medical Directors and senior A&E medical staff of both Foundation Trusts and Detective Chief Superintendent from Cleveland Police. At that meeting, a wide range of actions were agreed in order to address the point you raised relating to the apparent lack of guidance or Memorandum of Understanding for aggressive detainees in custody being taken to A&E departments. These actions are: improvin henlth 9 together ef adetainee has a known past mental health history they should be taken to the 136 unit at Roseberry Park. ef there are serious concerns regarding physical health, detainees should be presented to an A & E department where they will be assessed. ° If the detainee is violent and aggressive a joint decision by senior A & E staff and the police will be taken as where best to provide treatment ie if the department is full and there is a risk to other patients, assessment may even take place outside of the department possibly in police vehicles. ef there is the suggestion that a detainee is ill or injuredand the ingestion of drugs is causing problems, treatment with restraints may be appropriate be it physical or medical restraints. Depending on the circumstances this may include assistance from anaesthetic colleagues. e Ifthe medical assessment concludes that the detainee is not in need of treatment they will be returned to police custody. e If, following any necessary treatment, the detainee is returned to police custody, a copy of the A & E notes will be given on discharge detailing treatment given. e If there are any further concerns following return to poice custody, the police doctor should contact the A & E department for further advice. e All relevant staff, both NHS and Police, to be informed of the guidelines agreed for future reference. In relation to point 5.1 in the report, Cleveland Police have confirmed that all front line officers are required to undertake Personal Safety Training on an annual basis and that during the training they receive an input on “excited delirium” We have been advised by Cleveland Police that they are in the process of briefing staff about the new guidelines. Staff working in the custody environment induding medical staff and all front line officers will be briefed by 12 January 2015. In addition, the Police will be reviewing the effectiveness of the guidance in six months’ time and will take any appropriate action where necessary, ie amending guidance in conjunction with South Tees Hospitals NHS Foundation Trust and North Tees & Hartlepool NHS Foundation Trust or providing further training to ensure staff are aware of, and are implementing, the guidance. As a final point, the Trusts, CCGs, North East Ambulance Senice and Tees, Esk and Wear Valleys NHS Trust have signed up to the Crisis Care Concordat to work towards continuing to improve the care of patients in crisis. NHS Durham Dales, Easington and Sedgefield CCG and NHS North Durham CCG - Durham Constabulary County Durham and Darlington NHS Foundation Trust have confirmed that the lead Security Officer for the Trust has held discussions with Durham Constabulary lead officers to ensure that all police officers know that patients should be taken to the Emergency Department. The process is kept under review by the Trust and any arising issues are discussed on a monthly basis in relevant meetings depending on the nature of the concerns raised, ie. frequent attenders; mental health, drugs or alcohol related issues or violence and aggression incidents. The Trust has confirmed that some of these meetings do include representatives from Durham Constabulary. In addition the Trust has confirmed that they have signed up to the Crisis Care Concordat with all agencies involved in treating or looking after patients in crises, this includes Durham Constabulary. As part of the work to progress the Concordat the Foundation Trust and all partner organisations meet on a monthly basis to share learning; discuss difficult cases and also discuss and monitor any patients who have been detained under a section 136 in the emergency department | trust this answers the questions you raised in the report, but if you require any additional information please do not hesitate to contact me. Yours sincerely Chief Officer cc SN Chief Officer, NHS Durham Dales, Easington and Sedgefield CCG and _ we Durham CCG Medical Director, North Tees & Hartlepoo! NHS Foundation Trust Medical Director, Durham and Darlington NHS Foundation Trust Cleveland Police Chief Officer, Hartlepool & Stockton on Tees CCG Medical Director, South Tees Hospitals NHS Foundation Trust improving health together
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