Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0138, written 15 Apr 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 15 Apr 2015 |
|---|---|
| Reference | 2015-0138 |
| Deceased | Nicholas Rowley |
| Coroner | Ian Smith |
| Coroner area | Stoke-on-Trent & North Staffordshire |
| Category | Police related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
ANNEX A
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
NOTE: This form is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Staffordshire Police as the police force in charge of the deceased at the
time of his arrest and death.
2. National Police Chiefs’ Council as the association with power to issue
advice and guidance to police forces nationally.
3. G4S as the organisation responsible for the custody officers at the time of
death and the holder of contracts for the provision of custody officers to
Police forces in several part of the country.
4, Nestor Primecare who hold the contract for the provision of medical
services to Staffordshire Police in respect of detainees in custody.
5. Department of Health who will be taking responsibility in 2016 for the
provision of medical services to police forces nationally in respect of
detainees in custody.
This report is being sent to the National Police Chiefs’ Council, Nestor
Primecare and the Department of Health under the provisions of
Regulation 28(4)(c) and no response is required of them save for an
acknowledgement that this report will find its way to an appropriate
person within its organisation.
CORONER
| am lan Stewart Smith, senior coroner, for the coroner area of Stoke-on-Trent & North
Staffordshire.
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 16" November 2011 an Inquest was opened into the death of the deceased and
concluded on 9" April 2015 after a 10 day hearing with a jury. The conclusion was a
detailed narrative conclusion. The medical cause of death was 1a Methadone
intoxication. 1b Alcohol withdrawal in a chronic alcoholic. II Fatty infiltration of the liver.
CIRCUMSTANCES OF THE DEATH
On Saturday 2"? October 2011 the deceased was arrested on a no-bail warrant and
taken to the Northern Area Custody Facility, Etruria, Stoke-on-Trent. He had a history of
(former) heroin abuse, was receiving prescribed medication but he was also an admitted
heavy abuser of alcohol, drinking over 10 cans of strong lager each day. He remained
in custody, at times under close observation, for lengthy periods being viewed through a
cell camera, was seen by four doctors on 6 separate occasions and received medication
in the form of his prescribed methadone plus diazepam and chlordiazepoxide for alcohol
withdrawal. He was found unresponsive in his cell shortly before 9.00pm on Sunday 3"
October 2011. Although attended upon by doctors there was evidence of poor or no
communication between doctors and custody sergeants and frequent
misunderstandings over the required level of observation. It was accepted that these
failures did not materially cause or contribute to death and that some steps have been
taken to correct failings. There is potential for failings to occur nationally. | recommend
that the following be considered (see paragraph 5 below).
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.
The MATTERS OF CONCERN are as follows. —
1. That consideration be given to issuing guidance that whenever a detainee is
attended upon by a medical practitioner there should be a verbal consultation
between the medical practitioner and custody sergeant as to any issues of
concern and the level of observations to be had for that detainee in addition to
the medical practitioner making detailed notes on the detainee’s custody
medical record.
2. That consideration be given to the provision of joint training exercises for
medical practitioners, custody sargeants and custody detention officers and
assistants.
3. That training should provide targeted emphasis on the correct levels of
observation.
4. That consideration should be given to eliminating the phrase ‘continue
observations at the current level’ and require that doctors and custody sargeants
specify the level of observation precisely.
5. That training should include targeted training on the risks and dangers of drug
and alcohol abuse, including methadone intoxication and alcohol withdrawal,
particularly if the detainee is likely to be in custody for upwards of 24 hours.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe you
[AND/OR 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 Friday 12" June 2015. |, 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
| have sent a copy of my report to the following:-
1. Chief Coroner, Regulation 28 Reports, Chief Coroner's Office, 41" Floor
Thomas More Building, Royal Courts of Justice, The Strand, London, WC2A
2LL
2. (father of the deceased),
3. {mother of the deceasd)
1 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 usefut
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.
2 | [DATE] 1 aloois [SIGNED BY CORONER] Wy
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.
nN 6 +ES8 Colle ici Mh... ge of Policing g College of 10th Floor = Riverside House Pol ici Nn g 2a Southwark Bridge Road London SE1 SHA Ian S Smith HM Senior Coroner Coroners Chamber 547 Hartshill Road Stoke-on-Trent ST4 6HF 09 June 2015 H.M.C. JS -9 UN 2015 STOKE-ON-TRENT AND NORTH STAFFORDSHIRE Dear Sir, Re: Nicholas James ROWLEY (deceased) We are writing with reference to your correspondence of 15, April 2015 enclosing a section 28 report with regards Nicholas James Rowley. You sent this report to the National Police Chiefs Council, amongst others and we are hereby issuing a response on behalf of the College of Policing and DCC Nick Ephgrave, who is the National Police Lead for the Detention and Custody portfolio. We have noted your concerns and would like to take the opportunity to respond to each, as follows; 1. That consideration be given to issuing guidance that whenever a detainee is attended upon by a medical practitioner there should be a verbal consultation between the medical practitioner and custody sergeant as to any issues of concern and the level of observations to be had for that detainee in addition to the medical practitioner making detailed notes on the detainees custody medical record. We feel that this represents a common sense approach, which we would suggest would ensue in the majority of circumstances, therefore we take no issue with incorporating appropriate guidance to this affect as part of the interim review of the Detention and Custody Authorised Professional Practice which is currently ongoing. We anticipate that the updated guidance will be published and available via the College website circa summer 2015. 2. That consideration be given to the provision of joint training exercises for medical practitioners, custody sergeants and custody detention officers and assistants. We suggest this represents a local training issue and whilst there are perpetual issues engaging partner agencies we would suggest a further approach to the NHS. 3. That training should provide targeted emphasis on the correct levels of observation. The College of Policing Limited is a company registered in England and Wales, with registered number 8235199 and VAT registered number 152023949_ Our registered office is at Leamington Road, Ryton-on- Dunsmore, COVENTRY CV 3EN. Training standards already emphasise the importance of the correct levels of observation. Training refers to Authorised Professional Practice for further information on the levels. 4. That consideration should be given to eliminating the phrase ‘continue observations at the current level’ and require that doctors and custody sergeants specify the level of observation precisely. We will make additions to the Detention and Custody Authorised Professional Practice providing this advice. We anticipate that the updated guidance will be published and available via the College website circa summer 2015. 5. That training should include targeted training on the risks and dangers of drug and alcohol abuse, including methadone intoxication and alcohol withdrawal, particularly if the detainee is likely to be in custody for upwards of 24 hours. Authorised Professional Practice already makes reference to the risks of drug and alcohol consumption and withdrawal, there is a separate section on drugs and alcohol denoting the significance of these issues within the custody environment. Training emphasises that where there are any concerns about an individual due to suspected drug or alcohol issues, the detainee should be referred to the health care professional and a medical assessment undertaken. We trust these responses meet with your approval, however if you wish to discuss any item further please do not hesitate to contact us. Yours sincerely, Criminal Justice Liaison Manager a The College of Policing Limited is a company registered in England and Wales, with registered number 8235199 and VAT registered number 152023949, Our registered office is at Leamington Road, Ryton-on-Dunsmore, COVENTRY CV8 JEN.
Policing Support Services G4S Care & Justice Services (UK) Ltd Lincolnshire Police Headquarters Deepdale Lane Nettleham Lincoln 4 LN2 2LT, UK Telephone: Email www.94s.com/uk IAN S. SMITH LL.B, Hon DUniv Her Majesty’s Coroner Coroner’s Chambers 547 Hartshill Road STOKE-ON-TRENT ST4 6HF 43" July 2015 H.M.C. JS 14 JUL 2015 JON-TRENT AND ro errerenesmine Your refi Dear Sir Re: Nicholas James ROWLEY (deceased) Date of birth: 27/07/1977 Date of death: 02/10/2011 May | initially sincerely apologise for the delay in G4S responding to the recommendations contained in your Regulation 28 Report to Prevent Future Deaths. Since the conclusion of your inquest on the 9" April 2015 it is worth noting that since June 2015, G4S no longer provide Detention Officer Services to Staffordshire Police, as a new provider was contracted following a procurement exercise. In order to provide clarity my numbering below refers directly to each of the numbered recommendations contained within your report:- 1. This is a matter between Staffordshire Police and the medical practitioners and thus G4S have no comment to make as regards this recommendation. Whilst G4S agree with HM Coroner that this recommendation is a sound and sensible suggestion, G4S can only operate within the remit of the contract as stipulated by Staffordshire Police (or other such police forces) and thus it would be for Staffordshire Police (or the other police forces) to stipulate that such joint training ventures should take place. Where that to happen, G4S would of course comply with that contractual stipulation. G4S will undertake to formally write to all of our contracting police forces to outline this recommendation and recommend this as best practice which G4S support. G4S always have and continue to provide mandatory training as regards setting the levels of observation to each of its custody officers as part of an initial induction training programme. That training was taught in conjunction with PACE and later (and now) also in conjunction with the Association of Chief Police Officers Guidance on the Safer Detention and Handling of Person in Police Custody 2012 (“ACPO”) and the College of Policing Authorised Professional Practice Guidance “APP". G43 Core Justice Serviogs (UK) Limited Regletered Office: Securing Your World see aco SWE GOT Regletered In England No: 0200328 GS 4. This is a matter between Staffordshire Police and the medical practitioners and thus G4S have no comment to make as regards this recommendation. 5. As per response three above, G4S have and continue to provide mandatory first aid training to each of its custody officers as part of an initial induction training programme. The first aid training is taught over three days and includes (but is not limited to); Defibrillator and Advanced Airway training; training on Alcohol and Drugs (including associated risks). In addition, each of the custody detention officers is required to undertake a refresher first aid training course annually. Again training on the risks and dangers of drug and alcohol abuse will be taught during that refresher course. G4S will also examine opportunities to provide additional guidance via an ‘on line’ Learning Management System. The death of any person in custody is understandably extremely distressing for the family concerned and for all those involved in the persons care. G4S and | personally take the health and safety of those in our care as our primary duty and will work to ensure that our staff receive the best possible training and support to ensure the safety of some of the most vulnerable people in society. Yours sincerely Operations Director Custody Services G4S Public Services Policing Support Services Page 2 of 2 Securing Your World
Keeping our communities safe and reassured From the office of Assistant Chief Constable Investigative Services ; H.M.C. JS ; Mr tan Smith Direct Line: Fs HM Coroner 16 JUN 2015 Fax: i 547 Hartshill Road 6 JUN OurRef: iii’ Stoke-on-Trent ST46HF |STOKEON TIEN’ pc «= Your Ref: a’ Date: 12 June 2015 Dear Mr Smith Nicholas ROWLEY (Deceased) Date of Birth: 27/07/1977 Date of Death: 02/10/2011 With reference to the Regulation 28 report to prevent future deaths following the inquest into the death in police custody of Nicholas Rowley dated 15 April 2015, the response to the issues raised by yourself, from Staffordshire Police are as follows : 1. Guidance has been issued to all custody trained staff and our medical services provider, Nestor Primecare, to ensure that a verbal update is given by the medical practitioner to the appropriate Custody Sergeant following any consultation of a detained person by such a medical practitioner within the custody environment. This will be captured within Force Policy which is being reviewed currently, and tested through the monthly QA process already in place. 2. A Custody Training sub-group has been created to oversee the training of all custody personnel. This sub-group will report directly to the Force Custody, Mental Health and Vulnerability Steering Group, which | currently chair. The first meeting of this sub-group will take place on Monday 8" June 2015, and will include the following personnel : Head of Custody Learning and Development Manager, People Services Custody Managers Custody Detention Services Provider (Resource Group — Training Manager) Custody Detention Services Provider — Contract Manager eaog® The group will plan and oversee the training programme for custody personnel in Staffordshire, and consideration for joint training will be given for all future subject matter. 3. Further guidance has recently been issued with regard to the correct levels of observation, although we will consider further training to supplement and enhance this guidance. www.staffordshire. police.uk ‘YS — 4. Custody Officers and medical practitioners have been instructed to specify the agreed level of observation within the custody record and to avoid the use of such phrases as / agree with the current observation level’ or ‘Continue observations at the current level’. This will be monitored within the monthly monitoring process and feedback provided where necessary. 5. Training will be secured by the Force regarding the risks and dangers of drug and alcohol abuse, including Methadone intoxication and alcohol withdrawal. This will be built into the aforementioned training programme. | believe that we have learned lessons from this very tragic incident and we will continue to strengthen and develop our practices and policy within the custody environment. The scrutiny that is now in place over custody within Staffordshire Police is far greater now that has been previously and we will strive to make our custody facilities as safe as possible. Yours sincerely S| T/Assistant Chief Constable Executive Suite, Staffordshire Police HQ, PO Box 3167, Stafford ST16 9/2 SOs 4 Onl CRIMESTOPPERS BYU Ete 1 0800555 111 www.staffordshire.police.uk spe? ~ ~
See every Prevention of Future Deaths report matching Police related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.