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Tel: (01924) 292002
Temporary Chief Consiable Email: ccoffice @ westyorkshire.pnn.police.uk

18" April 2016

David Hinchliff

Senior Coroner

Coroners Office and Court
71 Northgate

Wakefield

WF1 3BS

Dear Mr Hinchliff

inquest touching the death of Adam RICE 8" February - 16 February 2016
Response to announcement pursuant to Regulation 28 of the Coroners (Investigations) Rules 2013.

| am writing in response to the matters you raise in Annex A paragraph 5B of the Regulation 28 report
directed towards West Yorkshire Police.

First of all | wish to take this opportunity to express my sincere condolences to the family of Adam. | can
appreciate how distressing the loss of a family member would be, particularly in these tragic
circumstances. | would like to apologise for the distress that the death of Adam has caused for all those
who knew him and assure you and Adam’s family, that lessons have been learnt. Please could | stress
that West Yorkshire Police has not waited until the conclusion of your inquest to learn lessons, but has
actively been putting measures in place to reduce the risk of a similar situation arising again. We are
committed to ensuring that those persons who come into contact with the Police who are vulnerable,
receive the best possible care.

In your report to prevent future deaths Annex A paragraph 5B you identified 4 matters of concern which
I shall reply to in turn.

1. To ensure that Custody Staff (Police Officers of all ranks, Civilian Detention Officers and Nursing
Staff) have a full and comprehensive knowledge of the Police and Criminal Evidence Act (PACE), the
relevant Codes of Practice and the relevant provisions of the College of Policing ‘Authorised
Professional Practice’ (APP) in respect of Detention and Custody and Custody Management

Planning.

All Custody Staff employed by West Yorkshire Police undergo a full training programme in line with
the College of Policing requirements prior to working in a live custody suite. During this initial
course, Custody Officers, Detention Officers and PC Gaolers all receive training on the Police and
Criminal Evidence Act (Code C) and Authorised Professional Practice (APP).

Each year, all permanent and ‘ad hoc’ Custody Staff attend refresher training which is currently of
4 days duration. Both PACE and APP are covered on these refresher courses.

APP and PACE are both available electronically to all staff for reference should the need arise ona
day to day basis and all custody suites have hard copies of Code C available should staff need to
remind themselves of its content. In addition, Custody Services and Custody Training are available
centrally to provide guidance and clarity on more complex matters should the need arise.

On promotion, ail Inspectors attend a professional development and leadership course which
contains a custody module. This ensures that all Inspectors have knowledge and awareness of the
key issues relating to custody. In addition each custody suite has at least one dedicated Custody
Inspector to oversee the daily running, provide advice and support and to ensure standards are

maintained.

Healthcare in custody is provided by Leeds Community Healthcare Trust (LCHT). All Healthcare Staff
attend a week long training programme prior to commencing a shadowing period ina live custody
suite. This programme was devised in conjunction with West Yorkshire Police and PACE is included
and delivered by a suitably qualified police officer. There is a knowledge test on PACE for health
care professionals at the end of the week. Key elements of APP (including levels of observation) are
also included in the training plan.

That West Yorkshire Police only recruit Custody Staff of the highest calibre to carry out this vital
role, as it involves some of the most vulnerable members of society.

Staff are only able to train as a Custody Sergeant or PC Gaoler once they are substantive in role and
have received authorisation from their line manager to apply. This ensures suitability of the staff.

Detention Officers are non-warranted and do not conduct any other roles, if they are employed as
Detention Officers. The application process currently entails an application form and interview by
our Human Resources (HR) Team. We are currently progressing and developing proposals to involve
Custody Services (led by Inspector J to have involvement in the selection of future
Detention Officers, which will further ensure suitability for role at time of selection.

Should Custody Staff not perform to the highest of standards, there are recognised practices
available to deal with them. This ranges from training and developmental support, to the
Unsatisfactory Police Performance Process and Police Misconduct Regulations for Officers and
capability procedures and code of conduct for Police staff. All Custody Staff, like all West Yorkshire
Police employees, are subject to an annual staff appraisal by their line manager, called a Personal
Development Review (PDR).

3a. To ensure that there are adequate staffing levels of all ranks and grades to fulfil this vital role
particularly during periods of high demand when it is known that Custody facilities will be extremely
busy and in particular Fridays, Saturdays and Sundays.

West Yorkshire Police currently has 7 Inspectors, 55 Custody Sergeants and 147 detention Officers
working across the five custody suites. A new Police shift pattern was introduced in February 2016
which contains periods of overlap across the busy times and the shift templates have been adjusted
to meet the needs of each district. AC 52s also reviewed the staffing levels at the
five custody suites in February 2016, the result being that an extra five Detention Officers (one per
shift) are being recruited to work at Leeds. This will result in reducing the need to bring in ‘ad-hoc’
PC gaolers at the Detention Officers meal times. Furthermore, at a recent Custody Partnership
Board, HE: askec the healthcare provider (Leeds Community Healthcare Trust) to review
their nurse coverage at both the Bradford and Leeds custody suites and suggested options for them
to move nurses from a less busy custody suite, which has low medical demand, to ensure there are
no ‘medical queues’ at the busier custody suites of Bradford and Leeds.

The additional benefit of this change in Police shift pattern is that the Neighbourhood Patrol Teams
are aligned to the same pattern as the Custody Staff making it easier to draft in ‘ad hoc’ staff when

necessary.

3b. To ensure that they have a bank of staff which might ordinarily be engaged in other duties but who
are trained and have experience in Custody work who can be drafted in at short notice during such
periods of high demand when it becomes obvious that the existing staff cannot cope with the
demands being placed upon them.

West Yorkshire Police have staff who work permanently in our custody suites, but also have a bank
of ‘ad hoc’ staff who are fully trained. ‘Ad hoc’ staff are used to cover periods of abstraction of the
permanent staff {such as annual leave) or when demand is such that additional resources are
required during a busy shift. These ‘ad-hoc’ staff receive exactly the same level of training as
permanent staff, including the annual refresher training. Whilst this is a very costly training
requirement for staff that will only be used on an ‘ad-hoc’ basis, it is absolutely necessary to have
all staff who may work in a custody suite, trained to the highest standards.

There are currently 61 ‘ad hoc’ Custody Sergeants and 146 PC Gaolers who are distributed across
the 5 Districts of the Force, but can be called upon to work in any suite if required. Of note, these
‘ad hoc’ trained staff now work the same shift pattern as the permanent Custody Staff and have
done since the new Police shift pattern commenced in February 2016, thus making cover much
easier to plan and much speedier to put into action, in peaks of high demand. These figures are
monitored quarterly by Force Training Schoo! to ensure sufficient staff are available to provide
additional capacity when necessary.

1 do hope that the information provided above allays your concerns which you expressed in
your letter dated 3 March 2016. | also hope that this provides the family and any interested
parties with assurance that West Yorkshire Police are committed to ensuring that those persons
who come into contact with the Police who are vulnerable will receive the best possible care.

Yours sincerely
——— Ke
ee Collins
Temporary Chief Constable
West Yorkshire Police

The Leeds Teaching Hospitals

NHS Trust

Date: 27th April 2016
Our Ref: YONA “
YourRef:  DH/JS/1263/14 WIA & Ste.

Chief Medical Officer
Private & Confidential Trust Headquarters
Mr D Hinchliff St James’s University Hospital
Senior Coroner West Yorkshire (Eastern) Beckett Street
Coroner’s Office and Court Leeds
71 Northgate LS9 7TF
Wakefield . _
WF1 3BS Pirect tine: (0113) 20 64688

PA:
www. ieedsth.nhs.u

Dear Mr Hinchliff
RE: INQUEST TOUCHING THE DEATH OF ADAM RICE (Deceased)

| refer to your correspondence of 3" March 2016, received on 7" March 2016, regarding the
inquest touching the death of Adam Rice and the Regulation 28 Report to Prevent Future
Deaths in respect of this case.

| can confirm that the contents of your Regulation 28 Report have been shared with the
relevant clinical staff and our risk management team to enable us to provide you with a
comprehensive response.

In your report at paragraph 5 you highlight your concerns as:

1. When a patient self-discharges against medical advice and it is known or it is highly
likely that the Police will immediately thereafter become involved and it can be foreseen
that the patient will be taken into Custody.

2. Then the Clinician(s) involved should inform the Police that the person has self-
discharged against advice and should give brief details of any desired and outstanding
investigations or treatment (e.g. reference to a possible head injury would suffice and
the desire to carry out a CT head scan). This | suggest would not breach confidentiality.

In your narrative conclusion you make reference to the following:

a) Adam Rice was taken to Leeds General Infirmary on 11" May 2014 at 15.09 after being
found under a skate ramp in Hyde Park, intoxicated and with a possible head injury.

b) In hospital he refused a CT head scan.

c) He discharged himself against medical advice, which was not communicated to the
Police.

d) Due to an outstanding arrest warrant, Mr Rice was immediately arrested and taken to
Elland Road Custody Suite.

e) He was placed in cell 19 where he later exhibited features consistent with alcohol
withdrawal.

f) At 06.37 on 12" May 2014, Mr Rice suffered a seizure.

Chair Dr Linda Pollard CBE DL Chief Executive Julian Hartley

The Leeds Teaching Hospitals NHS Trust incorporating: Chapel Allerton Hospital, Leeds Cancer Centre, Leeds Children’s Hospital,
Leeds Dental Institute, Leeds General Infirmary, Seacroft Hospital, St James's University Hospital, Wharfedale Hospital.

g) At 07.04 Mr Rice was found unresponsive in his cell and CPR was commenced.

h) Adam Rice was pronounced dead by paramedics at 07.43 on 12" May 2014 at Elland
Road Custody Suite.

i) Adam Rice’s death was coincidental and not as a consequence of his detention within
the Eiland Road Custody Suite

! note that the pathologist concluded that the most likely cause of Mr Rice’s death was a fatal
cardiac arrhythmia caused by an acute dissection of the aortic root. No evidence of a head
injury was found at post mortem examination.

The clinical team advised me that Mr Rice was a 46 year old gentleman who was brought to
Leeds General Infirmary on 11" May 2014 at 15.09. Mr Rice, who was known to the
Department, appeared intoxicated and had sustained a nasal wound. He was generally
uncooperative but his observations were satisfactory. After a fall in the Emergency
Department, Mr Rice was examined by a CT1 doctor who was unable to find any new or
lateralising signs to suggest that a CT head scan was urgently required. a:
experienced ED registrar, also reviewed Mr Rice and concluded that he was uncooperative
and intoxicated. She arranged for Mr Rice to be transferred to the Clinical Decisions Unit
(CDU) for observations and a CT head scan in due course.

At approximately 22.00 Mr Rice was demanding to leave hospital. At this point he was
independently mobile, coherent and did not appear to be impaired by alcohol. Mr Rice was
informed that the medical staff wished for him to have a precautionary CT head scan. He was
clearly told of the risks of taking his own discharge against medical advice. Some
considerable time was spent attempting to persuade Mr Rice to remain in hospital. However,
he was clear that he wished to leave. ventually concluded that Mr Rice had the
necessary capacity for this specific decision in that he understood the information being given
to him, was able to retain and weigh up the information, and then communicate that
information back tol “Mr Rice stated that he intended to go to St George’s crypt
(adjacent to the LGI) and was advised of the importance of seeking shelter and warmth
indoors.

Although Police officers had accompanied Mr Rice to hospital, the Emergency Department
staff were unaware that the Police were considering arresting Mr Rice immediately after
discharge.

No subsequent request for information was received by the LGI emergency department from
the Elland Road Custody Suite staff.

My staff have provided me with detailed comments following your Regulation 28 Report, which
| hope you will find helpful.
a) ER is clear that Mr Rice had the necessary capacity to make a decision
about taking his own discharge, however unwise that decision.
b) There was no conventional ‘safety net’ of family or regular GP that could be informed of
the recent admission and features that should trigger re-attendance, but Mr Rice’s
intention which was clearly expressed, to attend St George’s crypt, provided some

Chair Dr Linda Pollard CBE DL Chief Executive Julian Hartley

The Leeds Teaching Hospitals NHS Trust incorporating: Chapel Allerton Hospital, Leeds Cancer Centre, Leeds Children’s Hospital,
Leeds Dental Institute, Leeds General Infirmary, Seacroft Hospital, St James's University Hospital, Wharfedale Hospital.

reassurance that he would be in an environment following discharge where any
concerns could be acted upon.

c) In your Regulation 28 Report you suggest at Section 5 A(2) that it could have been
foreseen that Mr Rice would be taken into Custody and that clinicians should have
informed the Police about any desired or outstanding investigations. You suggested
that this would not constitute a breach of patient confidentiality. In response to this
point, the staff have made the following comments:

i) The General Medical Council set out in their 2009 guidance (“Confidentiality”) at Paragraph
36 the circumstances where a disclosure without patient consent can be made in the public
interest. Essentially this is confined to a situation where there is a need to protect individuals
from serious harm, such as serious communicable diseases or serious crime. As you know,
the GMC takes the view that there is a clear public good from having a confidential medical
service and quite rightly doctors who break patient confidentiality put themselves at risk of
serious censure. After extensive multi-disciplinary discussion on this matter, we have been
unable to identify either an indication for disclosing information about Mr Rice’s medical
assessment or a justification in this case for such disclosure without the necessary
permissions.

ii) The staff were unaware that the Police were considering arresting Mr Rice followin
discharge. Indeed, this decision appears to have been formalised by PCsOMlllland PC
nce Mr Rice had left the building. No subsequent request for information was received

from the Elland Road Custody Suite.

iii) Our Emergency Department staff would like to reassure you that there are already
arrangements in place for a handover of relevant medical information when patients are
discharged from the Emergency Department. When a patient leaves the department for their
own home, their GP will receive a discharge summary and the patient will normally be given
advice in the presence of their next of kin as to features which warrant re-attendance.
Similarly, when a patient is transferred to another hospital, relevant details will accompany the
patient to the new healthcare provider and a formal handover of care will take place. The
same principle applies where a patient is being transferred to a facility, such as a Police
Custody Suite that is recognised to have trained medical or nursing staff. In this case a direct

transfer was not being facilitated and the decision to arrest Mr Rice was made by PCSO

land BE orcs Mr Rice had left the care of Leeds Teaching Hospitals NHS Trust
and without liaison with the responsible medical team. Had the decision been made to arrest
Mr Rice in the Emergency Department and take him directly into custody, an appropriate
medical discharge note would have been provided as is the normal practice together with a
verbal handover of care.

iv) The reality of a current day Emergency Department is that many patients take their own
discharge every week. Many such patients will be known to the Police. We do not believe it
feasible or reasonable to expect a healthcare practitioner to make a judgement as to whether
that patient is likely to be arrested soon after discharge against medical advice. We believe
that routinely contacting the Police in these circumstances would take a significant amount of

Chair Dr Linda Pollard CBE DL Chief Executive Julian Hartley

The Leeds Teaching Hospitals NHS Trust incorporating: Chapel Allerton Hospital, Leeds Cancer Centre, Leeds Children’s Hospital,
Leeds Dental Institute, Leeds General Infirmary, Seacroft Hospital, St James's University Hospital, Wharfedale Hospital.

time and in most cases would be associated with an unjustified breach of patient
confidentiality. This category of patient would be unlikely to attend, or to stay for conventional
investigations or observations, if they were aware that healthcare practitioners would be
liaising with the police as to their potential arrest for incidents that fall beyond those which
warrant urgent disclosure. This scenario would be likely to have a detrimental impact on
overall heaithcare provision to this class of patient, which would represent an unintended
adverse consequence of a course of action intended to prevent future deaths of a similar

nature.

| can reassure you that all the staff involved in Mr Rice’s care were saddened to learn of his
untimely death. However, they are confident following reflection that they acted appropriately
and professionally at all times, despite the challenges presented by such patients, with nothing
to suggest any discrimination or shorifalls in anticipated care standards. Sadly it would seem
Mr Rice suffered a sudden and unexpected death that could not have been predicted during
his assessment at Leeds General Infirmary and was seemingly not in any way contributed to
by his subsequent detention at Elland Road Custody Suite.

In conclusion, | can reassure you that there are appropriate mechanisms already in place to
share patients’ medical information with other healthcare providers. However, doctors must
act within the confines of their professional regulator and only share information with third
parties with appropriate consent or where there is clear public interest to disclose information
without consent. If however, the scenario arises where a patient is to be arrested within the
ED either because no further medical management is required or because this has been
capacitously refused, the staff would predictably provide a summary of the relevant healthcare
issues to the arresting officers to ensure that that process was informed. That expectation
would exist before these events and before your Regulation 28 letter.

The Trust is receptive to a need to review practice following any adverse incident or outcome
as hopefully demonstrated by this response and we would be happy to have further dialogue if
any element of our review and response is unclear or causes concerns. We would always
wish to cooperate fully with any initiative that reduces future deaths and as such are very
much aligned to your responsibilities as coroner.

Thank you for bringing these matters to my attention.

Yours sincerely

Chief Medical Officer
Leeds Teaching Hospitals NHS Trust

Chair Dr Linda Pollard CBE DL Chief Executive Julian Hartley

The Leeds Teaching Hospitals NHS Trust incorporating: Chapel Allerton Hospital, Leeds Cancer Centre, Leeds Children’s Hospital,
Leeds Dental Institute, Leeds General Infirmary, Seacroft Hospital, St James's University Hospital, Wharfedale Hospital.