Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0371, written 20 Oct 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 Oct 2016 |
|---|---|
| Reference | 2016-0371 |
| Deceased | Sian Jones |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Police related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: Prevention of Future Deaths report
Susan Sian JONES (died 15.02.15)
THIS REPORT IS BEING SENT TO:
1. Commander Lucy D’Orsi
New Scotland Yard
10 Broadway
London SW1A 0BG
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 19 February 2015, I commenced an investigation into the death of
Sian Jones, aged 47 years. The investigation concluded at the end of the
inquest earlier today.
The jury made a narrative determination, which I attach. They concluded
that Ms Jones’s death resulted from methadone and alcohol intoxication,
coupled with inadequate police policies, procedures and training.
The medical cause of death was recorded as:
diffuse cerebral ischaemia
cardiorespiratory arrest
combined toxic effects of alcohol and methadone
1a
1b
1c
in an individual with myocardial fibrosis and significant
atherosclerotic stenosis of two major epicardial coronary arteries
1
4
CIRCUMSTANCES OF THE DEATH
Ms Jones suffered a cardiorespiratory arrest in Hornsey Police station
whilst waiting to see specialist officers to make a statement concerning
an allegation of a historical sexual assault.
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.
The MATTERS OF CONCERN related to policy in respect of the
monitoring of non detained members of the public by police officers.
I heard evidence at inquest that there is no specific protocol or training
regarding the monitoring of members of the public in police stations who
are not in police custody. This was acknowledged by the Metropolitan
Police Service to be a gap. In seeking to plug this gap by way of policy
development, it may be helpful for you to consider the following.
Snoring is not always a reassuring sign and may indicate a partial
life
A partial airway obstruction can be
airway obstruction.
threatening.
In considering whether snoring is sign for concern, the fact of
intoxication by alcohol or drugs or both – even if the individual is
capable – is highly relevant. In addition, officers should bear in mind
that members of the public sometimes lie about alcohol or drug
taking, even when there seems no obvious reason to lie.
Any relevant information gleaned by officers, for example that an
individual is a methadone user, should be passed on to colleagues
with responsibility (and preferably recorded in some way or other).
The only way of determining whether snoring is benign is by rousing,
most particularly by waking the individual and determining whether
they are able to sit up and hold a conversation.
The rousing itself may have a therapeutic purpose even over and
above its value as a tool of assessment. And an unresponsive
individual must be treated as a medical emergency.
All police officers and staff should know the location of the nearest
defibrillator. If they are attending a police station for the first time,
they should make themselves aware of its location.
2
In terms of feedback regarding officer training generally and for the officer
who led this resuscitation attempt, I should also point out that after Ms
Jones’s cardiorespiratory arrest, the cardiopulmonary resuscitation given
was later noted by a paramedic to be extremely effective.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you and your organisation have the power to take such
action.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date
of this report, namely by 30 December 2016. 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.
8
COPIES and PUBLICATION
I have sent a copy of my report to the following.
HHJ Mark Lucraft QC, the Chief Coroner of England & Wales
Chief Inspector
sister of Sian Jones
daughter of Sian Jones
policy lead
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
interest. You may make
he believes may
representations to me, the Senior Coroner, at the time of your response,
about the release or the publication of your response by the Chief
Coroner.
it useful or of
find
9
DATE SIGNED BY SENIOR CORONER
20.10.16
3
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