Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0310, written 29 Oct 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 29 Oct 2018 |
|---|---|
| Reference | 2018-0310 |
| Deceased | Karl Brunner |
| Coroner | Martin Oldham |
| Coroner area | Bedfordshire & Luton |
| Category | Alcohol, drug and medication related deaths · Police related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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.
40517-2016 for Bedfordshire & Luton REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: , Mr Jon Boutcher Chief Constable of Bedfordshire Association of Chief Police Officers Bedfordshire Police Headquarters (ACPO) Woburn Road q 10 Victoria Street London Kempston Bedford. MK43 9AX SW1H ONN CORONER | am Martin Oldham, Assistant Coroner, for Bedfordshire & Luton CORONER'S LEGAL POWERS | 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. http//www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www. legislation .gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 12 May 2016 | commenced an Investigation into the death of KARL BRUNNER, aged 48 years . The Investigation concluded at the end of the inquest on 09 March 2018. The Conclusion of the inquest was ‘Accidental Death’. Mr Brunner died because he choked after swallowing a package of drugs to avoid arrest. Givers of first aid did not realise it was choking, therefore, despite attempts to give CPR, he did not recover. Mr Brunner died on Battison Street, Bedford, on the 11th May 2016 at 12.34 pm, when he attempted to swallow a package of individually wrapped drugs - approximately 4 x 3cm, whilst in the process of being arrested by police officers, under Section 23 Misuse of Drugs Act. The package lodged behind his epiglottis and choked him. In April 2016 the police conceived an operation with the objective of arresting Mr Karl Brunner. Mr Brunner was a known drug user and dealer, who had undertaken rehabilitation and who sold Class A drugs in the Midland Road area of Bedford. The operation was set in train in April, although was postponed Senior Coroner, The Court House, Woburn Street, AMPTHILL, Bedfordshire, MK45 2HX Tel 0300-300-6559 | Fax 0300-300-8267 because it was discovered that Mr Brunner was in hospital with breathing problems. After Mr Brunner was discharged from hospital he was seen in town on 9th May. On the 11th May he was seen by a Police Constable in Bedford Bus | station. It was decided to resume the operation and two officers were drafted in from Luton. A briefing happened over the phone and a discussion took place before four officers, in plain clothes, left Greyfriars Police Station, Bedford, in an unmarked van to carry out a stop-search in order to detain Mr Brunner: two Officers wore body cameras. One of them was trained as a Police Medic, but was not operating in that role on the day. The other three had undertaken basic First Aid Training. Mr Brunner was a known "swallower" who had swallowed drugs on two 2 or 3 occasions previously. To mitigate the risk of swallowing, the plan was to approach him from behind to prevent him from swallowing so that they could catch him with enough Class A drugs to obtain a conviction for supplying. The CTT had successfully dealt with people who had been arrested for swallowing before. The officers approached along Midland Road. There were three on foot and one was in a van. Mr Brunner and another man were walking towards Battison Street, Bedford. The weather conditions were adverse. The Officers knew who Mr Brunner was, and Mr Brunner knew who some of the police officers were. The element of surprise was lost when an associate of Mr Brunner, who clearly knew the police officers, shouted a warning. Because of this, police picked up their pace. One of the police officers moved towards the other man, as he made moves to run away. The other two went to Mr Brunner. One of these, Officer A, attempted to detain Mr Brunner by means of a bear hug. The other went straight away to help arrest the second man. Mr Brunner saw the officers and turned away and appeared to reach across to one of his pockets. The officer in the van (B) parked and came to the assistance of A as Mr Brunner was resisting arrest. Shortly afterwards, Mr Brunner was seen to put a package into his mouth, by officer C, who shouted out that he had put it in. Mr Brunner did this by dropping his weight forward and bringing his hand up to his mouth, and mouth to hand. Mr Brunner and two of the officers fell on to the floor during the struggle and they moved his arms towards his back to put handcuffs on him at 12.36.02 hours. The package was described as a large ball, roughly the size of a golf ball. The three PCs (A, B and C) shouted at Mr Brunner to spit out the package, and one of them tried to apply a mandibular angle twice. The mandibular angle was applied with an open grip and was meant to gain compliance by causing pain but did not succeed. This police officer believed that Mr Brunner had swallowed the package because he saw his open mouth. The police officers applied reasonable force to detain Mr Brunner and make him complaint in order to spit out the package, including a ground pin and holding his arms. On the Body Cam Mr Brunner could faintly be heard to say “I can't breathe" but because of a number of factors - awful weather, the frenetic nature of the incident, interruption of bystanders, relative position of officers and cameras - he could not be heard by human ear. Once Mr Brunner had appeared to become compliant Pc B noticed that he was in and out of consciousness and called an ambulance at 12.36.55 hours. Another call to an ambulance was made at 12.37.31 hours. At 12.38.10 hours an officer mentions that he thought that Mr Brunner was not breathing. The officers removed the Senior Coroner, The Court House, Woburn Street, AMPTHILL, Bedfordshire, MK45 2HX. Tel 0300-300-6559 | Fax 0300-300-8267 handcuffs, looked in his mouth, sat him up, turned him into the recovery position before starting cardiac compressions at 12.39.20hours. Mr Brunner did not regain consciousness or begin to breathe again. The police officers worked together to give Mr Brunner compressions until the ambulances and paramedics arrived at 12.46 hours. When paramedics took charge of the care of Mr Brunner, they were happy with the PCs compressions and asked them to continue whilst they arranged a Lucas Il Machine to mechanically carry out compressions and attempted to establish an airway. They tried to establish an airway five times, but this was a difficult task because of signs of blood, vomit, and Mr Brunner's physiology/anatomy. The lead paramedic mentioned a Blue Form at 12.51 hours. By this time, because of the length of time since Mr Brunner had last been seen to breathe, irreversible brain damage was highly likely. At no point did anyone see the package in Mr Brunner's throat. The PCs assumed that he had swallowed the package and although this was difficult for the jury to understand, no-one involved in the incident, police, paramedics or afterwards in the hospital, saw the package. Therefore choking was not considered an option. Karl Brunner choked and stopped breathing sometime around 12.38 hours and did not recover, despite efforts of police officers on the scene and paramedics. His death was certified at 13.17 hours at Bedford Hospital. The cause of death given after forensic post mortem was: la Foreign body airway obstruction (choking) with close temporal relationship to an attempted police arrest whilst under the influence of heroin and diazepam CIRCUMSTANCES OF THE DEATH At 12:36 hrs on 11 May 2016 Tasking Officers from Bedfordshire Police were engaged in a Drugs Operation in Midland Road, Bedford, when they saw the deceased with another male person, The Police stopped the 2 men for the purposes of a Section 23 Drug Search. The deceased ran a short distance and is believed to have swallowed a quantity of Class A Drugs. The officers detained _ the deceased in Battison Street, Bedford, and ended up on the ground when suddenly the deceased became unresponsive. CPR was commenced and Paramedics attended and continued with advanced life support. The deceased was then conveyed to Bedford Hospital South Wing, Bedford, where death was confirmed shortly after arrival. 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. Senior Coroner, The Court House, Woburn Street, AMPTHILL, Bedfordshire, MK45 2HX Tel 300-300-6559 | Fax 300-300-8267 The MATTERS OF CONCERN are as follows : 1. The evidence before me showed that police officers were trained to deal with suspects who had swallowed drugs. The evidence however disclosed a complete lack of knowledge of the risks of choking when suspects were either arrested or in the process of being detained. This should urgently be addressed in the Officers’ training and the appropriate medical procedures should be adopted. 2. Police Officers are provided with mouth and face guards which are so defective and inappropriate when dealing with high risk suspects who may have significant health issues that they are neither carried nor used in appropriate cases. This should be urgently addressed. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you 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 20" December 2048, 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 | have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Senior Coroner, The Court House, Woburn Street, AMPTHILL, Bedfordshire, MK45 2HX Tel 0300-300-6559 | Fax 300-300-8267 who may find it useful or of interest. | 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. Dated 29" October 2018 MARTIN OLDHAM ASSISTANT CORONER Bedfordshire & Luton Senior Coroner, The Court House, Woburn Street, AMPTHILL, Bedfordshire, MK45 2HX Tel 0300-300-6559 | Fax 300-300-8267
1 response 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.
IN AMPTHILL CORONER’S COURT
IN THE MATTER OF THE INQUEST TOUCHING
UPON THE DEATH OF KARL BRUNNER
REGULATION 29 RESPONSE ON BEHALF OF THE
CHIEF CONSTABLE OF BEDFORDSHIRE POLICE
A
Introduction
1.
Following an inquest held into the death of Karl Brunner, HM Assistant Coroner for
Bedfordshire and Luton Martin Oldham (“the Coroner”) exercised his powers under
regulation 28 of The Coroners (Investigations) Regulations 2013 (“the Regulations”), to
publish a report to prevent future deaths, dated 29 October 2018 (“the PFD Report”).
The Chief Constable of Bedfordshire (“Bedfordshire Police”) hereby provides this
response to the PFD Report, pursuant to regulation 29 of the Regulations (“the
Response”).
B
Facts
2. The facts are summarised at §3 of the PFD report and will not be rehearsed here in
detail. In summary, Mr Brunner died on 11 May 2016 as a result of choking, after
attempting to swallow a package of drugs, whilst he was being arrested by police. At the
conclusion of the inquest on 09 March 2018 the Coroner recorded a conclusion of
‘accidental death’.
C
Matters of Concern
3.
The Coroner expresses two matters of concern regarding police officers, namely:
(i)
(ii)
Training on choking risks during detention; and
Usage of mouth and face guards.
Training
4.
Across Bedfordshire, Cambridgeshire and Hertfordshire police forces all officers,
special constables, detention officers and Police Community Support Officers receive
First Aid training at least annually on a rolling programme. Student officers receive
training more often as it is incorporated within their two year probationary period. Thus
training is provided in accordance with the standards set down by the College of
Policing, which remain under review.
5.
Included within the training is a module which deals specifically with persons who are
choking. It sets out the appropriate manner in which a choking detainee should be
managed, and specifically incorporates the comprehensive lesson plan produced by
the College of Policing In particular, this includes:
(i)
(ii)
(iii)
(iv)
(v)
(vi)
Identifying any dangers to the officer and detainee;
Identifying the signs typically demonstrated by a choking conscious
detainee;
Administering back slaps to a choking detainee;
Performing abdominal or chest thrusts on a choking detainee including
on child or infant;
Monitoring changes in detainee’s condition;
Reassuring the detainee; and
(vii)
Taking any necessary further action.
6. Officers receive training on a training aid known as ‘Choking training vest’ for adults,
and ‘Baby Annie’ for young children. All students will then be expected to use the
device in order to learn the correct procedure. The training officer will also demonstrate
how to carry out thrusts from the front in the event that it is not possible to put arms
around the casualty.
7. Officers and custody staff are given the following specific instructions in the event they
are faced with a scenario similar to that which occurred during the detention of Mr
Brunner. These are in line with the recommendations issued by the Independent
Office for Police Conduct (“IOPC”) and state that:
(i)
If the detainee places an item in their mouth, do not attempt to remove
it, as there is no currently approved safe and effective method for
searching mouths;
(ii)
Consider what might have been placed in the detainee’s mouth and
assess what risk it may present to the detainee and the officer.
Officers should make every effort to encourage the detainee to
voluntarily empty their mouth;
(iii)
Officers must inform the detainee of the risk they face from choking
and/or poisoning as a result of swallowing items. All actions should be
recorded in full and body worn video used where available. Officers
should maintain communication with the detainee and allow them the
opportunity to voluntarily remove any items;
(iv)
If the detainee swallows the item, the situation should be treated as a
medical emergency and an ambulance called. This also applies if the
detainee begins to choke following an attempt to swallow an item. An
ambulance should be called and emergency life support provided to
the detainee. The College of Policing procedure outlined above at §5
should be followed.
8.
The regular training provided to all Bedfordshire Police officers complies with the
recommendations of the IOPC and meets the standards set out by the College of
Policing.
Mouth/face guards
9.
Prior to August 2016 all Bedfordshire Police officers were issued with a mouth/face
guard which comprised a flat plastic sheet with either a hole or a piece of gauze in the
middle which allowed the user to breathe into to give mouth to mouth resuscitation.
Since August 2016, all officers are now issued with a personal Pocket Face Mask and
instructed on its correct use in mouth to mouth resuscitation. The Personal Safety
Team Leader for Bedfordshire, Cambridgeshire and Hertfordshire Police has stated
that this piece of equipment is adequate and appropriate for its required use. In
addition to the mouth/face guard issued to all officers during their training, all response
vehicles contain first aid equipment.
D
Conclusion
10. Bedfordshire Police are grateful to the Coroner for the opportunity to address the steps
which have been taken in respect of the matters of concern outlined in the PFD
Report.
Legal Services Department
6th December 2018
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