Terrence Smith — PFD report 2019-0095

Date of report	21 Feb 2019
Reference	2019-0095
Deceased	Terrence Smith
Coroner	Richard Travers
Coroner area	Surrey
Category	Emergency services related deaths (2019 onwards) · Hospital Death (Clinical Procedures and medical management) related deaths
Organisation named	South East Coast Ambulance Service NHS Foundation Trust
Source	judiciary.uk record · original PDF
Responses published	none published

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

Re : Terrence Arthur Albert Smith Deceased

Regulation 28 Report to Prevent Future Deaths

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT TO:

1. South East Coast Ambulance Service NHS Foundation Trust (in

relation to paragraph 5 A and B below),

2. NHS England / NHS Digital (in relation to paragraph 5 A

below),

3. Joint Royal Colleges Ambulance Liaison Committee (in relation

to paragraph 5 C below),

4. Mitie Care & Custody (Health) (in relation to paragraph 5 D

below),

5. Teesside University (in relation to paragraph 5D below),

6. The Chief Constable of Surrey Police (in relation to paragraph 5

E and F below), and

7. The College of Policing (in relation to paragraph 5 E below).

1 CORONER

I am Richard Travers, HM Senior Coroner for the coroner area of Surrey.

2 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

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(Investigations) Regulations 2013.

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INVESTIGATION and INQUEST

I commenced an investigation into the death of Terrence Arthur Albert

Smith who died on 13 November 2013 aged 32 years.

The investigation concluded on 24 January 2019 after I had conducted an

Inquest, which began on 12 February 2018 and was completed on 5 July

2018, and a subsequent hearing for evidence relevant to the prevention of

future deaths which ran from 21 to 24 January 2019.

4 CIRCUMSTANCES OF THE DEATH

The circumstances of the death of Terrence Smith (referred to at the

Inquest as “Terry”) were as follows :

On the evening of 12 November 2013 Terry was at his parents’ home

when he began to behave in a bizarre manner. He had taken

amphetamines and he showed signs of agitation, suffering hallucinations

and paranoia, incoherence, some aggression, and overheating and he

demonstrated extreme strength. He ran from the premises and stood

outside, shouting at the sky, wearing only his underwear.

It was established at the Inquest that Terry was displaying “textbook”

signs and symptoms of the condition known as Excited Delirium or

Acute Behavioural Disturbance (“ED/ABD”) and that he continued to do

so until he collapsed approximately two hours later. The evidence at the

Inquest also established that ED/ABD is a medical emergency.

Judging that he needed medical help, Terry’s parents telephoned 999 and

asked for the attendance of the ambulance service. The South East Coast

Ambulance Service (“SECAMB”) call handler did not identify that Terry

was suffering ED/ABD. She dispatched two Emergency Medical

Technicians and asked for Surrey Police to attend. The first two police

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officers in attendance approached Terry and he ran away. They chased

and caught him, restrained him on the ground, applied handcuffs, and

detained him under section 136 of the Mental Health Act 1983. Further

police officers arrived and, because Terry was resisting restraint, he was

restrained by about six police officers, leg restraints were applied, and a

spit hood was placed over his head.

The police officers and Emergency Medical Technicians learned that

Terry had taken drugs and they were handed a white powder which had

been found in his bedroom. The Police Sergeant who was in attendance

alerted the other police officers present to the possibility that Terry was

suffering Excited Delirium but the police officers stated in evidence that

their training had not made them aware that the condition constituted a

medical emergency. The two Emergency Medical Technicians had

received no training at all on ED/ABD and did not recognise that Terry

was suffering the condition or that he was in a state of medical

emergency.

The police decided that Terry should be taken to and detained at a police

station rather than a hospital Accident and Emergency Department. The

two Emergency Medical Technicians did not question this, even though

they had not been able to examine Terry sufficiently to form a view as to

his medical needs.

The police placed Terry on the floor of the caged area of a police van, still

restrained by handcuffs and leg restraints and wearing the spit hood.

They transported him to Staines Police Station, arriving at 22.59 hours. A

short time later, whilst still in the van, Terry was arrested for possession

of a Class A drug.

The Custody Sergeant approved his detention and he was then carried in

to the station by six officers and placed on the floor of a cell. Throughout

his time in the cell Terry was restrained by at least six police officers or

custody staff and he resisted that restraint with extreme strength.

Throughout, he remained in leg restraints and the spit hood, but his

handcuffs were removed and replaced with a body cuff. Terry continued

to be largely incoherent but he stated that he “could not breathe” 13

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times.

Whilst in the cell and under restraint Terry was seen, for less than two

minutes, by a Forensic Medical Examiner who informed the Custody

Sergeant that he needed to go to hospital because of a cut on his foot and

because he had taken drugs. The doctor did not mention ED/ABD

although he was aware of the condition and knew it was a medical

emergency.

At 00.13 hours on 13 November 2013 (one hour 14 minutes after arriving

at the station) the police officers carried Terry from the cell back to the

police van, where they again placed him on the floor of the caged area in

order to take him to hospital. Terry was restrained in the caged area of

the van by three police officers, with the body cuff, leg restraints and the

spit hood still in place. Shortly afterwards, Terry stopped breathing. He

was subsequently taken by ambulance to St. Peter’s Hospital where he

died later that day.

The medical cause of death was found to be :

Ia Multiple hypoxic organ failure
Ib Cardiorespiratory collapse
Ic Amphetamine-induced excited delirium in association with restraint.

The jury’s conclusion as to the death was that :

Narrative Conclusion

The Deceased died as a result of an amphetamine-induced Excited

Delirium in association with :

1. A serious failure by those who owed a duty of care (to the

deceased), to recognise the signs and symptoms of Excited

Delirium as a medical emergency. There was also a failure to find

out more about Excited Delirium after the term had been raised.
2. A failure to carry out an adequate assessment (of the deceased) at

any stage.

3. Inadequate training of those who owed a duty of care, with a

serious failure to check their learning.

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4. Prolonged and excessive restraint, and a failure to understand that

the resistance to the restraint (by the deceased) was leading to an

ongoing depletion of oxygen and an increased level of adrenaline

and that this was speeding up the effects of the Excited Delirium

in his body.

Neglect

The death was contributed to by Neglect.

Other Contributory Causes

The death was caused or more that minimally contributed to by the

failure on the part of Surrey Police to :

1. Ensure that all response and custody officers and staff were

sufficiently trained in relation to Excited Delirium.

2. Treat Terry as a medical emergency.
3. Take Terry to hospital from Douglas Road [home address].
4. Assess sufficiently or at all his fitness to be detained at Staines

Police Station prior to his detention there being authorised.
5. Ensure that Terry was taken to the Accident and Emergency

Department of the hospital, prior to 23.45 hours on the 12th

November 2013.

6. Monitor and consider sufficiently or at all the length of time for

which Terry was under restraint and his response to it, prior to

23.45 hours on the 12th November 2013.

7. Consider his containment rather than restraint at Staines Police

Station, prior to 23.45 hours on the 12th November 2013.

8. Have in place an adequate policy in relation to the management of

those detained under section 136 of the Mental Health Act 1983.

5 CORONER’S CONCERNS

During the course of the inquest the evidence revealed matters giving rise

to concern, some of which have now been addressed. However, in my

opinion there is a risk that future deaths will occur unless action is taken

in respect of the matters which have not yet been addressed or

sufficiently addressed. In the circumstances it is my statutory duty to

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report to you.

A. To : (i) The South East Coast Ambulance Service NHS
Foundation Trust and (ii) NHS England / NHS Digital

The MATTER OF CONCERN is as follows :

1. Call Handling : Emergency calls for an ambulance are triaged by
SECAMB’s call handlers using a tool known as NHS Pathways

which is produced by NHS England / NHS Digital. The tool is

designed to enable the non-clinical operator to assess the urgency

of a call, to recognise a medical emergency, and to categorise

SECAMB’s level and speed of response. The version of NHS

Pathways currently in use is version 16 which does not enable

operators to recognise potential ED / ABD and respond

accordingly. I was told that it is intended that version 17 will do

so but this is not yet in use. My concern is that, unless and until it

is in use, there will continue to be a failure by call handlers to

recognise ED/ABD and respond appropriately.

B. To : The South East Coast Ambulance Service NHS Foundation

Trust

The further MATTERS OF CONCERN are as follows :

1. Call Handling : I was told that, whilst waiting for version 17 of
NHS Pathways, SECAMB has provided its call handlers with

guidance (by way of a “Hot Topic”) that a call from the Police or a

Health Care Professional stating that a patient is suffering

ED/ABD should be given a category 2 response. I was also told,

however, that SECAMB’s call handlers have no discretion when

using NHS Pathways which must be followed precisely. I have

three concerns about the current situation. First, there appears to

be a contradiction between the call handlers being told they have

no discretion when using NHS Pathways and their being given

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additional guidance for certain calls. This contradiction could

cause confusion. Secondly, the guidance given in the “Hot Topic”

is concerned only with calls from the Police or an HCP in which

ED/ABD is identified. Currently, therefore, there is no provision

for identifying the condition in calls from the Police or an HCP

which do not expressly mention ED/ABD or in calls from the

public (meaning the call from Terry’s family would still not be

recognised as a call relating to ED/ABD, even today). Thirdly, the

“Hot Topic” does not guide the call handlers to ask whether the

patient is under restraint. If a patient suffering ED/ABD is under

restraint this could add to his risk of sudden death and this

information could affect the proper categorisation of the response

to the call.

2. Training of Clinical Staff : I was told that in 2016/17 SECAMB

sought to address the absence of training of its clinical staff b

providing some “key skills” training in relation to the condition of

ED/ABD and its management, but that it was only in 2018 that it

introduced a specific training package on the condition. I have

two concerns about this training package. First, its content is

potentially confusing in that (a) it refers to the condition of

ED/ABD as “controversial” (when it is not) and (b) it links

ED/ABD to patients detained under section 136 of the Mental

Health Act (which a patient suffering ED/ABD will not necessarily

be). Secondly, to date the training has been given to only about

150 out of about 650 front-line response staff (and out of a much

higher number of all employees who should be trained). I was

told that there are plans to create an e-learning package to aid

faster delivery, but this has not yet been created.

3. Conveyance Policy : The Joint Surrey Police, Sussex Police, Kent

Police and South East Coast Ambulance Service NHS Foundation

Trust Conveyance Policy is currently being re-drafted but I have

concerns about the current and draft proposed versions I was

shown. Both versions indicate that a patient suffering ED/ABD (or

other life threatening conditions) should not be conveyed to

hospital by police vehicle under any circumstances or unless a

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series of 11 conditions are satisfied. Some of the 11 conditions

could take some time to satisfy and some are dependent on the

presence of SECAMB at the scene (which could be subject to

delay). I am concerned that the policy could prevent a patient who

is suffering a medical emergency being conveyed to hospital as

soon as possible, and by police vehicle if necessary, and could

result in a fatal delay in the provision of life-saving treatment.

4. Data Gathering and Auditing : I am concerned that SECAMB is
not currently monitoring accurately the incidence of cases of

ED/ABD in the regions it covers. A witness told me that she

believed there were very few incidents (under ten a year) and that

they were all apparent from the data gathered. On the basis of the

evidence heard at the Inquest it seems unlikely that there are very

few incidents given that SECAMB cover three large counties with

a total population of over 4 million people and given the much

higher incidence in other areas. Further, there were at least two

incidents of ED/ABD (from 2018 and 2019) referred to in evidence

which had not been captured at all by SECAMB’s data gathering.

5. Senior Management Awareness : I was told by the Chief Executive

Officer of SECAMB that he was not aware of Terry’s death and

SECAMB’s involvement in it, nor of the issues arising at the

Inquest, until very shortly before being required to give oral

evidence at the Regulation 28 hearing. Given the length of the

Inquest and the seriousness of the issues arising in relation to

SECAMB (including their failure to recognise that Terry was

suffering ED/ABD and to ensure he was treated as a medical

emergency and taken to an Accident and Emergency Department),

I am concerned that there is no system in place to ensure that such

matters are drawn to the attention of the most senior management

in a timely manner so as to ensure there is strategic planning for

the prevention of other deaths.

C. To : Joint Royal Colleges Ambulance Liaison Committee

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The MATTER OF CONCERN is as follows :

1. I was told that although the London Ambulance Service has

provided out of hospital rapid tranquilisation of patients (such as

may well be needed by a patient suffering ED/ABD) for some

years, SECAMB will not do so until a national protocol or

guidance has been issued by JRCALC. In those circumstances,

whilst I understand that work on the production of such guidance

is being undertaken, I am nevertheless concerned that none is yet

in place.

D. To : (i) Mitie Care & Custody (Health) and (ii) Teesside

University

The MATTER OF CONCERN is as follows :

1. Although it was clear from the evidence that, as a provider of

Forensic Medical Examiners to custodial settings, Mitie Care &

Custody (Health) has in place thorough systems for the

recruitment and monitoring of staff, I am concerned about aspects

of the training currently being provided in relation to ED/ABD. I

was told that this training is being delivered in conjunction with

Teesside University and I was provided with a copy of the training

materials. I am concerned about the following within the training

materials :

(a) Under the heading “What causes Death in Excited Delirium ?”
there follows a series of six slides dealing with positional

asphyxia when a patient has been “hogtied”. A later slide,

headed “Hypoxia The last nail in the coffin?”, suggests that

hypoxia is an element in what causes death from ED/ABD.

In fact, the evidence provided to me at the Inquest established

that ED/ABD and positional asphyxia are two entirely separate

and quite different conditions. Death from ED/ABD can result

even though there is no asphyxiation or hypoxia. Whilst many

patients suffering ED/ABD in a custodial setting may well be

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under restraint (although they will not necessarily be), it is of

real importance that FMEs (and all involved) understand that

there is a risk of sudden death from ED/ABD whatever the

patient’s position, whether or not there is restraint, and

whether or not there is hypoxia. The evidence I heard showed

that it is vital that it is understood that the risk of death from

ED/ABD comes from the condition itself, which can be

exacerbated by restraint and resistance against the restraint, no

matter what the sufferer’s position. On the basis of the current

training material, students may be misled in to thinking that a

patient is not at risk of death as long as the position in which he

is being restrained is not causing him asphyxiation (which was

the thinking of the officers restraining Terry), and that they will

fail to understand that there is a risk of death from ED/ABD

whatever the sufferer’s position under restraint and even if he

is not being restrained at all.

(b) The material suggests that FMEs should encourage the use of

minimal force and minimal restraint and the use of de-

escalation techniques, but it makes no reference to encouraging

the containment rather than restraint of the patient.

E. To : (i) The Chief Constable of Surrey Police and (ii) The College

of Policing

The MATTER OF CONCERN is as follows :

1. Training : It is clear that Surrey Police now ensure that all officers

and staff receive training in relation to ED/ABD and its

management, including the fact that it is a medical emergency. I

was provided with a copy of the current training material and told

that it was, to a very large extent, reflective the material provided

by The College of Policing’s National Curriculum, Module 5. I

have two concerns :

(a) I am concerned that the material includes reference to ED/ABD

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being “controversial” when this is not the case. A number of the

officers who restrained Terry stated in evidence that they believed

the condition was “controversial”. The inclusion of this reference

continues the risk that trainees are misled into doubting the

existence of ED/ABD and this may result in their failing to

recognise or accept a presentation of ED/ABD.

(b) I am concerned that, within the training material, the guidance

in relation to ED/ABD is closely linked to the guidance in relation

to positional asphyxia. The evidence provided to me at the

Inquest established that ED/ABD and positional asphyxia are two

entirely separate and quite different conditions. Death from

ED/ABD can result even though there is no asphyxia. Whilst

many of those suffering ED/ABD may well be under restraint

(although they will not necessarily be) it is of real importance that

police officers and staff understand that there is a risk of sudden

death from ED/ABD whatever the sufferer’s position and whether

or not he is under restraint. It is vital that it is understood that the

risk of death from ED/ABD comes from the condition itself, which

can be exacerbated by restraint and resistance against the restraint.

On the basis of the current training material, there is a risk that

students may be misled in to thinking that there is no risk of death

as long as there is no positional asphyxiation (which was the

thinking of the officers restraining Terry).

F. To : The Chief Constable of Surrey Police

The further MATTERS OF CONCERN are as follows :

1. Mental Health Guide : Surrey Police’s Mental Health Guide

addresses ED/ABD only in bullet point form alongside reference to

Positional Asphyxia. The conditions are separate and different

and the absence of a separate sheet addressing ED/ABD alone

could mislead those reading the Guide in to thinking that the

conditions are necessarily connected.

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2. Conveyance Policy : The Joint Surrey Police, Sussex Police, Kent