Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0289, written 16 Jul 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Jul 2019 |
|---|---|
| Reference | 2019-0289 |
| Deceased | Darren Cumberbatch |
| Coroner | Delroy Henry |
| Coroner area | Warwickshire |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: Prevention of Future Deaths Report Mr Cumberbatch CUMBERBATCH (died 19th July 2017) THIS REPORT IS BEING SENT TO: Chief Executive Officer, HM Prison & Probation Service‐ CORONER I am: Delroy Henry, Assistant Coroner, Warwickshire. The Coroner's Office, Coroners Office Warwickshire Criminal Justice Centre, Newbold Terrace, Leamington Spa, CV32 4EL 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. 1. INVESTIGATION and INQUEST On 20th July 2017, I commenced an investigation into the death of Mr Darren Keith Cumberbatch (aged 32 years). The investigation concluded at the end the inquest on 25th June 2019 at Warwickshire Coroners Court. The conclusion of the death of Mr Cumberbatch Cumberbatch was that death was “drug related” with a narrative appended, a copy of which I attach to this report. 2. CIRCUMSTANCES OF THE DEATH Mr Darren Cumberbatch in July 2017 was living at McIntyre House, Nuneaton. This is a hostel run by the probation service. On 10th July 2017 Mr Cumberbatch was behaving oddly. He was running around the hostel and shouting. Such was the concern by the probation staff for Mr Cumberbatch as a risk to himself or others, the decision was made to call the police at 00.23. Two police officers arrived initially and saw Mr Cumberbatch’s agitated behaviour. The concern it seems was that he ‘may’ have taken drugs, perhaps suffering from a mental health issue and/ or Acute Behavioural Disturbance. This led more officers being called as a contingency. Mr Cumberbatch got into a toilet area and police officers engaged him verbally to calm his state of agitation. Whilst inside the toilet cubicle Mr Cumberbatch then got hold of a metal ‘grab’ rail. Police officers became physical engaged with Mr Cumberbatch and amidst a struggle with Mr Cumberbatch in which officers used physical force, Tasers were deployed, incapacitant spray (PAVA) discharged and baton used aside from strikes with hand and foot. Mr Cumberbatch was then restrained by police officers and was the taken out of McIntyre House and placed into a police van just outside. Mr Cumberbatch was then taken in the police van to George Elliot Hospital which is a few minutes away. An ambulance arrived in the interim. At George Elliot Hospital car park Mr Cumberbatch was still behaving in an agitated state. He was taken inside the Accident and Emergency Department still in a state of agitation so clinicians could try to obtain observations. It was thought he had taken “something”, observations indicated he was very sick, Mr Cumberbatch when asked telling those treating him that he had taken drugs, in particular cocaine. A high temperature and high heart rate meant his condition was serious, highlighted by his blood results a working diagnosis being a ‘drug overdose’ and that prolonged aggression and attempts to resist restraint could have contributed to the clinical condition. Mr Cumberbatch did calm down and immediate condition improved however the levels of protein in his blood was very high. He was then transferred to the Intensive Treatment Unit (ITU) on 11th July 2017 as Mr Cumberbatch’s kidney functions and urine output were not improving. Mr Cumberbatch’s condition over the next few days steadily got worse despite multi organ support and continued reviews as to his treatment. By 17th July Mr Cumberbatch was rapidly deteriorating, he was suffering from multi‐organ failure and died on the 19th July 2017. CONCERNS During the course of the inquest, the evidence and information 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. 3. The MATTERS OF CONCERN are as follows: i. Acute Behavioural Disturbance in simple terms is when a person exhibits violent behaviour in a bizarre and manic way rather than being simply violent. ABD is an ‘Umbrella’ term that covers a variety of conditions that can give similar signs and symptoms which can prove fatal. ABD can be caused by substance misuse such as drink or drugs or psychiatric illness. ii. Signs/ symptoms included: Bizarre and/or aggressive behaviour; impaired thinking and incoherent speech; hot to the touch and/or removal of clothing; disorientation and hallucinations; acute onset of paranoia; rapid breathing (which can be irregular); unexpected physical strength; significantly diminished sense of pain; sudden tranquillity after frenzied activity. This is not an exhaustive list. iii. Before the police were called to attend, Mr Cumberbatch presented with many signs / symptoms suggestive of him suffering with Acute Behavioural Disturbance (ABD) [bizarre behaviour; impaired thinking; frustrated, confused, frantic and running around]. iv. ABD can be triggered from substance misuse or a mental health issue. It was likely cocaine was the trigger factor for Mr Cumberbatch. The probation hostel staff observed Mr Cumberbatch develop these acute signs / symptoms and the staff did have knowledge of Mr Cumberbatch’s history of substance misuse. v. National Probation service staff receive mandatory training which includes an aspect of substance misuse. The probation hostel staff had no awareness or training in relation to Acute Behavioural Disturbance. vi. ABD is a potential medical emergency. vii. Information sharing of an individual possibly suffering from ABD is very significant and those with a basic knowledge of it can be implemental in formulating a plan to manage a person suspected to be suffering with ABD which include the use of de‐ escalation techniques so as to minimalise the use of restraint. viii. The police have basic training to recognise the signs / symptoms which can dictate as to how an individual is managed, in particular with regards to restraint (detain/ contain rather than restrain). ix. West Midlands Ambulance call assessors receive information to determine the appropriate level of care at the point of a telephone call to the ambulance service. A patient suspected to be suffering with “ABD” is automatically a ‘category 2’ situation i.e. a potentially serious condition that may require rapid assessment with a response target time frame of 18 minutes. x. Basic training for probation hostel staff (e.g. similar to simple basic training materials that are provided to the police by the college of policing to increase awareness of ABD) is possible and this may prevent future deaths. Such awareness combined with opportunities to engage with an individual and a familiarisation with residents may better aid in the de‐escalation of a person suspected to be suffering with ABD and thereby potentially minimalizing the necessity to resort to any restraint (which can be very dangerous to a person suffering since restraint and struggle against restraint increases the acidosis in the body which can lead to muscle breakdown which can lead to rhabdomyolysis and multi organ failure). It may best facilitate the individual engaging willingly seeking the necessary medical attention. 4. ACTION SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths and I believe that you have the power to take such action. 5. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 10th September 2018. 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. 6. COPIES and PUBLICATION I have sent a copy of my report to the following: 1. HHJ Mark Lucraft QC the Chief Coroner of England & Wales Chief Coroner's Office, 11th Floor Thomas More, Royal Courts of Justice, Strand, London, WC2A 2LL. chiefcoronersoffice@judiciary.gsi.gov.uk 2. Darren Cumberbatch’s family 3. Warwickshire Police 4. George Eliot Hospital 5. 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 he believes may find it useful or of interest. You may make representations to me, the Assistant Coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 7. DATED ‐ 16th July 2019 SIGNED BY Assistant CORONER ‐ D Henry
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.
Mr. Delroy Henry,
Assistant Coroner, Warwickshire,
The Coroner’s Office,
Warwickshire Criminal Justice Centre,
Newbold Terrace,
Leamington Spa.
CV32 4EL
Amy Rees
Director General of Probation and Wales
HM Prison and Probation Service
3rd Floor Churchill House
Churchill Way
Cardiff CF10 2HH
e-mail: DirectorGeneralProbation@justice.gov.uk
c/o Coroner’s Officer:
6 September 2019
Dear Mr Henry / Annwyl Mr. Henry
Inquest into the death of Mr Darren Keith Cumberbatch
Thank you for your Regulation 28 Report, issued following the Inquest into the death of Mr Darren
Keith Cumberbatch, addressed to the Chief Executive Officer of Her Majesty’s Prison & Probation
Service (HMPPS). I am replying as the Director General Probation, part of HMPPS.
I know that you will share a copy of this response with the family and I would first like to express my
sincere condolences for their loss. Every death in such circumstances is a tragedy and the
implementation of learning from this is my absolute priority.
You have raised areas of concern relating to a condition known as acute behavioural disturbance
(ABD), its presentation and that it can potentially lead to a medical emergency. You identified that,
unlike the police, probation hostel (approved premises) staff had no awareness or training in relation
to (ABD) and consider that such basic training for probation hostel (approved premises) staff would
increase awareness of ABD and may prevent future deaths.
In response to your recommendation I confirm that the National Probation Service now has plans in
place to assess the most appropriate training package to meet this training requirement and to
develop an implementation plan across the whole approved premises estate with the intention to start
the roll out of ABD awareness training early in 2020.
Thank you for bringing this matter of concern to my attention. Please be assured that learning from
the circumstances of this tragic death will also be shared more widely with colleagues across the NPS
Divisions.
Yours sincerely / Yn gywir
Amy Rees,
Director General of Probation and Wales, HM Prison and Probation Service
Cyfarwyddwr Cyffredinol y Gwasanaeth Prawf a Chymru, Gwasanaeth Carchardai a Phrawf EM
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