Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0042, written 20 Feb 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 Feb 2020 |
|---|---|
| Reference | 2020-0042 |
| Deceased | Jon James |
| Coroner | Rachel Knight |
| Coroner area | South Wales Central |
| Category | Alcohol, drug and medication related deaths · Police related deaths · Wales prevention of future deaths reports (2019 onwards) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The National Institute for Health and Care Excellence 1 CORONER I am Rachel Knight, Assistant Coroner, for the coroner area of South Wales Central. 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 (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 11th July 2017 I commenced an investigation into the death of Jon David JAMES. The investigation concluded at the end of the inquest 23rd January 2020. The conclusion of the inquest jury was Narrative. The medical cause of death was found to be: 1a. Hypoxic/Ischaemic Brain Damage 1b. Cardiac arrest during restraint of a man suffering acute behavioural disturbance associated with long-term use of cocaine and anabolic steroids 4 CIRCUMSTANCES OF THE DEATH The narrative conclusion read as follows: On the 24th June 2017, police were called by concerned members of the public, to Preston Close, Llantrisant. It was a G1 rated call for assistance. Mr Jon David James had spent time in the Cross Keys pub the previous evening. He had drunk alcohol and had taken a high volume of cocaine. At 1:37 police arrive in the area. At 1:39:51 to 1:40:00 police are at the scene. Police saw Jon standing on a car and displaying erratic behaviour, but pleading for help. After a brief interaction between Jon and the police, he got down from the car but soon ran off. Police chased him into a nearby garden and a struggle started, which lasted approximately 16 minutes. Attempts were made to de- escalate the situation. Suddenly Jon became motionless. Police initially thought Jon was faking his motionless state, because a pulse was detected. However, recovery position was then put into place, while handcuffed, as a precautionary measure because pain tests were done with no reaction. The police were emotionally and physically exhausted. At 2:01 a pulse could not be found and Jon had had a cardiac arrest, CPR was started. At 2:11 an ambulance arrived at the scene. At 2:30 the ambulance arrived at Royal Glamorgan Hospital, but Jon never regained consciousness. Tests showed that Jon had taken heavy abuse amounts of cocaine before the incident as well as alcohol. Tests and history shows Jon was a chronic cocaine and anabolic steroid user. This lead to an enlarged heart, which had an effect upon his body and contributed to his death. Jon died on the 27th June 2017. 1 The Inquest focused upon:- a. The circumstances in which Mr James came to lose consciousness; b. Mr James’ drug use in the period leading up to the incident; c. During the period after the restraint/struggle had taken place, the actions of the police at the scene; and d. The response to Mr James showing signs of Acute Behavioural Disturbance 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 are as follows. – 1. Extensive evidence was received from a Consultant Forensic Pathologist and an expert who is a lead trainer for South Wales Police. They were both of the firm opinion that the publication of NICE guidance on the subject of Acute Behavioural Disturbance would be of vital benefit in preventing future deaths. 2. ABD is clearly a complex topic, with understanding ever-increasing. There have been other PFD reports from coroners seeking to implement national training and guidance on ABD, primarily for frontline police, emergency call handlers and paramedics. However, it is only the paramountcy of NICE guidance that would place ABD at the forefront of the national agenda. Critically, such guidance would be of enormous practical use not only to medical professionals, but also to police and any others who find themselves in the difficult position of having to respond to any individual exhibiting signs of ABD in either public places or clinical settings. 3. There is no current NICE guidance dealing specifically with ABD, and the number of deaths related to it is rising. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe 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 16th April 2020. 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 family who may find it useful or of interest. , mother of Jon James Chair of National Police Chiefs Council Chair of the Board of The College of Policing , Consultant Forensic Pathologist, University Hospital of Wales, Cardiff South Wales Police Headquarters, Bridgend 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 2 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. 9 20th February 2020 SIGNED: Rachel Knight, Assistant Coroner for South Wales Central 3
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.
18 March 2020 Rachel Knight HM Assistant Coroner Coroner’s Office The Old Courthouse Courthouse Street Pontypridd CF37 1JW Your ref: 10672 Our ref: EH-305718 Dear Ms Knight, I am writing in response to your correspondence, dated 20 February 2020, regarding the death of Jon David James. I was very sorry to read of Mr James’ death. We have reflected on the circumstances surrounding Mr James’ death, and your concern that publication of guidance on acute behavioral disturbance (ABD) would benefit in preventing future deaths. NICE has published a guideline on violence and aggression: short-term management in mental health, health and community settings (NG10) which covers the the short-term management of violence and aggression, and aims to safeguard both staff and people who use services by helping to prevent violent situations and providing guidance to manage them safely when they occur. It is relevant for mental health, health and community settings. The guideline does not focus on the very specific condition of acute behavioural disturbance (ABD), also known as ‘excited delirium’. However, there is a reference to the latter within recommendation 1.5.5 which says: 1.5.5 Healthcare provider organisations should train staff in emergency departments to distinguish between excited delirium states (acute organic brain syndrome), acute brain injury and excited psychiatric states (such as mania and other psychoses). I am aware that the Royal College of Emergency Medicine has published guidelines for the Management of Excited Delirium / Acute Behavioural Disturbance (ABD). This publication covers the early recognition, intervention and proactive treatment of ABD. Our guideline on violence and aggression (NG10) is due to undergo a full update in due course and your concerns have been noted for further consideration by the guidelines team as part of this work, including whether it is appropriate for the scope of NG10 to be extended to cover ABD, and any necessary clarification to the terminology in recommendation 1.5.5. Yours sincerely, Sir Andrew Dillon Chief Executive
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