Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0401, written 26 Nov 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 26 Nov 2021 |
|---|---|
| Reference | 2021-0401 |
| Deceased | Gary Williams |
| Coroner | Andre Rebello |
| Coroner area | Liverpool and Wirral |
| Category | Police 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: REPORT TO PREVENT FUTURE DEATHS
NOTE: This form is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT DEATHS
THIS REPORT IS BEING SENT TO:
1 National Police Chiefs' Council
Chair -
1st Floor, 10 Victoria Street
London
SW1H 0NN
1 CORONER
I am Andre REBELLO, Senior Coroner for the coroner area of Liverpool and Wirral
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 30 August 2017 I commenced an investigation into the death of Gary WILLIAMS aged
56. The investigation concluded at the end of the inquest held from 8th to the 25 November
2021. The verbatim conclusion of the Jury at the inquest from was that:
was reasonable in calling the police to the
“Based on the medical evidence we find that Mr Gary Williams acute behavioural
disturbance in the early hours of 18th July 2017 was a result of an episode of Ictal
Automatism due to temporal lobe epilepsy.
Based on the evidence given, we heard that the furniture had been rearranged in the
garden and a trail of blood was left. We find that Gary had been injured prior to the police
arrival at Bardon Close.
We find that the householder of
incident happening at her front door about 3 am on the 18th of July 2017. We find that the
householder was alerted to knocking on her front door at 3 am, she opened the door after
applying the security chain and was confronted by her neighbour Gary Williams, She noted
he was completely naked and was trying to gain entry. Gary then tried to remove the
security chain, and was saying "we need to be together". Over concerned for safety she
shut the door. She considered getting Gary a dressing gown given concerns of Gary's well-
being. After the door was closed the banging intensified which caused the householder to
feel threatened of a potential assault and the welfare of her elderly mother, who was also a
resident of the household. This then prompted a 999 call to request police and ambulance.
Gary's behaviour continued to escalate with banging to punching then changing to
pounding. This lead to a vase inside the house to fall and smash, which them prompted a
second 999 call as the incident became more threatening.
Police arrived on the scene around 10 minutes of the first 999 call.
In consideration of the action of Police at
that the police actions were as followed: Tactical communications (i.e. "its the police stop"),
("get on your knees"). These were unsuccessful. One officer then deployed pava spray
which had no effect on Gary.
Due to the this and Gary's aggressive behaviour towards police, the three police officers
deployed the use of batons. Each of the three officers delivered several baton strikes. We
understand this to be in accordance with their training and consideration of the NDM
on the 18th July 2017. We find
Regulation 28 – After Inquest
Document Template Updated 30/07/2021
(National decision making model). However in our judgement the combined number of
strikes was inappropriate.
Due to continued escalation and ineffective previous actions, Gary was then then forcibaly
restrained by way of a headlock. Handcuffs were applied to the front by other officers.
Due to further agitated behaviour leg restraints were then applied to protect the officers
and Gary.
Mr Williams was then carried out of the garden to a grass verge at the front of the house,
the handcuffs were then repositioned to the rear as witnessed by a neighbour.
Gary was then moved from the grass verge into the bulk head area of a police carrier by
several officers whilst awaiting the arrival of medical proffessionals. Whilst in the police
carrier theire is evidence via body cam which shows Gary to be agitated, still restrained and
trying to be calmed by officers. We therefore consider the action of the Police reasonable at
this time.
At approximately 03.45 hours Gary was place on a stretcher and was taken to the
ambulance.
We have found that the actions by the police were reasonable in the circumstances known
to them at the time.
From the evidence available at the time we found there was no alternative course of action.
A Police officers oath is to protect people and property first before considering the reason
for the given circumstances.
We find the actions of the police officers both in the ambulance and at the Royal Liverpool
hospital on the 18th July to 26th July 2017 were reasonable in assisting therapeutic support
to Gary, and his continued restraints. However their was a lack of detailed information
passed on during hand overs to the medical teams. This is evidenced by insufficient
information recorded which omitted key factors, in relation to use of restraints/use of force
and mechanism of injuries during Gary's arrest.
We find that due to Gary's condition, He did not have the capacity to consent to treatment,
therefore we find the treatment given to Gary in the circumstances was reasonable. We find
the treatment administered to Gary was appropriate considering the balance of risk. This
treatment included being admitted to ICU on the morning of the 18th July following
sedation and a CT scan which showed up clear. Gary spent a period of 10 days in critical
care, three of which were under Anaesthesia, whilst continually being assessed. During this
time he received 9 doses of preventative anti-coagulant medication to help reduce any risk
of blood clots forming. There was no aspect of care delivered that was not appropriate or
necessary. However some communication during Gary's time at the Royal hospital between
departments was lacking due to inconsistencies and omissions within reports and notes
from the medical staff.
In relation to the cause of death, we find this to be:
1a Pulmonary Thromboembolism (caused)
1b Deep Venous thrombosis
2 Ictal automatism due to temporal lobe epilepsy
We find that the pulmonary Thromboembolism was causes at least in part, that is more
than minimally, negligibly or trivially by the following:
B. Injuries and bleeding sustained in a entering the back garden of
C: Restraint and baton strikes by the police in effecting his arrest and detention.
D : Therapeutic support in critical care - including restraint, sedation, anaesthetic,
ventilation, peripheral venous access, central venous line access ext.
From the medical evidence from medical staff and experts theire is no direct link that
Temporal lobe epilepsy causes the pulmonary Thromboembolism, however this was the
catalyst that lead to the incident that occurred on the 18th of July 2017 and the subsequent
chain of events.
We find that Gary Williams was certified as having died at 18:50 on 28th July 2017 at his
sisters home
given all the circumstances known at the time when intervention was possible we find that
Gary Williams death was not preventable.”
.
.
4
CIRCUMSTANCES OF THE DEATH
As set out in the Narrative Conclusion above
The cause of death being found as:
Regulation 28 – After Inquest
Document Template Updated 30/07/2021
I a Pulmonary Thromboembolism
I b Deep venous thrombosis
2. Ictal automatism due to temporal lobe epilepsy
5 CORONER’S CONCERNS
During the course of the investigation, my inquiries revealed matters giving rise to concern.
In my opinion, there is a risk that future deaths could occur unless action is taken. In the
circumstances, it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows:
(brief summary of matters of concern)
Gary Williams suffered from Temporal lobe epilepsy. He was a retired police officer who
was a very friendly and polite gentleman, when not unwell. He had previously had
absences. However, nothing that can compare with the events in the eleven days before his
death on the 28th July 2017. On the 18th July 2017 he suffered from an extreme acute
behavioural disturbance, described as what appeared to be a psychotic delusional state in
which affray and violence to life and property was demonstrated. This was Ictal automatism
due to temporal lobe epilepsy. A neurologist explained at the inquest that he felt sorry for
the police, as they did not know the patient or with what they were dealing. He explained
that there was no way to rationalise with some in this state - they are like a zombie and
though they do not feel pain the use of PAVA, baton strikes and restraint will be responded
to by the person’s fight and flight instincts. It is important to approach such a person with
calm. In a neurological ward, it can take four experience health care professional and a fifth
to sedate to deal with such a presentation. There is no treatment as such for this
presentation just sedation and if necessary critical care support until the person has
recovered. This condition is not part of the college of policing training materials with regard
to use of restraint. You may consider that it would be helpful to include it in the minimum
of 12 hours future mandatory annual restraint refresher training undertaken by all officers.
In this case, officers, members of the public and health care professionals were distressed
and exhausted but fortunately officers, healthcare professionals and the public did not
suffer permanent serious or fatal harm.
6 ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I believe you (and/or
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 21st January, 2022. 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 Chief Coroner and to the following Interested
Persons
Gary Williams - Family
Merseyside Police
Gary Williams’ GP
Liverpool University Hospitals NHS Foundation Trust
Regulation 28 – After Inquest
Document Template Updated 30/07/2021
I have also sent it to
Independent Office for Police Conduct
who may find it useful or of interest.
I am also under a duty to send a copy of your response to the Chief Coroner and all
interested persons who in my opinion should receive it.
I may also send a copy of your response to any person who I believe may find it useful or
of interest.
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.
9 Dated: 26/11/2021
Andre REBELLO
Senior Coroner for
Liverpool and Wirral
Regulation 28 – After Inquest
Document Template Updated 30/07/2021
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.
André Rebello OBE Senior Coroner Liverpool and Wirral Area Hon Secretary Coroners’ Society of England & Wales HM Coroner’s Court Gerard Majella Courthouse Boundary Street Liverpool L5 2QD Date: 11th January 2022 Dear Mr Rebello, Regulation 28 Report – Mr Gary Williams I write on behalf of the National Police Chiefs Council (NPCC) in relation to paragraph 7, Schedule 5 of the Coroners and Justice Act 2009, and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, in relation to the prevention of future deaths report sent via email to the NPCC dated 26th November 2021. The notice sets out concerns that arose from the information received during the inquest into the death of Mr Williams which occurred in July 2017. I am very sorry to read of the circumstances of Gary’s death. My sympathies are with his family and friends, and I share your commitment to addressing the issues that contributed to his untimely loss. The notice sets out your principal concern stating that Mr Williams’ condition (ABD) is not part of the College of Policing training materials with regard to use of restraint, and that this should be considered to include in future annual refresher restraint training. The issue you have highlighted has been addressed recently, following a regulation 28 notice in relation to the death of Douglas Oak (also in 2017). 1st Floor, 10 Victoria Street, London SW1H 0NN | | www.npcc.police.uk The Self Defence Arrest and Restraint (SDAR) working group led by DAC , works closely with the College of Policing. This group reviews the learning from coroners, the Independent Office of Police Conduct (IOPC), Her Majesty’s Inspectorate of Constabularies and Fire and Rescue Services (HMICFRS), stakeholders and police forces. Following the Oak inquest, the SDAR group immediately reviewed and updated the existing ABD power point and the PST Manual. This included incorporating additional training which was identified and documented within our response to the coroner overseeing the proceedings in this case. Specialist advice was sought from experts in emergency and forensic medicine who provided expert advice to SDAR relating to the ABD PowerPoint, notes for trainers and the National Personal Safety Manual. Subsequently the ABD Training Package for UK Police Forces was updated and circulated in March 2021 with a direction for Forces to deliver the revised ABD package with immediate effect. Additionally, The Royal College of Emergency Medicine Best practice Guidelines: Guidelines for the Management of Excited Delirium/Acute Behaviour Disturbance (ABD) May 2016, was also circulated to forces in September 2021 which contains a section on ‘restraint’ in relation to medical settings. I will ensure that this notice along with my response is shared with the College of Policing and the SDAR group for completeness. I hope that the information that has been provided goes some way to reassure you that the matters of concern you have raised have been addressed and will be subject to continual review. Yours sincerely, Chair, National Police Chiefs’ Council
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