Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0234, written 5 Jul 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 Jul 2023 |
|---|---|
| Reference | 2023-0234 |
| Deceased | [REDACTED] |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Alcohol, drug and medication 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
THIS REPORT IS BEING SENT TO:
1.
Metropolitan Police Service (MPS)
6th Floor, New Scotland Yard
Victoria Embankment
London SW1A 2JL
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
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.
3
INVESTIGATION and INQUEST
On 25 March 2021, I commenced an investigation into the death of
, aged 44 years. The investigation concluded at the
end of the inquest earlier today. I made a determination at inquest that
death was drug related. I recorded the medical cause of death as:
1a complications arising from cocaine intoxication.
4
CIRCUMSTANCES OF THE DEATH
took cocaine and
On the afternoon of 18 March 2021,
went to a friend’s home. He demonstrated features of acute behavioural
disturbance (ABD) and police were called. They recognised this as a
medical emergency and sought an ambulance, but
arrested
before the ambulance arrived. With police assistance paramedics
achieved a return of spontaneous circulation, but
died in
hospital the following day.
1
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.
The police officers who attended
acted quickly. They:
restrained him carefully and safely;
recognised a medical emergency and potential ABD;
requested an ambulance;
looked for a defibrillator;
responded to an emerging situation and continued to monitor;
-
- sought to protect his airway;
- supported his head;
-
-
-
-
- moved
- sought additional information that might be of assistance in the
resuscitation by running a police national computer (PNC) check,
belongings and
looking for a medical alert amongst
searching the bathroom where it appeared he may have taken
drugs;
to a better location;
- noted that he was hot and removed his thick jacket to try to cool
him down;
- eventually moved to cardiopulmonary resuscitation (CPR); and
flagged down the ambulance when it arrived in the street.
-
This was all the more commendable because three out of the four
officers were probationers, including the officer who entered the property
first and took the lead. The response was described by the Home Office
pathologist who gave evidence as exemplary.
However, there were two other aspects of the resuscitation that I want to
bring to your attention to help with organisational learning.
1. What was particularly challenging for the officers was knowing
when to move
to the floor and when to commence CPR.
was in peri arrest/arrest for probably around three and
a half minutes before CPR was commenced. Although earlier
CPR would not have changed the outcome for him, it might for
another casualty.
intensive care consultant giving evidence at
The
articulated his view of the point at which
arrest.
inquest
was in peri
2
He recognised that this was a difficult call to make, but told me
that if in doubt about such an arrest situation, first aiders should
move straight to CPR.
I am aware of the work the MPS has undertaken to improve the
first aid training of its front line officers. The recognition of the
deteriorating patient is notoriously difficult, sometimes even in a
hospital setting. However, given that it is a difficulty I have seen
recur for the MPS, it seems to me that it would benefit from further
consideration.
2. Whilst the officers worked well as a team in many respects, it
seemed to me that there could have been more focus on pro-
vital
active support from those not directly monitoring
signs.
For example, the experienced officer who initially held down
legs and then later stood close by, would have assisted
further if he had been asked. However, because he was confident
in his colleagues’ abilities he did not act as what would have been
a very useful pair of eyes. He did not provide that focused
consideration of a situation that can be so useful when other
members of the team are very busy with immediate tasks.
I heard at inquest about the MPS training to speak up, speak out
in such a situation. I know that the MPS trains on the value of a
helicopter view from a secondary safety officer. However, it
seemed to me that this was not completely embedded within the
frame of reference of the officers attending. It is not about criticism
of one’s colleagues,
the
resuscitation.
is about remaining active
in
it
I am wary of recommending a counsel of perfection but, as this is
an issue I have observed on previous occasions, I feel I would be
failing in my duty if I did not raise it with you.
6
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.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date
of this report, namely by 4 September 2023. I, the coroner, may extend
the period.
3
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 following.
wife of
•
•
•
•
•
• HHJ Thomas Teague QC, the Chief Coroner of England & Wales
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 other 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.
9
DATE SIGNED BY SENIOR CORONER
05.07.23 ME Hassell
4
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.
Coroner ME Hassell Senior Coroner Inner North London St Pancras Coroner’s Court Camley Street London N1C 4PP Deputy Assistant Commissioner Metropolitan Police Service New Scotland Yard Victoria Embankment London SW1A 2JL 1 September 2023 Re: Prevention of Future Deaths Report – Mr Emmanuel Seisay Dear Ms Hassell I am the Deputy Assistant Commissioner for the Directorate of Professional Standards in the Metropolitan Police Service (“MPS”). On behalf of the Commissioner of Police of the Metropolis, I write to provide the response to the matters of concern addressed to the MPS following the inquest into the death of Mr Emmanuel Seisay and your Report to Prevent Future Deaths dated 5 July 2023. On behalf of the MPS may I express my sincere condolences to the family and friends of Mr Emmanuel Seisay, our thoughts and sympathies are very much with them. The Coroner’s “Matters of Concern” The Prevention of Future Deaths report dated 5 July 2023 records:- “There were two other aspects of the resuscitation that I want to bring to your attention to help with organisational learning. 1. What was particularly challenging for the officers was knowing when to move Mr Seisay to the floor and when to commence CPR. Mr Seisay was in peri arrest/arrest for probably around three and a half minutes before CPR was commenced. Although earlier CPR would not have changed the outcome for him, it might for another casualty. The intensive care consultant giving evidence at inquest articulated his view of the point at which Mr Seisay was in peri arrest. He recognised that this was a difficult call to make, but told me that if in doubt about such an arrest situation, first aiders should move straight to CPR. I am aware of the work the MPS has undertaken to improve the first aid training of its front line officers. The recognition of the deteriorating patient is notoriously difficult, sometimes even in a hospital setting. However, given that it is a difficulty I have seen recur for the MPS, it seems to me that it would benefit from further consideration. MPS Response Since this incident in March 2021, the MPS has introduced the following changes to the MPS Emergency Life Support (ELS) training, which will assist in reducing any delays in administering CPR. • The introduction of the trapezius muscle squeeze when checking for a response in order to ensure an accurate response level is established. Additionally the changing of the term unresponsive to unconscious to ensure there is no confusion when informing the London Ambulance Service of the response level. • Since June 2021, it is mandatory for all officers to complete an agonal breathing digital package which assists in identifying breathing that is not normal and to commence CPR more quickly. • The introduction of the jaw thrust manoeuvre as standard to open an airway when breathing is noisy, and for a casualty to be maintained on their back with a jaw thrust manoeuvre applied until medical help arrives. The recovery position is only to be used to clear fluid from the airway. Where a jaw thrust manoeuvre does not clear noisy breathing, CPR is commenced immediately. 2. Whilst the officers worked well as a team in many respects, it seemed to me that there could have been more focus on pro-active support from those not directly monitoring Mr Seisay’s vital signs. I heard at inquest about the MPS training to speak up, speak out in such a situation. I know that the MPS trains on the value of a helicopter view from a secondary safety officer. However, it seemed to me that this was not completely embedded within the frame of reference of the officers attending. It is not about criticism of one’s colleagues, it is about remaining active in the resuscitation. I am wary of recommending a counsel of perfection but, as this is an issue I have observed on previous occasions, I feel I would be failing in my duty if I did not raise it with you. MPS Response In April 2024, the MPS will be introducing the “first aid safety officer” as part of the annual first aid training cycle, which all officers are required to attend. This role is for when there are a number of officers dealing with a casualty, one officer steps back and takes an overview of the first aid delivery and requirement and ensures that all checks and monitoring are completed. In May 2023, the National Police Chief Council endorsed recommendations from its First Aid Forum’s review following the Manchester Arena public inquiry. This increased ELS Module 2 training from 9-12 hours (and increased refresher training by 2 hours). This training will introduce techniques such as the ‘jaw thrust’ and also provide more practical scenario-based drills with the aim of improving officers’ confidence in dealing with casualty situations. The MPS will start to deliver this additional training from April 2024. Please do not hesitate to contact me should you have any queries. Yours sincerely,
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