Nicholas Gedge

White Rose Office Park
Building 3
Millshaw Park Lane
Leeds
LS11 0DL
                                                                                                                       Tel: 0113 220 8500
                                                                                       www.leedscommunityhealthcare.nhs.uk

Mr Oliver Longstaff
HM Area Coroner for West Yorkshire
His Majesty's Coroner's Office
Burgage Square
Wakefield
WF1 2TS

1 May 2025

By email: 

Dear Mr Longstaff

Re: Regulation 28 response: Inquest touching the death of Nicholas Oliver James Gedge

I write in response to your Regulation 28 report dated 11 March 2025 concerning the death of Mr
Nicholas Oliver James Gedge. In advance of responding to the specific concerns raised in your
report, may I begin on behalf of Leeds Community Healthcare NHS Trust ("the Trust") by conveying
my deepest condolences to the family of Mr Gedge for their loss.
Your  report  that  was  issued  to  The  Chief  Constable,  West  Yorkshire  Police  and  to  Leeds
Community Healthcare NHS Trust, raised the following concerns:

"From  the  point  when  the  Detention  Officer  first  entered  Nicholas’  cell  to  when  CPR  was
commenced, 8 minutes and 12 seconds elapsed without CPR being given. Within that timeframe,
two  Detention  Officers  and  a  nurse  were  present  in  the  cell  after  75  seconds  had  passed.

On the evidence, there did not appear to be any shared understanding between the three people
in the cell with Nicholas of the urgency of starting CPR on an unresponsive person. There did not
appear to be a co-ordinated approach to assisting Nicholas, with the Detention Officers and the
they  understood  and  undertook.
nurse  not  appearing 

to  have  defined  roles  which 

It was not clear whether there were any protocols in place to define the respective roles of detention
staff and medical staff attending a medical emergency in a cell. The passage of time before CPR
was  commenced  gives  rise  to  a  concern  either  that  the  importance  of  early  CPR  was  not

Leeds Community Healthcare NHS Trust is a research active teaching Trust

Chair: 

                                         Chief Executive: 

 appreciated, or that the communication between detention and medical staff did not facilitate its
prompt commencement."

These matters of concern have been given careful consideration by the Trust and I set out below
the actions that have been agreed in response.

  At the time of the event, Health Care Professionals (HCP) employed by LCH received Life
Support training on an annual basis. This included basic life support (affiliated to the Resus
Council UK standards) and training on the automated external defibrillators and emergency
bag contents including bag valve mask, nasal and Guedel airways, oxygen and emergency
drugs.

  Since  January  2024,  (after  this  incident)  the  training  session  for  LCH  staff  has  been
expanded to include the use  of  a  further airway adjunct (i-gel) and reflective  discussions
around any clinical issues or themes (e.g. recently staff have experienced an increase in
opiate overdoses in custody). This is in addition to introducing medical emergency / CPR
scenarios to introduce elements of teamwork.

I would like to reassure you and Mr Gedge's family that the concerns raised in your Regulation
28 report have been listened to and reflected upon and in order to improve the timeliness and co-
ordination of basic life support, the Trust will implement the following actions:

Concern

Response

Lack of shared
understanding
and co-
ordination
between
detention
officers and
healthcare
professionals for
starting CPR

 

In addition to the organisational
mandatory bespoke life support training,
LCH will expand the scenario aspect of
training to include simulation exercises
in the custody suite environment with
the aim of improving the co-ordination
between LCH staff and detention
officers in the event of emergency
scenarios.

  The service has added a photographic
description of the contents of the
emergency bag to aid the quick
identification of items in an emergency.

Timescale

Discussion to
take with
police by May
28th, 2025,
with the aim of
introducing
joint scenarios
in training by
August 31st,
2025.

  A working group consisting of LCH

HCP’s, led by a clinical team manager,
has commenced to review the Death in
Custody (DIC) procedure.

The task group
will conclude
by August 31st,
2025.

  The service will ensure that they include

‘coordination of response’ in the
investigation process of incidents where
there has been a life-threatening
response or a DIC.

  The procedure will be agreed with the 
police to ensure the coordination of 
response in life threatening situations is 
robust.

 LCH has conducted a reflective 

conversation with the staff involved in 
the incident and has incorporated their 
recommendations and suggestions for 
improvements into the CPR training.

 The DIC review will also enhance the 

joint reflection process with all 
colleagues involved in the incident.

 All current LCH protocols are 

organisation specific and are agreed 
with the police.

Unclear if 
protocols in 
place to define 
roles and 
responsibilities 
in emergency

As a matter of clarification, Leeds Community Healthcare NHS Trust would also like to note that
within the Regulation 28 report (page 1, section 4) it states:

“Nicholas  was  moved  from  the  cell  bench  to  the  floor,  and  the  nurse  inserted  an  intraosseous
needle at 1548 hours and an oxygen mask shortly thereafter.”

This was in fact not an intraosseous needle and it was the administration of Naloxone (medicine
that rapidly reverses opioid overdose) as an intramuscular injection.

We hope the above actions taken by Leeds Community Healthcare has addressed the Coroner’s
concerns, but should the Coroner have any further queries, please do not hesitate to contact
Leeds Community Healthcare Trust.

Yours Sincerely,

Executive Director of Nursing and Allied Health Professionals
Leeds Community Healthcare NHS Trust

IN THE WAKEFIELD CORONERS’ COURT 

IN THE MATTER OF AN INQUEST INTO THE DEATH OF  

NICHOLAS GEDGE 

POLICE RESPONSE TO REPORT TO PREVENT FUTURE DEATHS 

1. 

This response is prepared on behalf of the Chief Constable of West Yorkshire Police to the 

Coroner’s Report to Prevent Future Deaths in the case of Nicholas Gedge.  

2. 

It is hoped that the following will allay some of the Coroner’s concerns: 

(a) 

The evidence of the Detention Officer who found Mr Gedge unresponsive was that 

when  she  called  for  the  nurse  she  believed  that  Mr  Gedge  was  breathing.  The 

Healthcare  Professional  who  attended  recorded  in  her  notes  that  she  found  slight 

breath and a faint pulse on examination. 

(b) 

Police Detention Officers have basic life support training only. They are not trained to 

start CPR on “unresponsive” individuals who are breathing. Starting CPR on people 

who  are  unresponsive  but  breathing  can  cause  harm.  For  this  reason  only  a 

Healthcare  Professional,  who  has  Intermediate  Life  Support  training  would  be 

qualified to start CPR on a person who was believed to be breathing.  

(c) 

In  a  medical  emergency,  Detention  Officers  do  have  a  defined  role  which  is  made 

clear to them in regular training: 

 
 
 
 
 
 
 
 
 (i) 

Until the custody Healthcare Professional attends, they are to follow their 

training and provide Basic Life Support, including giving CPR to people who 

are not breathing.  

(ii) 

Once  the  Healthcare  Professional  arrives,  Detention  Officers  are  to  take 

direction from the Healthcare Professional. The Detention Officers in this 

case understood this and did so when requested, such as when a Detention 

Officer assisted in moving Mr Gedge from the bench to the floor. It would be 

inappropriate and dangerous for a Detention Officer with lesser training to 

be doing anything other than following directions in an emergency response 

when an individual with greater training is present and leading the response.  

(d) 

The  Chief  Constable  makes  no  comment  on  the  actions  of  the  Healthcare 

Professional, which is a matter for the Trust.  

3. 

Nevertheless, the Chief Constable intends to review the contracts, policies and procedures 

that are in place between Leeds Community Healthcare and the Force, in partnership with 

Leeds Community Healthcare, to ensure that the respective roles of the Detention Officers 

and Healthcare Professionals in custody in an emergency situation are sufficiently clear.