Eugeniusz Niedziolko

Date of report	10 Jul 2018
Deceased	Eugeniusz Niedziolko
Coroner	David Ridley
Coroner area	Wiltshire and Swindon
Category	Alcohol, drug and medication related deaths · Mental Health related deaths
Source	judiciary.uk record · original PDF
Responses published	none published

The report

Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.

DAVID W. G. RIDLEY
Senior Coroner for Wiltshire and Swindon

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT TO:
Chief Constable Kier Pritchard
Wiltshire Police

Wiltshire Police HQ

London Road

DEVIZES

Wiltshire

SN10 2DN

Ken Wenman Esq

The Chief Executive

South Western Ambulance Service
NHS Foundation Trust

Abbey Court

Eagle Way

EXETER

EX2 7HY

Chief Constable Mike Cunningham
Chief Executive of the College of Policing
College of Policing,

1-7 Old Queen Street,

Westminster,

London, SW1H 9HP

Chief Constable Mark Collins

Dyfed & Powys Police

(National Police Chiefs’ Council Lead in relation to Mental Health)
Police Headquarters

PO BOX 99

LLANGUNNOR

Carmarthen

Carmarthenshire

SA31 2PF

CORONER
lam DAVID W. G. RIDLEY, Senior Coroner for Wiltshire and Swindon

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.

http://www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http:/Awww.legislation.gov.uk/uksi/2013/1629/part/7/made

INVESTIGATION and INQUEST

On the 14 February 2017 | commenced an investigation into the death of Eugeniusz Niedziolko
and_an Inquest was opened by Assistant Coroner, Dr. Claire Balysz on the 11 April 2017. The

Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP
Tel 01722 438900 | Fax 01722 332223

Inquest, which was held with a Jury, was concluded on the 28 June 2017 and the Jury
determined that the medical cause of death was 1a) Acute Alcohol Toxicity and Hypothermia.
In box 3 in the Record of Inquest the Jury in relation to the mechanism of the death recorded as
regards the how, when and where Eugeniusz came by his death:-

At 7.45 am on 14 February 2017, Eugeniusz Niedziolko was found unresponsive in a
lavatory block at Lush House Car Park, Salisbury, after being left by the police at 3.17 am
to sleep off the effects of alcohol consumption in the early hours of that morning.

Eugeniusz was pronounced dead at 8.17 am on 14 February 2017 and died as a result of
acute alcohol intoxication and hypothermia.

The short form conclusion and narrative conclusion recorded by the Jury in box 4 of the Record
of Inquest was recorded as follows:-

“Accident contributed by neglect"
“Narrative Conclusion”

Failure by the Police and Ambulance Services to relay and clarify key information from
the control room to front line staff. In addition, failure to follow protocol and document
findings by the Police and Ambulance Services was compounded by inappropriate
training delivery processes. With insufficient knowledge of the options available this
culminated in poor decision making and a lack of professional judgment by the Police
who subsequently left Eugeniusz in the toilet block at Lush House car park at 0317 on the
14th February 2017 rather than being taken to an appropriate place of safety to be
monitored and receive appropriate care if necessary.

CIRCUMSTANCES OF THE DEATH

At around 0130 on the morning of the 14 February 2017 the Police were called to attend a
believed drunken person that had gained access into a communal hallway area inside a private
block of flats at Mitl Road Mews in Salisbury. Eugeniusz had been asked to leave a train a few
hours earlier in Salisbury partly because it was suspected that he had no ticket but also due to
the degree of his intoxication. Police Officers were tasked to attend the flats at 0200 hours and
arrived at the flats at 0227, the call having been given “priority” status. Eugeniusz was found by
both Officers lying on his left-hand side on the top landing intoxicated and in a pool of his own
urine. Right from the outset it was clear that the attending police officers were having
communication issues with Eugeniusz whose English was not good at all. Initially they assisted
him to his feet and escorted him out of the block of flats whereupon one of the officers called the
ambulance service with the intention of them checking Eugeniusz over. The call to the
ambulance service was made at 0244. The Paramedics were dispatched at 0248 and arrived at
the scene some 4 minutes later at 0252. Contrary to the relevant Paramedic protocol (the
Appropriate Care Pathway Policy dated 2014) no observations were carried out on Eugeniusz
and as a consequence nothing was recorded. The lead Paramedic opted to carry out a visual
examination at the roadside using scene lighting and not inside the ambulance. Neither the lead
paramedic nor the trainee paramedic that formed the ambulance crew noted that Eugeniusz had
been incontinent of urine. It was clear however that Eugeniusz was drunk and that there was a
degree of unsteadiness noted although he was able to walk with a rucksack on his back, slightly
staggering but unaided. The lead Paramedic assesses a Glasgow coma scale of 15 and has no
reason to believe as do the Police that Eugeniusz did not have mental capacity. Eugeniusz at
one point tried to get into the ambulance cab and is stopped by the lead Paramedic. Eugeniusz
said that he was a “good alcoholic” and that he wanted to go to hospital. When asked why he
said “detox”. The lead Paramedic went on to indicate that there were no detox facilities at
Salisbury at that time of night. In evidence, no one in attendance considered that actually
Eugeniusz might have been asking for help as a result of having drunk too much. The lead
Paramedic forms the view that the matter is a social issue in nature as opposed to a medical one
and decides that hospital was not the appropriate place for Eugeniusz to be taken. The
Paramedic at the time had 10 months experience in front line operations. At the time the
Paramedics were leaving the scene, one of the options that was being considered was for
Eugeniusz to be taken to a nearby hotel. After the Paramedics had left it was ascertained that

Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 {DP
Tel 01722 438900 | Fax 01722 332223

Eugeniusz does not have sufficient money for a hotel. Around the same time at 0312 the 2
police officers received an update following a PNC check however only 1 of 3 markers appears
to have been effectively communicated to the 2 officers on the ground, both officers in their
evidence were clear that they were only aware of the ailment being an alcoholic marker. Their
view was supported by the transcript of the recording of the communications that the control
room operator had with the officer at the scene. The Control room operative in evidence believed
that she would have passed on all 3 markers and would not have picked out 1 or 2 in priority to
the complete set. Within 5 minutes of receiving this communication, Eugeniusz had been taken
round and deposited in the male lavatory at the Lush House Car Park public lavatory located in
Crane Bridge Road, Salisbury, Wiltshire. The police officers had considered taking him to an
area frequented by other homeless people near Sainsbury's but decided against that due to
concerns that he may be picked upon. Eugeniusz had in his possession a rucksack and a TV
box, although both officers were unclear as to whether it contained a television or not and at no
stage did they confirm the position. Eugeniusz was able to walk into the lavatory block unaided
carrying his rucksack and television. A remaining bottle of Gin was confiscated by one of the
Officers and the contents disposed of later. Eugeniusz is left with a 70cl bottle of rum containing
about 50m! of rum, which when his body was found was empty. That having been said the
Consultant A & E Expert said in evidence that it probably would not have
made a difference in respect of the outcome. No arrangements were made to check further on
Eugeniusz and he was left alone in the lavatory block which unbeknown to the Officers had no
heating in circumstances where the outside temperature dropped as low as 1° Celsius that night.
His unresponsive body was found 4% hours later by a cleaner and his death was confirmed at
0817 by an attending Paramedic. On post mortem examination, including toxicology, blood
alcohol levels were recorded at 434mgs per 100ml of litres of blood and 493mgs per 100m! of
urine. None of the usual signs in relation to hypothermia were found at post mortem hence in
her report i998 the Forensic Pathologist, records a single cause of death as 1a) Acute
alcohol toxicity. This as you will see from above was varied by the Jury to include hypothermia
we in her evidence thought was highly likely at the time of death, despite the
absence of the usual indicators, that there was a degree of hypothermia. Jas also of
the opinion that more likely than not the level of blood alcohol in Eugeniusz’s system was still
rising to a point of equilibrium with urine alcohol levels. a =< a were
both of the view that it was likely that Eugeniusz had a further period of incontinence prior to
death as he was found in a pool of urine and at post mortem his bladder was still relatively full.

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.

[PLEASE NOTE - the whole purpose of this Regulation 28 Report is to avoid a repeat of an
incident whereby a heavily intoxicated individual, who quite clearly was not capable of looking
after himself, was left alone in a public lavatory on a cold night and died as a result of acute
alcohol toxicity and hypothermia on the basis that the police officers concerned felt that they had
no other option available to them].

WILTSHIRE POLICE

a) RADIO PROTOCOL
When listening to the radio communications there appeared to be a non-existent radio
protocol of any form. My concern relative to this particular point is the absence of a
protocol which for example requires the recipient of important information such as PNC
markers to reflect or even repeat the information that has been given so that it can be
established at both ends that the information has been correctly and effectively
communicated. The situation that appears to have arisen in this case is that the
controller says that all 3 markers were communicated but the transcript supports the 2
officers on the ground recollections that they only received notification of 1. | am
concerned that the absence of any check could lead to critical information not being
communicated which could lead in certain circumstances to errors occurring that could
result in a worst case scenario to a death occurring. This issue of relaying critical

Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP
Tel 01722 438900 | Fax 01722 332223

co)

information was highlighted by the jury in their Narrative Conclusion.

TRAINING AND GENERAL LIFE SKILLS - It was quite clear during the evidence that both
police officers had a very limited knowledge in relation to the effects alcohol has on the
body. Neither officer asked, nor even attempted to ask, what | would term were obvious
questions at the time, namely how much had the individual had to drink and when the
last drink was consumed and over what period the alcohol was consumed. Considering
the Courts regard Police Officers as experts in relation to drunkenness (officers tend to
provide evidence in relation to drink related offences) neither officer appeared to have
any idea as regards the link between alcoholism and mental health issues; that sex, age
and build being all variables can affect how the body processes alcohol; the fact that
alcoholics can be quite difficult to judge having regard to tolerance levels (how much
they have consumed becoming essential information so as to factor that relevant
information to enable a decision to be reached, not just as to what the risk to that
individual was at that stage but also in the foreseeable immediate future (in terms of the
next few hours or so). The evidence from the Consultant A & E Specialist,

was that there was a poor correlation between visual presentation and the amount of
alcohol that might actually be in that individual's system. | am concerned here that a
blinkered approach adopted by officers attending somebody who is intoxicated can
easily lead to the wrong decision being taken and one which is based on assumptions. |
have been made aware of changes to training programmes but | am concerned that the
training does not provide sufficient awareness and that there may be still a significant
number of officers who simply do not have the life experience and general knowledge to
factor that experience into professional judgement making. It would not surprise me if
your officers in Swindon, more likely than not, have a better awareness of these issues
and perhaps they could be looked upon to improve the training and share their
experiences to officers elsewhere in the County.

AWARENESS OF MENTAL HEALTH ISSUES

| have already highlighted a concern with the 2 officers in question who were unaware of
the link between mental health and alcoholism that runs in both directions. What was
more concerning was that both officers were unaware that acute alcohol intoxication
amounts to a mental disorder for the purposes of the Mental Health Act 1983 and a
mental impairment for the Mental Capacity Act 2005. This point is being addressed
below to the Chief Executive of the College of Policing and also the Council of Chief
Police Officers Mental Health Lead as | suspect that the 2 officers involved in this case,
as indeed every other Police Officer who gave evidence, was unaware of this until
recently. This needs to change as a matter of urgency as in this case the use of Section
136 Mental Health Act 1983 was never considered as an option because neither officer
thought that Eugeniusz was suffering from a mental disorder. P| a consultant
psychiatrist also expressed a view to the court that he doubted that Eugeniusz actually
had mental capacity when appearing to agree to being left in the lavatory block.

COMMUNICATION OF POLICY AND PROCEDURE

| am aware that following this incident the 2009 Agreement between the Hospitals,
Ambulance Trust and Wiltshire Police as regards the assessment of people who appear
to be drunk and need of medical assessment was circulated. A newer agreement was
also subsequently entered into in June 2017. | am surprised and concerned that even
now front-line officers, who gave evidence, were unaware of either of these 2
agreements. It would appear that important communications are being sent out but that
there is no effective system in place to check that the important information is received
and more importantly is understood. This also applies to e-learning which is capable of
abuse if the same questions are asked at the end of modules. Interestingly, | heard from
Consultant Paramedic EEE that in relation to their e-learning systems random
questions are asked at the end of e-learning modules in an attempt to overcome the risk
of abuse. | fully appreciate that front line officers are under huge amounts of pressure
with increasing workloads and less resources but my fear is that there will be a repeat of
this incident and other issues arising that may lead to a death occurring through the lack
of effective communication of policies and procedures which, at the end of the day, are
designed to guide front line personnel and ultimately protect them. With busy workloads,
an expectation that these documents will be read is unrealistic and arguably idealistic.

Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SPt 1DP
Tel 01722 438900 | Fax 01722 332223

e) 2009 & 2017 MuLti PART AGREEMENT (copies enclosed) - As regards the Agreement in

2009, | noted with interest insofar as the Ambulance protocol was concerned that a risk
of deterioration should be assessed and that the patient should be left in the care of a 3%
party, with advice on seeking medical assistance later if required. | am concerned and
have aired as to why this is absent from the 2017 Agreement and also | am concerned
as to why consideration is not given for a similar provision being incorporated into the
police protocol in the 2017 Agreement. Such a measure appears to be eminently
sensible as a matter of common sense.

ARREST CULTURE _-_|_am_concerned having heard evidence in particular from

the former who had been told that you simply do not
arrest somebody for being drunk and incapable, the latter having given evidence that
there was a Culture that you do not arrest for drunk and incapable. If you look at the
2017 multi-party agreement one of the fall-back positions if hospital assistance is not
regarded as being necessary is the consideration of arresting that individual for being
drunk and incapable. Eugeniusz had no home and was vulnerable as well; the latter
confirmed by both _ii———iaiiteme so the necessity requirement for arrest
would have been satisfied. Eugeniusz was clearly drunk (approaching 5% times the
drink drive limit for blood alcohol) and having become incontinent of urine would also
have been regarded as being incapable as | see it. In evidence, the officers regarded
Eugeniusz as capable at the time they left him — that alone concerns me in terms of a
blinkered view as the bladder would have needed time to refill as the body processed
the alcohol and the evidence from the experts pointed to a further period of incontinence
prior to death. Eugeniusz was so incapable of looking after himself he was unable to
relieve himself appropriately even in a public lavatory. If such a culture exists then that
is a concern as it removed here an option that was disregarded by the officers
concerned and which if exercised may have resulted in Eugeniusz attending hospital or
spending the night safe in custody as opposed to having been left alone in a public
lavatory block. | would like you to review the guidance given to frontline officers and to
consider emphasising that drunk and incapable is still an arrestable offence if the
circumstances and necessity warrant such action being taken to protect life. Arresting
an individual does not mean that the person will necessarily be charged.

SOUTH WESTERN AMBULANCE

2017 AGREEMENT — | raised with Consul i , and he is aware
of my concern, that given the evidence o| Consultant in Accident &
Emergency who gave evidence that even if the observations had been carried out which
to the greatest sense and purpose includes the checks in algorithm on page 10 of 12 of
the 2017 Agreement, | am not convinced that if another Eugeniusz was to crop up that
this risk of significant deterioration and death would have been picked up and avoided
using this algorithm. Sometimes you have to spell it out and there was no questioning in
this case as to when the person last consumed alcohol and over what period and what
quantity they had consumed relative to the decision-making process. | queried whether
especially with somebody who is not being cooperative as to whether the use of a
breathalyser (if they were to consent) would aid in the intelligence gathering. There is
also no mention of physical presentation. In Eugeniusz’s case, he had become
incontinent of urine in respect of which | asked all relevant witnesses as to how many
people they knew who were deliberately incontinent of urine. The answer, not
unsurprisingly, was no-one. That factor from the common-sense point of view either is
suggestive of physical issue whereby Eugeniusz was incontinent or that it was related to
the degree of his intoxication in that he could no longer control and had no awareness of
bodily function in that respect. The algorithm needs to be reviewed and considered in
the tight of this case specifically so that it would pick up another “Eugeniusz’.

2009 & 2017 MULT! PART AGREEMENT - | have made the point to the police at
paragraph e) above that | am concerned that the eminently sensible suggestion that was
contained in the ambulance protocol as regards leaving individuals with a 3" party no
longer appears in the 2017 Agreement. | am aware of other Ambulance Services
incorporating such an inclusion, notably the London Ambulance Service. Such an

Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP
Tel 01722 438900 | Fax 01722 332223

inclusion appears to me to be a very sensible option and one which would have resulted
in Eugeniusz not being left on his own.

COLLEGE OF POLICING & MENTAL HEALTH LEAD, COUNCIL OF CHIEF POLICE OFFICERS

i) [hope in reaching this stage of the report that you will have read the points made above
and you will be aware of my concern that until recently it would appear that the College
of Policing and police officers within Wiltshire were unaware that acute alcohol
intoxication is regarded as being a mental disorder for the purposes of the Mental Health
Act 1983 and an Mental impairment for the purposes of the Mental Capacity Act 2005
(although senior Wiltshire Officers have or should have been aware of this concern since
dune 2017). The code of practice in relation to the Mental Health Act 1983 highlights
this and as | understand ever since 1993 acute alcohol intoxication has been recognised
by the World Health Organisation in I|CD-10 relating to mental and behavioural disorders
with acute alcohol intoxication being classified at F10 as being such a mental disorder.
Front line officers need to be aware of such matters so that when dealing with situations
that confront them that they have a full awareness and understanding of the range of
options and powers that they may have available to them. | fully accept and understand

point that he made in Court that Section 136 of the Mental
lealth Act 1983 should be sparingly used but that does not mean that it should not be
used because the Officers concerned do not recognise that the person in front of them
has a mental disorder so that they can then go on to consider whether or not the person
is in need of immediate care and contro! and ultimately a mental health assessment. In
this case they did not consider Section 136 simply because they did not think that
Eugeniusz was suffering from a mental disorder at the time. | would ask you to review
the training that is provided nationally to alt Police Forces in this respect.

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and | believe you have the power
to take such action.

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 2018.. |, 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.

COPIES and PUBLICATION

| have sent a copy of my report to the Chief Coroner and to the following Interested Persons
Sister of deceased, Bevan Brittan, Solicitors, Force Solicitor, Wiltshire Police Headquarters and
Slater & Gordon Lawyers

| have also sent it to Policing Minister, Nick Hurd, Jackie Doyle-Price, Dept. of Health & Social
Care and Chief Executive, HM Inspectorate of Constabulary who may find it useful or of interest.

| 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 coroner, at the time of your response, about the
release or the publication of your response by the Chief Coroner.

Dated 10 July 2018 7

soraure, SSO
for Wiltshire and Swindon

Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP
Tel 01722 438900 | Fax 01722 332223

The report

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