Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, written 22 Jul 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Jul 2016 |
|---|---|
| Deceased | Olawale Adelusi |
| Coroner | Jeremy Chipperfield |
| Coroner area | London (West) |
| Category | State Custody related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: THE CHIEF CONSTABLE OF METROPOLITAN POLICE Directorate of Legal Services Metropolitan Police Service 10 Lambs Conduit Street London WC1N 3NR 1 CORONER I am Jeremy Chipperfield, Assistant Coroner for the coroner area of West London. 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 20 June 2016 I commenced an inquest into the death of Olawale ADELUSI, (41 years old). The inquest concluded on 01 July 2016. The conclusion of the jury was Misadventure to which they recorded the following contributory factor: The "failure of transfer of information and documentation at each stage..." 4 CIRCUMSTANCES OF THE DEATH Olawale Adelusi was arrested on 28 October 2014 and kept in police custody for production at Uxbridge Magistrates' court on 30 October. Whilst at court, he attempted suicide by hanging. He was then remanded in custody and taken to HMP Wormwood Scrubs, where on the morning of 03 November he was found hanging in his cell. 1 ! 5 CORONER’S CONCERNS During the course of the inquest, evidence 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. MATTER OF CONCERN - SUMMARY The absence of an effective system to ensure appropriate transmission of all information relevant to assessment of the (i) risk of self-harm or (ii) mental health, of detained persons BASIS OF CONCERN : – Whilst in police custody Mr Adelusi had been taken to hospital where he remained under police guard. Police Officers kept a Hospital Guard Supervision Log covering a 6.5 hour period and in it recorded that Mr Adelusi had: on several occasions deliberately thrown himself from bed to floor in such a way as to cause concern for his safety; been observed crying on several occasions; been observed banging his head on the floor; spoken of a plot to kill him and of his son having been killed by police; and tried to bite the clinical drip pipe. On return to the police station, Mr Adeslusi was kept under constant supervision and a Constant Supervision Log was maintained by officers over a period of 23 hours in which they recorded that he had been observed: "pushing his thumbs down on to his neck" until he had to be told to desist; urinating in the corner of his cell; whispering to the Forensic Medical Examiner "they've killed him"; again crying and saying "you've killed him"; trying to strangle himself with a vest; kneeling with his head against the floor, crying; and accusing officers of killing his children and asking to see their bodies. Neither the logs, nor the information recorded in them, was included in Mr Adelusi's Personal Escort Record; nor was that information otherwise transmitted in writing to those responsible for his detention after removal from the police station. Whilst there was evidence of a verbal handover to Escort Personnel, at which some of this information may have been mentioned, no record was made of that conversation. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe 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. 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. 2 ! 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner I have also sent copies to the following interested persons: CLCH Trust CNWL Trust Serco Wormwood Scrubs 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 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 22nd July 2016 3 !
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