Investigation and inquest
On 12 May 2016 I commenced an Investigation into the death of KARL BRUNNER, aged 48 years . The Investigation concluded at the end of the Inquest on 09 March 2018. The Conclusion of the inquest was ‘Accidental Death’. Mr Brunner died because he choked after swallowing a package of drugs to avoid arrest. Givers of first aid did not realise it was choking, therefore, despite attempts to give CPR, he did not recover.
Mr Brunner died on Battison Street, Bedford, on the 11th May 2016 at 12.34 pm, when he attempted to swallow a package of individually wrapped drugs - approximately 4 x 3cm, whilst in the process of being arrested by police officers, under Section 23 Misuse of Drugs Act. The package lodged behind his epiglottis and choked him.
In April 2016 the police conceived an operation with the objective of arresting Mr Karl Brunner. Mr Brunner was a known drug user and dealer, who had undertaken rehabilitation and who sold Class A drugs in the Midland Road area of Bedford. The operation was set in train in April, although was postponed because it was discovered that Mr Brunner was in hospital with breathing problems. After Mr Brunner was discharged from hospital he was seen in town on 9th May. On the 11th May he was seen by a Police Constable in Bedford Bus station. It was decided to resume the operation and two officers were drafted in from Luton. A briefing happened over the phone and a discussion took place before four officers, in plain clothes, left Greyfriars Police Station, Bedford, in an unmarked van to carry out a stop-search in order to detain Mr Brunner; two Officers wore body cameras. One of them was trained as a Police Medic, but was not operating in that role on the day. The other three had undertaken basic First Aid Training. Mr Brunner was a known “swallower” who had swallowed drugs on two or 3 occasions previously. To mitigate the risk of swallowing, the plan was to approach him from behind to prevent him from swallowing so that they could catch him with enough Class A drugs to obtain a conviction for supplying. The CTT had successfully dealt with people who had been arrested for swallowing before. The officers approached along Midland Road. There were three on foot and one was in a van. Mr Brunner and another man were walking towards Battison Street, Bedford. The weather conditions were adverse. The Officers knew who Mr Brunner was, and Mr Brunner knew who some of the police officers were. The element of surprise was lost when an associate of Mr Brunner, who clearly knew the police officers, shouted a warning. Because of this, police picked up their pace. One of the police officers moved towards the other man, as he made he moves to run away. The other two went to Mr Brunner. One of these, Officer A, attempted to detain Mr Brunner by means of a bear hug. The other went straight away to help arrest the second man. Mr Brunner saw the officers and turned away and appeared to reach across to one of his pockets. The officer in the van (B) parked and came to the assistance of A as Mr Brunner was resisting arrest. Shortly afterwards, Mr Brunner was seen to put a package into his mouth, by officer C, who shouted out that he had put it in. Mr Brunner did this by dropping his weight forward and bringing his hand up to his mouth, and mouth to hand. Mr Brunner and two of the officers fell on to the floor during the struggle and they moved his arms towards his back to put handcuffs on him at 12.36.02 hours. The package was described as a large ball, roughly the size of a golf ball. The three PCs (A, B and C) shouted at Mr Brunner to spit out the package, and one of them tried to apply a mandibular angle to twice. The mandibular angle was applied with an open grip and was meant to gain compliance by causing pain but did not succeed. This police officer believed that Mr Brunner had swallowed the package because he saw his open mouth. The police officers applied reasonable force to detain Mr Brunner and make him compliant in order to spit out the package, including a ground pin and holding his arms. On the Body Cam Mr Brunner could faintly be heard to say "I can't breathe" but because of a number of factors - awful weather, the frenetic nature of the incident, interruption of bystanders, relative position of officers and cameras - he could not be heard by human ear. Once Mr Brunner had appeared to become compliant Pc B noticed that he was in and out of consciousness and called an ambulance at 12.36.55 hours. Another call to an ambulance was made at 12.37.31 hours. At 12.38.10 hours an officer mentions that he thought that Mr Brunner was not breathing. The officers removed the handcuffs, looked in his mouth, sat him up, turned him into the recovery position before starting cardiac compressions at 12.39.20hours. Mr Brunner did not regain consciousness or begin to breathe again. The police officers worked together to give Mr Brunner compressions until the ambulances and paramedics arrived at 12.46 hours. When paramedics took charge of the care of Mr Brunner, they were happy with the PCs compressions and asked them to continue whilst they arranged a Lucas II Machine to mechanically carry out compressions and attempted to establish an airway. They tried to establish an airway five times, but this was a difficult task because of signs of blood, vomit, and Mr Brunner’s physiology/anatomy. The lead paramedic mentioned a Blue Form at 12.51 hours. By this time, because of the length of time since Mr Brunner had last been seen to breathe, irreversible brain damage was highly likely. At no point did anyone see the package in Mr Brunner’s throat. The PCs assumed that he had swallowed the package and although this was difficult for the jury to understand, no-one involved in the incident, police, paramedics or afterwards, in the hospital, saw the package. Therefore choking was not considered an option.
Karl Brunner choked and stopped breathing sometime around 12.38 hours and did not recover, despite efforts of police officers on the scene and paramedics. His death was certified at 13.17 hours at Bedford Hospital. The cause of death given after forensic post mortem was:
Ia Foreign body airway obstruction (choking) with close temporal relationship to an attempted police arrest whilst under the influence of heroin and diazepam
Circumstances of the death
At 12:36 hrs on 11 May 2016 Tasking Officers from Bedfordshire Police were engaged in a Drugs Operation in Midland Road, Bedford, when they saw the deceased with another male person. The Police stopped the 2 men for the purposes of a Section 23 Drug Search. The deceased ran a short distance and is believed to have swallowed a quantity of Class A Drugs. The officers detained the deceased in Battison Street, Bedford, and ended up on the ground when suddenly the deceased became unresponsive. CPR was commenced and Paramedics attended and continued with advanced life support. The deceased was then conveyed to Bedford Hospital South Wing, Bedford, where death was confirmed shortly after arrival.
Coroner’s concerns
1. The evidence before me showed that police officers were trained to deal with suspects who had swallowed drugs. The evidence however disclosed a complete lack of knowledge of the risks of choking when suspects were either arrested or in the process of being detained. This should urgently be addressed in the Officers’ training and the appropriate medical procedures should be adopted.
2. Police Officers are provided with mouth and face guards which are so defective and inappropriate when dealing with high risk suspects who may have significant health issues that they are neither carried nor used in appropriate cases. This should be urgently addressed.