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Investigation and inquest
On 16th November 2011 an Inquest was opened into the death of the deceased and concluded on 9th April 2015 after a 10 day hearing with a jury. The conclusion was a detailed narrative conclusion. The medical cause of death was a Methadone intoxication. 1b Alcohol withdrawal in a chronic alcoholic. II Fatty infiltration of the liver.
Circumstances of the death
On Saturday 2nd October 2011 the deceased was arrested on a no-bail warrant and taken to the Northern Area Custody Facility, Etruria, Stoke-on-Trent. He had a history of (former) heroin abuse, was receiving prescribed medication but he was also an admitted heavy abuser of alcohol, drinking over 10 cans of strong lager each day. He remained in custody, at times under close observation, for lengthy periods being viewed through a cell camera, was seen by four doctors on 6 separate occasions and received medication in the form of his prescribed methadone plus diazepam and chlordiazepoxide for alcohol withdrawal. He was found unresponsive in his cell shortly before 9.00pm on Sunday 3rd October 2011. Although attended upon by doctors there was evidence of poor or no communication between doctors and custody sergeants and frequent misunderstandings over the required level of observation. It was accepted that these failures did not materially cause or contribute to death and that some steps have been taken to correct failings. There is potential for failings to occur nationally. I recommend that the following be considered (see paragraph 5 below).
Coroner’s concerns
1. That consideration be given to issuing guidance that whenever a detainee is attended upon by a medical practitioner there should be a verbal consultation between the medical practitioner and custody sergeant as to any issues of concern and the level of observations to be had for that detainee in addition to the medical practitioner making detailed notes on the detainee’s custody medical record.
2. That consideration be given to the provision of joint training exercises for medical practitioners, custody sergeants and custody detention officers and assistants.
3. That training should provide targeted emphasis on the correct levels of observation.
4. That consideration should be given to eliminating the phrase ‘continue observations at the current level’ and require that doctors and custody sergeants specify the level of observation precisely.
5. That training should include targeted training on the risks and dangers of drug and alcohol abuse, including methadone intoxication and alcohol withdrawal, particularly if the detainee is likely to be in custody for upwards of 24 hours.
Information checked against the published report and official responses