Investigation and inquest
On 4 September 2019 I commenced an investigation into the death of Cherylan CLULOW. The investigation
The conclusion of the inquest was: Drug related death
1a Multi-organ failure
1b Stroke
1c Infective Endocarditis (Staph. Aureus & Steptococcus)
II Intravenous Drug use
Circumstances of the death
Ms Clulow lived alone in local authority accommodation at ████████ ████████ Bournemouth. She was offered support from the Specialist Drug and Alcohol Service but in the 4 months preceding her death she did not attend 5 out of 5 key working appointments. On 28/8/19 neighbours had concerns for her welfare and notified the Council who in turn contacted Dorset police. Officers attended late on 28/8/19 and could not gain access to the property beyond the communal door. Officers attended on 29/8/19 and forced entry and discovered Ms Clulow semi conscious. Paramedics were called and she was taken to hospital. Scans revealed she had suffered extensive and multiple strokes. Her health continued to deteriorate and she died in hospital on 30/8/19.
Coroner’s concerns
(1) The Police Officers who were tasked with the initial attendance could not gain access beyond the communal doors.
(2) The Police Officers did not believe it was proportionate (based on the information which they had) to force entry through the communal doors which required specialist input. They were aware that a colleague had purchased for himself a fire drop key (to be used in emergency situations which could be used to override the communal lock door. There was a delay in gaining access to the address of the deceased.
(3) The Police Officers had no formal information as to where they could source a fire drop key. There was no knowledge of formal steps to be taken to access to a fire drop key particularly as access to communal properties is that more difficult to gain.
(4) There appears to be no general distribution of such keys or key fobs to Dorset Police Officers in order to gain access to shared accommodation by officers in an emergency situation 24 hours a day, 365 days per year.
(5) There appears to be no training or dissemination of information as to how such keys can be obtained.