Susan Sian JONES · Prevention of Future Deaths report

On 19 February 2015, I commenced an investigation into the death of Sian Jones, aged 47 years. The investigation concluded at the end of the inquest earlier today.

The jury made a narrative determination, which I attach. They concluded that Ms Jones’s death resulted from methadone and alcohol intoxication, coupled with inadequate police policies, procedures and training.

The medical cause of death was recorded as:

1a diffuse cerebral ischaemia
1b cardiorespiratory arrest
1c combined toxic effects of alcohol and methadone
in an individual with myocardial fibrosis and significant
atherosclerotic stenosis of two major epicardial coronary arteries

Ms Jones suffered a cardiorespiratory arrest in Hornsey Police station whilst waiting to see specialist officers to make a statement concerning an allegation of a historical sexual assault.

I heard evidence at inquest that there is no specific protocol or training regarding the monitoring of members of the public in police stations who are not in police custody. This was acknowledged by the Metropolitan Police Service to be a gap. In seeking to plug this gap by way of policy development, it may be helpful for you to consider the following.

• Snoring is not always a reassuring sign and may indicate a partial airway obstruction. A partial airway obstruction can be life threatening.

• In considering whether snoring is sign for concern, the fact of intoxication by alcohol or drugs or both – even if the individual is capable – is highly relevant. In addition, officers should bear in mind that members of the public sometimes lie about alcohol or drug taking, even when there seems no obvious reason to lie.

• Any relevant information gleaned by officers, for example that an individual is a methadone user, should be passed on to colleagues with responsibility (and preferably recorded in some way or other).

• The only way of determining whether snoring is benign is by rousing, most particularly by waking the individual and determining whether they are able to sit up and hold a conversation.

• The rousing itself may have a therapeutic purpose even over and above its value as a tool of assessment. And an unresponsive individual must be treated as a medical emergency.

• All police officers and staff should know the location of the nearest defibrillator. If they are attending a police station for the first time, they should make themselves aware of its location.

In terms of feedback regarding officer training generally and for the officer who led this resuscitation attempt, I should also point out that after Ms Jones’s cardiorespiratory arrest, the cardiopulmonary resuscitation given was later noted by a paramedic to be extremely effective.