NICHOLAS OLIVER JAMES GEDGE · Prevention of Future Deaths report

On 22nd November 2022 I commenced an investigation into the death of Nicholas Oliver James Gedge ("Nicholas"). The investigation concluded at the end of the Inquest on 07/03/2025. The conclusion of the Inquest was that Nicholas' death was due to natural causes, the medical cause of his death being 1a) Out of Hospital Cardiac Arrest; 1b) Dilated Cardiomyopathy; 2) Chronic Substance Misuse (Cocaine, Heroin), Thrombosis of Pulmonary Vasculature, Pulmonary Granulomas (from injection of illicit drugs)

Nicholas had been arrested and detained in the custody Suite at Elland Road Police Station, Leeds, overnight on 13th-14th November 2022. On 14th November he was remanded in custody pending being put before a court on 15th November.

During the afternoon of 14th November, Nicholas was provided with a hot drink and a snack bar in his cell. AT 1507 hours he was observed by his in-cell CCTV (which was not regularly monitored) to pull his blanket over his head and shortly thereafter to become motionless. A Detention Officer looked through the observation panel in Nicholas' cell door at 1522 hours and observed him to be breathing.

At 1544 hours, Nicholas was found to be unresponsive by another Detention Officer who had entered his cell as part of a final check before handing over the late shift. Another Detention Officer and a Healthcare Professional (a nurse) attended the cell. Nicholas was moved from the cell bench to the floor, and the nurse inserted an intraosseous needle at 1548 hours and an oxygen mask shortly thereafter. The nurse continued to attempt to rouse Nicholas and applied defibrillator pads to him at 1551 hours. CPR was commenced at 1552 hours. Ambulance staff arrived at 1556 hours and Nicholas was taken from the cell to hospital at 1626 hours. He was pronounced deceased in the Rssus area of the Emergency Department at Leeds General Infirmary at 1656 hours. His heart had remained in asystole or pulseless electrical activity from the point of his being discovered unresponsive in his cell.

(1) From the point when the Detention Officer first entered Nicholas' cell to when CPR was commenced, 8 minutes and 12 seconds elapsed without CPR being given. Within that timeframe, two Detention Officers and a nurse were present in the cell after 75 seconds had passed.

(2) On the evidence, there did not appear to be any shared understanding between the three people in the cell with Nicholas of the urgency of starting CPR on an unresponsive person. There did not appear to be a co-ordinated approach to assisting Nicholas, with the Detention Officers and the nurse not appearing to have defined roles which they understood and undertook.

(3) It was not clear whether there were any protocols in place to define the respective roles of detention staff and medical staff attending a medical emergency in a cell. The passage of time before CPR was commenced gives rise to a concern either that the importance of early CPR was not appreciated, or that the communication between detention and medical staff did not facilitate its prompt commencement.