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Investigation and inquest
On 14/12/2019 I commenced an investigation into the death of John Allan TUCKER DOB: 2/6/1975.
The investigation concluded at the end of the inquest on: 3/11/2020
The conclusion of the inquest was recorded as: Natural Causes
The medical cause of death was:
1a) Congestive cardiac failure
1b) Cardiomegaly and ischaemic heart disease
1c) Coronary Artery Disease (operated)
2. Drugs (methadone and cocaine) and alcohol intake.
Circumstances of the death
John Tucker had a medical history of significant cardiac disease. This was in part caused by hypercholesterolaemia (abnormally high cholesterol levels in the blood) which caused plaque to be laid down in the arteries that supply blood to the heart. There was also a family history of coronary artery disease.
As a result John did suffer from occlusion of the arteries and suffered a heart attack which resulted in the need for him to undergo surgery and in 2018 he underwent a coronary artery bypass grafting of all 4 coronary arteries.
John was thrown life-line by this surgery but due to his underlying predisposition of high cholesterol and diabetes, the coronary disease would return if he did not change his lifestyle. This included taking drugs and alcohol.
John was under supervision by the MOSOVO team and was apparently last seen alive by ████████ a member of the team on 10th June 2019. I am satisfied that John was alive when seen by ████████ and I did not consider there was any evidence of respiratory distress (as suggested by the family). However, during questioning ████████ was asked about John’s condition and whether she would be able to recognise and manage signs of respiratory distress, ████████ confirmed she had received first aid training but could not confirm that she would recognise respiratory distress or know how to manage such a problem.
DS ████████ also gave evidence in relation to the police investigation and to confirm there was no evidence of third party involvement in John’s death. In relation to training, DS ████████ also confirmed that officers are given training in basic life support but she could also not confirm that she could recognise or manage treat respiratory distress.
There was no evidence of any flaw or omission in care afforded to John by Gwent Police and no evidence, as aforementioned, that John was suffering from respiratory distress at the time. This was a line of argument advanced by the family.
Coroner’s concerns
The information from ████████ of the MOSOVO team and DS ████████ ████████ raised some concerns about the nature and extent of basic life support and first aid training provided to the different staff employed by Gwent police who of course may be in regular contact with people who are unwell or injured giving rise to respiratory problems.
Information checked against the published report and official responses