Source · Prevention of Future Deaths

Karl Brunner

Ref: 2018-0310 Date: 29 Oct 2018 Coroner: Martin Oldham Area: Bedfordshire & Luton Responses identified: 1 / 2 View PDF

The incident highlights a risk of future deaths where individuals swallow drugs during police stops, requiring a review of procedures for managing such medical emergencies.

Date 29 Oct 2018
56-day deadline 20 Apr 2019 est.
Responses identified 1 of 2
Alcohol, drug and medication related deaths Police related deaths

Coroner's concerns

AI summary
The incident highlights a risk of future deaths where individuals swallow drugs during police stops, requiring a review of procedures for managing such medical emergencies.
View full coroner's concerns
Senior Coroner. The House; Woburn Street, AMPTHILL, Bedfordshire, MK45 ZHX Tel 0300-300-6559 Fax 0300-300-8267 the they They May from they the Court

1 . The evidence before me showed that police officers were trained to deal with suspects who had swallowed drugs: The evidence however disclosed complete lack of knowledge of the risks of choking when suspects were either arrested or in the process of being detained. This should urgently be addressed in the Officers' training and the appropriate medical procedures should be adopted. 2_ Police Officers are provided with mouth and face guards which are SO defective and inappropriate when dealing with high risk suspects who may have significant health issues that they are neither carried nor used in appropriate cases This should be urgently addressed.

Responses

1 respondent
Bedfordshire Police Police / Law Enforcement
29 Oct 2018 PDF
Noted

Bedfordshire Police states that their officer training includes a module on managing choking detainees, and they issue officers with personal Pocket Face Masks. They believe their training complies with IOPC recommendations and College of Policing standards. (AI summary)

View full response
IN AMPTHILL CORONER’S COURT

IN THE MATTER OF THE INQUEST TOUCHING UPON THE DEATH OF KARL BRUNNER

REGULATION 29 RESPONSE ON BEHALF OF THE CHIEF CONSTABLE OF BEDFORDSHIRE POLICE

A Introduction
1. Following an inquest held into the death of Karl Brunner, HM Assistant Coroner for Bedfordshire and Luton Martin Oldham (“the Coroner”) exercised his powers under regulation 28 of The Coroners (Investigations) Regulations 2013 (“the Regulations”), to publish a report to prevent future deaths, dated 29 October 2018 (“the PFD Report”). The Chief Constable of Bedfordshire (“Bedfordshire Police”) hereby provides this response to the PFD Report, pursuant to regulation 29 of the Regulations (“the Response”). B Facts
2. The facts are summarised at §3 of the PFD report and will not be rehearsed here in detail. In summary, Mr Brunner died on 11 May 2016 as a result of choking, after attempting to swallow a package of drugs, whilst he was being arrested by police. At the conclusion of the inquest on 09 March 2018 the Coroner recorded a conclusion of ‘accidental death’.

C Matters of Concern
3. The Coroner expresses two matters of concern regarding police officers, namely: (i) Training on choking risks during detention; and (ii) Usage of mouth and face guards.

Training
4. Across Bedfordshire, Cambridgeshire and Hertfordshire police forces all officers, special constables, detention officers and Police Community Support Officers receive First Aid training at least annually on a rolling programme. Student officers receive training more often as it is incorporated within their two year probationary period. Thus training is provided in accordance with the standards set down by the College of Policing, which remain under review.

5. Included within the training is a module which deals specifically with persons who are choking. It sets out the appropriate manner in which a choking detainee should be managed, and specifically incorporates the comprehensive lesson plan produced by the College of Policing In particular, this includes: (i) Identifying any dangers to the officer and detainee; (ii) Identifying the signs typically demonstrated by a choking conscious detainee; (iii) Administering back slaps to a choking detainee; (iv) Performing abdominal or chest thrusts on a choking detainee including on child or infant; (v) Monitoring changes in detainee’s condition; (vi) Reassuring the detainee; and (vii) Taking any necessary further action.

6. Officers receive training on a training aid known as ‘Choking training vest’ for adults, and ‘Baby Annie’ for young children. All students will then be expected to use the device in order to learn the correct procedure. The training officer will also demonstrate how to carry out thrusts from the front in the event that it is not possible to put arms around the casualty.

7. Officers and custody staff are given the following specific instructions in the event they are faced with a scenario similar to that which occurred during the detention of Mr Brunner. These are in line with the recommendations issued by the Independent Office for Police Conduct (“IOPC”) and state that: (i) If the detainee places an item in their mouth, do not attempt to remove it, as there is no currently approved safe and effective method for searching mouths; (ii) Consider what might have been placed in the detainee’s mouth and assess what risk it may present to the detainee and the officer. Officers should make every effort to encourage the detainee to voluntarily empty their mouth; (iii) Officers must inform the detainee of the risk they face from choking and/or poisoning as a result of swallowing items. All actions should be recorded in full and body worn video used where available. Officers should maintain communication with the detainee and allow them the opportunity to voluntarily remove any items; (iv) If the detainee swallows the item, the situation should be treated as a medical emergency and an ambulance called. This also applies if the detainee begins to choke following an attempt to swallow an item. An ambulance should be called and emergency life support provided to the detainee. The College of Policing procedure outlined above at §5 should be followed.

8. The regular training provided to all Bedfordshire Police officers complies with the recommendations of the IOPC and meets the standards set out by the College of Policing. Mouth/face guards
9. Prior to August 2016 all Bedfordshire Police officers were issued with a mouth/face guard which comprised a flat plastic sheet with either a hole or a piece of gauze in the middle which allowed the user to breathe into to give mouth to mouth resuscitation. Since August 2016, all officers are now issued with a personal Pocket Face Mask and instructed on its correct use in mouth to mouth resuscitation. The Personal Safety Team Leader for Bedfordshire, Cambridgeshire and Hertfordshire Police has stated that this piece of equipment is adequate and appropriate for its required use. In addition to the mouth/face guard issued to all officers during their training, all response vehicles contain first aid equipment.

D Conclusion
10. Bedfordshire Police are grateful to the Coroner for the opportunity to address the steps which have been taken in respect of the matters of concern outlined in the PFD Report.

Legal Services Department 6th December 2018

Report sections

Investigation and inquest
On 2016 commenced an Investigation into the death of KARL BRUNNER, aged years The Investigation concluded at the end of the Inquest on March 2018. The Conclusion of the inquest was 'Accidental Death'_ Mr Brunner died because he choked after swallowing package of drugs to avoid arrest Givers of first aid did not realise it was choking, therefore, despite attempts to give CPR, he did not recover Mr Brunner died on Battison Street; Bedford, on the 11th 2016 at 12.34 pm, when he attempted to swallow package of individually wrapped drugs approximately 4 X whilst in the process of arrested by police officers , under Section 23 Misuse of Drugs Act The package lodged behind his epiglottis and choked him; In April 2016 the police conceived an operation with the objective of arresting Mr Karl Brunner. Mr Brunner was known user and dealer, who had undertaken rehabilitation and who sold Class A drugs in the Midland Road area of Bedford: The operation was set in train in April, although was postponed Senior Coroners The Court House; Woburn Street; ^ MPTHILL, Bedfordshire; MR4S 2HX Tel 0300-300-6359 Fax 0300-300-8267 the May May 3cm; being drug because it was discovered that Mr Brunner was in hospital with breathing problems_ After Mr Brunner was discharged from hospital he was seen in town on 9th On the 11th he was seen by a Police Constable in Bedford Bus station. It was decided to resume the operation and two officers were drafted in from Luton: briefing happened over the phone and discussion took place before four officers, in plain clothes, left Greyfriars Police Station, Bedford; in an unmarked van to out stop-search in order to detain Mr Brunner; two Officers wore body cameras. One of them was trained as Police Medic, but was not operating in that role on the The other three had undertaken basic First Aid Training: Mr Brunner was known "swallower' who had swallowed drugs on two 2 or 3 occasions previously_ To mitigate the risk of swallowing, the plan was to approach him from behind to prevent him from swallowing so that could catch him with enough Class drugs to obtain conviction for supplying: The CTT had successfully dealt with people who had been arrested for swallowing before. The officers approached along Midland Road There were three on foot and one was in a van_Mr Brunner and another man were walking towards Battison Street, Bedford. The weather conditions were adverse_ The Officers knew who Mr Brunner was, and Mr Brunner knew who some of the police officers were. The element of surprise was lost when an associate of Mr Brunner; who clearly knew the police officers, shouted warning Because of this, police picked up their pace_ One of the police officers moved towards the other man, as he made moves to run away The other two went to Mr Brunner: One of these, Officer A, attempted to detain Mr Brunner by means of a bear The other went straight away to help arrest the second man_ Mr Brunner saw the officers and turned away and appeared to reach across to one of his pockets The officer in the van (B) parked and came to the assistance of A as Mr Brunner was resisting arrest Shortly afterwards, Mr Brunner was seen to put a package into his mouth, by officer C, who shouted out that he had put it in Mr Brunner did this by dropping his weight forward and bringing his hand up to his mouth, and mouth to hand. Mr Brunner and two of the officers fell on to the floor during the struggle and they moved his arms towards his back to put handcuffs on him at 12.36.02 hours_ package was described as a large ball, roughly the size of a ball. The three PCs (A, B and C) shouted at Mr Brunner to spit out the package, and one of them tried to apply mandibular angle twice The mandibular angle was applied with an open grip and was meant to gain compliance by causing pain but did not succeed_ This police officer believed that Mr Brunner had swallowed the package because he saw his open mouth. The police officers applied reasonable force to detain Mr Brunner and make him complaint in order to spit out the package, including a ground pin and holding his arms_ On the Body Cam Mr Brunner could faintly be heard to say cant breathe" but because of a number of factors awful weather_ the frenetic nature of the incident; interruption of bystanders, relative position of officers and cameras he could not be heard by human ear. Once Mr Brunner had appeared to become compliant Pc B noticed that he was in and out of consciousness and called an ambulance at 12.36.55 hours. Another call to an ambulance was made at 12.37.31 At 12.38.10 hours an officer mentions that he thought that Mr Brunner was not breathing: The officers removed the Senior Coroner, Court House; Woburn Street; A MPTHILL, Bedfordshire, MK45 2HX Tel 0300-300-6559 Fax 0300-300-8267 May. May carry day. they hug: The golf hours_ The handcuffs, looked in his mouth, sat him up, turned him into the recovery position before starting cardiac compressions at 12.39.20hours_ Mr Brunner did not regain consciousness or begin to breathe again: The police officers worked together to give Mr Brunner compressions untii ambulances and paramedics arrived at 12.46 hours_ When paramedics took charge of the care of Mr Brunner, they were happy with the PCs compressions and asked them to continue whilst arranged a Lucas Il Machine to mechanically carry out compressions and attempted to establish an airway_ tried to establish an airway five times, but this was difficult task because of signs of blood, vomit; and Mr Brunner's physiologylanatomy. The lead paramedic mentioned Blue Form at 12.51 hours_ By this time because of the length of time since Mr Brunner had last been seen to breathe, irreversible brain damage was highly likely. At no point did anyone see the package in Mr Brunner's throat The PCs assumed that he had swallowed the package and although this was difficult for the jury to understand, no-one involved in the incident; police, paramedics or afterwards in the hospital, saw the package. Therefore choking was not considered an option: Karl Brunner choked and stopped breathing sometime around 12.38 hours and did not recover, despite efforts of police officers on the scene and paramedics His death was certified at 13.17 hours at Bedford Hospital. The cause of death given after forensic post mortem was: la Foreign body airway obstruction (choking) with close temporal relationship to an attempted police arrest whilst under the influence of heroin and diazepam
Circumstances of the death
At 12.36 hrs on 2016 Tasking Officers Bedfordshire Police were engaged in Drugs Operation in Midland Road, Bedford, when saw the deceased with another male person. The Police stopped the men for the purposes of a Section 23 Drug Search. The deceased ran a short distance and is believed to have swallowed a quantity of Class A Drugs. The officers detained the deceased in Battison Street, Bedford, and ended up on the ground when suddenly the deceased became unresponsive_ CPR was commenced and Paramedics attended and continued with advanced Iife support The deceased was then conveyed to Bedford Hospital South Wing, Bedford; where death was confirmed shortly after arrival. CORONER'S CONCERNS: During the course of the Inquest evidence revealed matters giving rise to concern In my opinion there is a risk that future deaths will occur unless action is taken: In the circumstances it is my statutory duty to report to you: Senior Coroner. The House; Woburn Street, AMPTHILL, Bedfordshire, MK45 ZHX Tel 0300-300-6559 Fax 0300-300-8267 the they They May from they the Court

The MATTERS OF CONCERN are as follows 1 . The evidence before me showed that police officers were trained to deal with suspects who had swallowed drugs: The evidence however disclosed complete lack of knowledge of the risks of choking when suspects were either arrested or in the process of being detained. This should urgently be addressed in the Officers' training and the appropriate medical procedures should be adopted. 2_ Police Officers are provided with mouth and face guards which are SO defective and inappropriate when dealing with high risk suspects who may have significant health issues that they are neither carried nor used in appropriate cases This should be urgently addressed.
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action_
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Report details

Reference
2018-0310
Date of report
29 October 2018
Coroner
Martin Oldham
Coroner area
Bedfordshire & Luton

Responses identified

Responses identified 1 of 2
1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 20 Apr 2019 (estimated).

Sent to

ACPO
Bedfordshire Police

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