Source · Prevention of Future Deaths

Olawale Adelusi

Date: 22 Jul 2016 Coroner: Jeremy Chipperfield Area: London (West) Responses identified: 0 / 1 View PDF

There was no effective system to transmit critical information regarding a detained person's self-harm risk and mental health, as detailed observations of distress were not included in formal handover documents.

Date 22 Jul 2016
56-day deadline 16 Sep 2016 est.
Responses identified 0 of 1
State Custody related deaths

Coroner's concerns

AI summary
There was no effective system to transmit critical information regarding a detained person's self-harm risk and mental health, as detailed observations of distress were not included in formal handover documents.
View full coroner's concerns
MATTER OF CONCERN - SUMMARY The absence of an effective system to ensure appropriate transmission of all information relevant to assessment of the (i) risk of self-harm or (ii) mental health, of detained persons

BASIS OF CONCERN : – Whilst in police custody Mr Adelusi had been taken to hospital where he remained under police guard. Police Officers kept a Hospital Guard Supervision Log covering a 6.5 hour period and in it recorded that Mr Adelusi had: on several occasions deliberately thrown himself from bed to floor in such a way as to cause concern for his safety; been observed crying on several occasions; been observed banging his head on the floor; spoken of a plot to kill him and of his son having been killed by police; and tried to bite the clinical drip pipe. On return to the police station, Mr Adeslusi was kept under constant supervision and a Constant Supervision Log was maintained by officers over a period of 23 hours in which they recorded that he had been observed: "pushing his thumbs down on to his neck" until he had to be told to desist; urinating in the corner of his cell; whispering to the Forensic Medical Examiner "they've killed him"; again crying and saying "you've killed him"; trying to strangle himself with a vest; kneeling with his head against the floor, crying; and accusing officers of killing his children and asking to see their bodies. Neither the logs, nor the information recorded in them, was included in Mr Adelusi's Personal Escort Record; nor was that information otherwise transmitted in writing to those responsible for his detention after removal from the police station. Whilst there was evidence of a verbal handover to Escort Personnel, at which some of this information may have been mentioned, no record was made of that conversation.

Report sections

Investigation and inquest
On 20 June 2016 I commenced an inquest into the death of Olawale ADELUSI, (41 years old). The inquest concluded on 01 July 2016. The conclusion of the jury was Misadventure to which they recorded the following contributory factor: The "failure of transfer of information and documentation at each stage..."
Circumstances of the death
Olawale Adelusi was arrested on 28 October 2014 and kept in police custody for production at Uxbridge Magistrates' court on 30 October. Whilst at court, he attempted suicide by hanging. He was then remanded in custody and taken to HMP Wormwood Scrubs, where on the morning of 03 November he was found hanging in his cell. ! 1
Copies sent to
CLCH Trust CNWL Trust Serco Wormwood Scrubs

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Report details

Date of report
22 July 2016
Coroner
Jeremy Chipperfield
Coroner area
London (West)

Responses identified

Responses identified 0 of 1
1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 16 Sep 2016 (estimated).

Sent to

METROPOLITAN POLICE SERVICE

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