Source · Prevention of Future Deaths

Nicholas Rowley

Ref: 2015-0138 Date: 15 Apr 2015 Coroner: Ian Smith Area: Stoke-on-Trent & North Staffordshire Responses identified: 3 / 5 View PDF

Insufficient verbal consultation between medical practitioners and custody staff, coupled with inadequate joint training, led to unclear observation levels and poor management of drug/alcohol risks in detainees.

Date 15 Apr 2015
56-day deadline 10 Jun 2015 est.
Responses identified 3 of 5
Police related deaths

Coroner's concerns

AI summary
Insufficient verbal consultation between medical practitioners and custody staff, coupled with inadequate joint training, led to unclear observation levels and poor management of drug/alcohol risks in detainees.
View full coroner's concerns
In the circumstances it is my statutory duty to report t0 you; 2s follows: That consideration be given t0 issuing guidance that whenever a detainee is attended upon by a medical practitioner there should be a verbal consultation between medical practitioner and custody sergeant as to any issues of concern and the level of observations to be had for that detainee in addition to the medical practitioner making detailed notes on the detainee's custody medical record. That consideration be given to the provision of joint training exercises for medical practitioners, custody sargeants and custody detention officers and assistants.
3. That training should provide targeted emphasis on the correct levels of observation. That consideration should be given t0 eliminating the phrase 'continue observations at the current level' and require that doctors and custody sargeants specify the level of observation precisely_ That training should include targeted training on the risks and dangers of drug and alcohol abuse, including methadone intoxication and alcohol withdrawal; particularly if the detainee is likely to be_in custody for upwards of 24 hours

Responses

3 respondents
College of Policing Police / Law Enforcement
9 Jun 2015 PDF
Action Planned

The College of Policing will incorporate guidance on verbal consultation between medical practitioners and custody sergeants and will make additions to the Detention and Custody Authorised Professional Practice providing advice on observation levels; updated guidance will be published circa summer 2015. (AI summary)

View full response
Dear Re; Nicholas James ROWLEY (deceased) We are writing with reference to your correspondence of 15, April 2015 enclosing a section 28 report with regards Nicholas James Rowley. You sent this report to the National Police Chiefs Council, amongst others and we are hereby issuing a response on behalf of the College of Policing and DCC Nick Ephgrave, who is the National Police Lead for the Detention and Custody portfolio. We have noted your concerns and would like to take the opportunity to respond to each, as follows;
1. That consideration be given to issuing guidance that whenever a detainee is attended upon by a medical practitioner there should be verbal consultation between the medical practitioner and custody sergeant as to any issues of concern and the level of observations to be had for that detainee in addition to the medical practitioner making detailed notes on the detainees custody medical record. We feel that this represents a common sense approach, which we would suggest would ensue in the majority of circumstances, therefore we take no issue with incorporating appropriate guidance to this affect as of the interim review of the Detention and Custody Authorised Professional Practice which is currently ongoing: We anticipate that the updated guidance will be published and available via the College website circa summer 2015. 2 That consideration be given to the provision of joint training exercises for medical practitioners, custody sergeants and custody detention officers and assistants: We suggest this represents a local training issue and whilst there are perpetual issues engaging partner agencies we would suggest a further approach to the NHS.
3. That training should provide targeted emphasis on the correct levels of observation. The College of Policing Limlted is comipany registered in England and Wales with registered number 8235199 and VAT registered number 152023949. Our registcred office is at Leamington Rojd, Ryton-on Dunsmore, COVENTRY CV8 3EN: GE Sir, part

Training standards already emphasise the importance of the correct levels of observation. Training refers to Authorised Professional Practice for further information on the levels:
4. That consideration should be given to eliminating the phrase 'continue observations at the current level' and require that doctors and custody sergeants specify the level of observation precisely. We will make additions to the Detention and Custody Authorised Professional Practice providing this advice: We anticipate that the updated guidance will be published and available via the College website circa summer 2015.
5. That training should include targeted training on the risks and dangers of drug and alcohol abuse, including methadone intoxication and alcohol withdrawal, particularly if the detainee is likely to be in custody for upwards of 24 hours. Authorised Professional Practice already makes reference to the risks of and alcohol consumption and withdrawal, there is separate section on drugs and alcohol denoting the significance of these issues within the custody environment: Training emphasises that where there are any concerns about an individual due to suspected or alcohol issues, the detainee should be referred to the health care professional and a medical assessment undertaken. We trust these responses meet with approval, however if you wish to discuss any item further please do not hesitate to contact uS. Yours sincerely_ Criminal Justice Liaison Manager The College of Policing Limited Is a company registered in England and Wales, with registered number 8235199 and VAT registered nurber 152023949, Our regislered office is at Leamington Road; Rylon-on Dunsmore, COVENTRY CV8 JEN: drug drug your
Staffordshire Police Police / Law Enforcement
12 Jun 2015 PDF
Action Taken

Guidance has been issued to custody staff and the medical services provider to ensure verbal updates are given by medical practitioners to the Custody Sergeant. A Custody Training sub-group has been created and further guidance issued regarding levels of observation, and training secured regarding drug and alcohol abuse. (AI summary)

View full response
Dear Mr Smith Nicholas ROWLEY (Deceased) Date of Birth: 27/07/1977 Date of Death: 02/10/2011 With reference to the Regulation 28 report to prevent future deaths following the inquest into the death in police custody of Nicholas Rowley dated 15 April 2015, the response to the issues raised by yourself;, from Staffordshire Police are as follows Guidance has been issued to all custody trained staff and our medical services provider; Nestor Primecare , to ensure that verbal update is given by the medical practitioner to the appropriate Custody Sergeant following any consultation of detained person by such a medical practitioner within the custody environment: This will be captured within Force Policy which is being reviewed curently, and tested through the monthly QA process already in place 2 A Custody Training sub-group has been created to oversee the training of all custody personnel: This sub-group will report directly to the Force Custody, Mental Health and Vulnerability Steering Group, which currently chair: The first meeting of this sub-group will take place o Monday 8h June 2015, and will include the following personnel Head of Custody
b. Learning and Development Manager; People Services Custody Managers
d. Custody Detention Services Provider (Resource Group _ Training Manager) Custody Detention Services Provider Contract Manager The group will plan and oversee the training programme for custody personnel in Staffordshire, and consideration for joint training will be given for all future subject matter:
3. Further guidance has recently been issued with regard to the correct levels of observation, although we will consider further training to supplement and enhance this guidance. saffordshlnc CRIMESTOPPERS 8 0800 555 111

OISABLEQ ( ABQU

Cont; Custody Officers and medical practitioners have been instructed to specify the agreed level of observation within the custody record and to avoid the use of such phrases as agree with the cunent observation level' Or 'Continue observations at the curent level' This will be monitored within the monthly monitoring process and feedback provided where necessary: 5_ Training will be secured by the Force regarding the risks ad dangers of drug and alcohol abuse, including Methadone intoxication and alcohol withdrawal; This will be built into the aforementioned training programme believe that we have leared lessons from this tragic incident and we will continue to strengthen and develop our practices and policy within the custody environment The scrutiny that is now in place over custody within Staffordshire Police is far greater now that has been previously and we will strive to make our custody facilities as safe as possible_
G4S1
13 Jul 2015 PDF
Noted

G4S no longer provides Detention Officer Services to Staffordshire Police as of June 2015. They state they always have and continue to provide mandatory training regarding setting levels of observation and first aid, and will write to contracting police forces to recommend joint ventures as best practice. (AI summary)

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Dear Sir Re: Nicholas James ROWLEY (deceased) Date of birth: 27/07/1977 Date of death: 02/10/2011 initially sincerely apologise for the in G4S responding to the recommendations contained in your Regulation 28 Report to Prevent Future Deaths Since the conclusion of your inquest on the gh April 2015 it is worth noting that since June 2015, G4S no longer provide Detention Officer Services to Staffordshire Police, as a new provider was contracted following a procurement exercise. In order to provide clarity my numbering below refers directly t0 each of the numbered recommendations contained within your report: - This is a matter between Staffordshire Police and the medical practitioners and thus G4S have no comment to make as regards this recommendation_
2. Whilst G4S agree with HM Coroner that this recommendation is a sound and sensible suggestion, G4S can only operate within the remit of the contract as stipulated by Staffordshire Police (or other such police forces) and thus it would be for Staffordshire Police (or the other police forces) to stipulate that such joint ventures should take place. Where that to happen, G4S would of course comply with that contractual stipulation. G4S will undertake to formally write to all of our contracting police forces to outline this recommendation and recommend this as best practice which G4S support. 3 G4S always have ad continue to provide mandatory training as regards setting the levels of observation to each of its custody officers as part of an initial induction training programme. That training was taught in conjunction with PACE and later (and now) also in conjunction with the Association of Chief Police Officers Guidance on the Safer Detention and Handling of Person in Police Custody 2012 (*ACPO) and the College of Policing Authorised Professional Practice Guidance APP_ 04 Cen Jundc Btntoet (UKI Llmard ReplelandOnc: Securing Your World dondon* 405 Vlclott stat GWYIE LOT Replelared I Enplend Ho: 03e0120 May delay training

GAS
4. This is a matter between Staffordshire Police and the medical practitioners and thus G4S have no comment to make as regards this recommendation
5. As per response three above, G4S have and continue to provide mandatory first aid training to each of its custody officers as of an initial induction training programme: The first aid training is taught over three days and includes (but is not limited to); Defibrillator and Advanced Airway training; training on Alcohol and Drugs (including associated risks) In addition, each of the custody detention officers is required t0 undertake a refresher first aid training course annually: Again training on the risks and dangers of and alcohol abuse will be taught during that refresher course. G4S will also examine opportunities to provide additional guidance via an 'on line' Learning Management System: The death of any person in custody is understandably extremely distressing for the family concerned and for all those involved in the persons care G4S and personally take the health and safety of those in our care as our primary duty and will work to ensure that our staff receive the best possible training and support to ensure the safety of some of the most vulnerable people in society.

Report sections

Investigation and inquest
On 16th November 2011 an Inquest was opened into the death of the deceased and concluded on g"h April 2015 after a 10 day hearing with a jury: The conclusion was a detailed narrative conclusion The medical cause of death was 1a Methadone intoxication. 1b Alcohol withdrawal in a chronic alcoholic infiltration of the liver:
Circumstances of the death
On Saturday 2nd October 201 the deceased was arrested on a no-bail warrant and taken to the Northern Area Custody Facility, Etruria, Stoke-on-Trent: He had a history of (former) heroin abuse, was receiving prescribed medication but he was also an admitted heavy abuser of alcohol, drinking over 10 cans of strong lager He remained in custody, at times under close observation, for lengthy periods viewed through a cell camera, was seen by four doctors on 6 separate occasions and received medication in the form of his prescribed methadone plus diazepam and chlordiazepoxide for alcohol withdrawal; He was found unresponsive in his cell shortly before 9.OOpm on Sunday 3r October 2011. Although attended upon by doctors there was evidence of poor or no communication between doctors and custody sergeants and frequent the being Fatty each day: being misunderstandings over the required level of observation. It was accepted that these failures did not materially cause or contribute t0 death and that some steps have been taken to correct failings There is potential for failings to occur nationally: recommend that the following be considered (see paragraph 5 below):
Action should be taken
In my opinion action should be taken t0 prevent future deaths and believe you [ANDIOR your organisation] have the power to take such action.
Copies sent to
have sent a copy of report to the following[DATE] [SIGNED BY CORONER] isalols

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Report details

Reference
2015-0138
Date of report
15 April 2015
Coroner
Ian Smith
Coroner area
Stoke-on-Trent & North Staffordshire

Responses identified

Responses identified 3 of 5
2 responses not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 10 Jun 2015 (estimated).

Sent to

Department of Health and Social Care
G4S
National Police Chiefs’ Council
Nestor Primecare
Staffordshire Police

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