Kirk Williams

Coroner's concerns

AI summary

A significant mismatch exists between police and A&E staff perceptions regarding the treatment of aggressive patients, including those with Excited Delirium, compounded by a lack of dialogue and clear guidelines.

View full coroner's concerns

(1) Police officers in Cleveland doubtless receive training about Excited Delirium and now understand in a way that they perhaps previously did not that the condition should be treated as a ‘medical emergency’ which thereby requires the detainee’s attendance at a hospital.

(2) Some police officers still consider that notwithstanding that they may be faced with a medical emergency, A&E departments will not treat violent or aggressive patients.

(3) The various consultants that gave evidence are clear that they will treat violent patients provided that (a) treatment is warranted and (b) they are provided with sufficient assistance from either or both the police or security staff.

(4) It therefore follows that there is a mismatch in perception and expectations between Cleveland police officers and local A&E staff.

(5) There did not appear to be a sufficiency of understanding within Cleveland Constabulary about how and whether detainees may be treated at A&E departments.

(6) Further or alternatively, the insufficiency in understanding lies with A&E consultants and their perception of what type of patients will be accepted and allowed to be treated in their departments.

(7) There does not appear to be a dialogue between Cleveland Constabulary and local A&E departments to address these particular misunderstandings or misconceptions.

(8) There does not appear to be any memorandum of understanding or guideline to cover aggressive detainees in police custody being taken to A&E departments.

(9) Without a fuller understanding of the true position, police officers will continue to be faced with the perennial dichotomy of whether to take an aggressive medical emergency detainee to an A&E department for treatment or to a police station to prevent self harm or harm to others.

Responses

3 respondents

South Tees Clinical Commissioning Group

24 Nov 2014 PDF

Action Taken

Multiple CCGs and Trusts report that if a detainee has a known past mental health history, they should be taken to the 136 unit at Roseberry Park; if serious concerns regarding physical health exist, detainees should be presented to A&E. Senior A&E staff and the police will jointly decide where best to provide treatment if a detainee is violent and aggressive. The Trusts, CCGs, Ambulance Service and Tees, Esk and Wear Valleys NHS Trust have signed up to the Crisis Care Concordat. The lead Security Officer for the Trust has held discussions with Durham Constabulary lead officers to ensure that all police officers know that patients should be taken to the Emergency Department; The process is kept under review by the Trust. All agencies involved in treating or looking after patients in crises meet monthly to share learning, discuss difficult cases and monitor patients detained under a section 136 in the emergency department. (AI summary)

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Dear Mr Faulks Inquest into the death of the late Kirk William WILLIAMS Regulation 28 Report Further to your letter of 24 November 2014 and subsequent email correspondence relating to the above, am now in position to respond to the issues raised in the Regulation 28 Report: As agreed, this response constitutes combined reply on behalf of NHS South Tees CCG, NHS Hartlepool and Stockton on Tees CCG, NHS Durham Dales, Easington and Sedgefield CCG ad NHS North Durham CCG As the health economy covered by the above CCGs covers tvo police forces, have provided response based on those boundaries: NHS South _Tees CCG and NHS Hartlepooland Stockton on Tees CCG _ Cleveland meeting was held between the Medical Directors and senior ARE medical staff of both Foundation Trusts and Detective Chief Superintendent Ifrom Cleveland Police. At that meeting, a wide range of actions were agreed in order to address the point you raised relating to the apparent lack of guidance or Memorandum of Understanding for aggressive detainees in custody being taken to A&E departments These actions are: together the Police Je

If a detainee has a known past mental health history they should be taken to the 136 unit at Roseberry Park. If there are serious concerns regarding physical health, detainees should be presented to an A & E department where will be assessed: If the detainee is violent and aggressive a joint decision by senior A & E staff and the police will be taken as where best to provide treatment ie if the department is full and there is a risk to other patients, assessment may even take place outside of the department possibly in police vehicles If there is the suggestion that a detainee is ill or injuredand the ingestion of drugs is causing problems, treatment with restraints may be appropriate be it physical or medical restraints. Depending on the circumstances this may include assistance from anaesthetic colleagues: If the medical assessment concludes that the detainee is not in need of treatment they will be returned to police custody: following any necessary treatment;, the detainee is returned to police custody, a copy of the A & E notes will be given on discharge detailing treatment given. If there are any further concerns following return to police custody, the doctor should contact the A & E department for further advice All relevant staff, both NHS and Police, to be informed of the guidelines agreed for future reference_ In relation to point 5.1 in the report, Cleveland Police have confirred that all front line officers are required to undertake Personal Safety Training on an annual basis and that during the training receive an input on "excited delirium' We have been advised by Cleveland Police that they are in the process of briefing staff about the new guidelines. Staff working in the custody environment incl medical staff and all front line officers will be briefed by 12 January
2015. In addition; the Police will be reviewing the effectiveness of the guidance in six months' time and will take any appropriate action where necessary, ie amending guidance in conjunction with South Tees Hospitals NHS Foundation Trust and North 'Tees & Hartlepool NHS Foundation Trust or providing further training to ensure staff are aware of, and are implementing, the guidance. As a final point; the Trusts, CCGs, North East Ambulance Senice and Tees, Esk and Wear Valleys NHS Trust have signed up to the Crisis Care Concordat to work towards continuing to improve the care of patients in crisis NHS Durham_Dales Easington_and_Sedgefield_ CCG and NHS North Durham CCG Durham Constabulary County Durham and Darlington NHS Foundation Trust have confirmed that the lead Security Officer for the Trust has held discussions with Durham Constabulary lead officers to ensure that all police officers know that patients should be taken to the Emergency Department; The process is kept under review by the Trust ad any arising issues are discussed o a monthly basis in relevant meetings depending on the nature of concerns raised, ie_ frequent attenders; mental health, drugs or alcohol related issues or violence and aggression incidents The Trust has confirmed that some of these meetings do include representatives from Durham Constabulary: In addition the Trust has confirmed that they have signed up lo the Crisis Care Concordat with all agencies involved in treating or looking after patients in crises this includes Durham Constabulary: As part of the work to progress the Concordat the Foundation Trust and all partner organisations meet on monthly basis to share learning; discuss difficult cases and also discuss ad monitor ay patients who have been detained under a section 136 in the emergency department they police they luding the

trust this answers the questions you raised in the repor, but if you require any additional information please do not hesitate to contact me.

Cleveland Police Police / Law Enforcement

5 Jan 2015 PDF

Action Taken

Cleveland Police provides annual Personal Safety Training to all front-line officers, including training on "excited delirium." The police, along with medical directors and A&E consultants, established new guidelines for aggressive detainees in custody being taken to A&E, and are briefing staff on these new guidelines. (AI summary)

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Dear they Tees,

The following actions were agreed and will now form the basis of guidance which will be issued to staff by both Trusts and Cleveland Police_ If a detainee has a known past mental health history they should be taken to the 136 unit at Roseberry Park If there are serious concerns regarding physical health, detainees should be presented to an A & E department where will be assessed. If the detainee is violent and aggressive a joint decision by senior A & E staff and the police will be taken as where best to provide treatment i.e if the department is and there is a risk to other patients, assessment may even take place outside of the department possibly in police vehicles. If there is the suggestion that a detainee is Ill or injured and the ingestion of drugs is causing problems, treatment with restraints may be appropriate be it physical or medical restraints_ Depending on the circumstances this may include assistance from anaesthetic colleagues_ If the medical assessment concludes that the detainee is not in need of treatment they will be returned to police custody: If, following any_necessary treatment;, the detainee is returned to police custody, copy of the A & E notes will be given on discharge detailing treatment given: If there are any further concerns following return to police custody, the police doctor should contact the A & E department for further advice. All staff both NHS and Police to be informed of the guidelines agreed for future reference The Force is in the process of briefing staff about the new guidelines, staff working in the Custody environment (including medical staff) and all front Iine fficers will be briefed. Due to the holiday period this has been delayed, but it is expected that all relevant staff will have been briefed by 12th January 2015. It is my intention to review the effectiveness of the guidance in six months' time and to take any appropriate action where necessary, whether that is amendments to the guidance in conjunction with the two Trusts, or further training to ensure staff are aware of and are implementing the guidance.

NHS England NHS / Health Body

28 Jan 2015 PDF

Action Planned

NHS England will consider the case further with the Northern Regional Medical Director to determine whether changes need to be made to relevant policies and guidance, including liaison with Public Health England regarding substance misuse services. They also acknowledge that various local healthcare organizations have signed up to the Crisis Care Concordat. (AI summary)

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Dear Mr Faulks Inquest into the death of Kirk Williams Further to your letter dated 14 November 2014 and theissue of the Regulation 28 report to prevent future deaths, would like to offer my sincere condolences to the family of Kirk Williams regarding his death. From our review and consideration, we note that the issues concerning substance misuse and possible mental health issues have been addressed in the responses from the local health care Commissioners and Trusts, However; in view of the serious nature of this case will be considering it further with NHS England's Northern Regional Medical Director, with a view to determining whether changes need to be made to relevant current policies and guidance. This will also include liaison with colleagues in Public Health England, with regard to commissioning and provision of substance misuse services_ Furthermore, it is acknowledged that South Tees Hospitals NHS Foundation Trust; North Tees and Hartlepool NHS Foundation Trust; Eskand Wear Valleys NHS Trust, the CCGs and North East ambulance Service, County Durham and Darlington NHS Foundation Trust have all signed up to the Crisis Care Concordat; to support people in crisis_ The Crisis Care Concordat is a national commitment between all services and agencies that come into contact with people in crisis. It sets out how they will work together and be involved in the care and support of people in crisis, and how they ensure people get High quality care for all, now and for future generations

the support they need, when they need it This commitment addresses the improvement in the commissioning and provision of services for those with co-existing mental health and substance misuse issues_ One of the aims of the Crisis Care Concordat is that people in health care crisis should be taken to health care facilities, rather than police cells The key ambition of the Concordat is for every local area to commit agree and deliver their own Mental Health Crisis Declaration and Action Plan. As one of the signatories to the Crisis Care Concordat; NHS England is committed to working alongside other agencies to improve the system of care and support for people in crisis, to work together to identify the causes of crises, and put in place prevention and early intervention plans whenever possible. am grateful to you for bringing this case to my attention

Report sections

Investigation and inquest

On 13.10.14 I resumed an inquest into the death of Kirk William Williams, aged 26. The investigation concluded at the end of the inquest on 06.11.14. The conclusion of the inquest was the cause of death was Ia Excited Delirium and II Coronary Artery Atheroma and Left Ventricular Hypertrophy. The narrative conclusions of the jury were elicited via a questionnaire. In summary it was found that it had been inappropriate for police officers to have taken Kirk Williams to a police station when he was detained. He should have been taken to hospital instead. The jury considered that Kirk Williams would have been accepted and treated in accident and emergency. However, the jury were unsure as to whether such treatment would have saved his life.

Circumstances of the death

On 17.04.11 Kirk Williams was seen running around fields adjacent to the Moorhouse Estate, Stockton-on-Tees. He had ingested a number of drugs including, alcohol, cocaine, ‘M-cat’, MEC and PVP. He had divested himself of all of his clothing and was exhibiting bizarre, aberrant and very agitated behaviour. It took 4 police officers to restrain Mr Williams, apply handcuffs, leg restraints and secure him in a police van. A total of 6 police officers were in attendance in the field. One officer, it is accepted, stated that Mr Williams should be taken to hospital. The dilated pupils, agitated state, intense heat and aberrant behaviour caused that officer to consider that Mr Williams may be suffering from a condition known as ‘Excited Delirium’. The other 5 officers did not accept that the local hospital (University Hospital North Tees) would accept such an unpredictable and aggressive patient. Because those officers were content that there would be medical staff at the local police station (Middlehaven or Middlesbrough police station,) they decided that Mr Williams should be taken there.

Having been taken into Middlehaven at 12:04pm, custody officers were advised by the locum forensic medical examiner at 12:19pm to have Mr Williams taken to hospital. Paramedics arrived at 12:29pm and following a cardiac arrest at 12:49pm Mr Williams was taken to James Cook University Hospital at 13:13 hours. Following extensive treatment, Mr Williams died at 14:32 hours. The pathology evidence was that Mr Williams died of Ia Excited Delirium and II Coronary Artery Atheroma and Left Ventricular Hypertrophy.

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NEAS, JCUH and Tascor (formerly Reliance). the IPCC

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