Over the three week inquest the court heard of how 28 year old Guyanese man Andrew Jordan died following attempts to detain him under the Mental Health Act on 7th October 2003. Andrew, who had a history of schizophrenia, had been visited by a Mental Health Team from Oxleas Primary Care Trust and the police at his home in Erith. After initially refusing entry to the house Andrew opened the door to talk to the police.
A number of police officers entered and proceeded to restrain him. Andrew was later carried belly down out of house, onto a stretcher, still cuffed, before beingplaced on a trolley, still cuffed face down and strapped in with two straps, one across his legs, the other across his chest out to an ambulance waiting outside the house. Shortly after the ambulance left with Andrew inside, accompanied by police officers, he started fitting. The ambulance crew assumed he was hyperventilating rather than fighting for breath and admitted at the inquest that if oxygen had been applied straight away, it would have given him the best chance of survival.
Andrew remained in a prone position, (belly down) face to the side; it was only when Andrew's hand turned cold and his lips purple that he was turned onto his back. By this time Andrew was effectively dead (no vital signs).
When Andrew was initially placed in the ambulance, the paramedic decided to take Andrew to the Woodlands mental health unit instead of taking him straight to A & E department where he would have received emergency life saving treatment. During his evidence he admitted this critical decision was an error on his part. Equally, as the only paramedic on the ambulance crew, he also conceded he should have remained in the back of the ambulance attending to Andrew as opposed to leaving this to his less qualified colleague.
The paramedic admitted in his evidence that:
- He, as the paramedic and therefore, more qualified of the two crew members, should have been in the back of the ambulance as opposed to driver;
- In retrospect, oxygen should have been administered at the first opportunity i.e. when Andrew first gets in ambulance and appears to have a fit, lasting 20 seconds, so that he had best chance of survival;
- He should have asked for doctor when Andrew started to collapse given that they would have been better qualified to assess Andrew rather than himself, especially as two doctors at scene;
- He should have driven straight to A & E rather than Woodlands Unit.
Other points of relevance that were identified over the 3 week inquest:
- The majority of police officers who attended Andrew's house in response for urgent back up were all probationary officers;
- All officers had been fully trained in positional asphyxia yet Andrew kept in semi-prone position, kneeling, chest over sofa, for at least 10 minutes. (Positional asphyxia sets in between 4-7 minutes);
- Sgt Sutcliffe, C & R expert, asked in evidence that given that Andrew was cuffed from behind with quick cuffs, if officer behind him then raises cuff in middle, this would force Andrew's face on sofa and therefore control him. Sgt said yes. He's then asked if this is so, why didn't police do that rather than have 4 officers restraining him. Sgt says doesn't know;
- 5 PCs all confirm that they raised issue of positional asphyxia with LAS crew, both LAS crew say that they do not recall it at all;
- LAS have never received training in positional asphyxia - training only came in since October 2005.
Since Andrew's death, protocol devised by Oxleas is much more detailed and requires more background information to be given about patients by the different services.