Douglas Oak inquest: Coroner calls for improved police and ambulance training on handling persons suffering from Acute Behavioural Disturbance

Wednesday 23 October 2019

Patrick Roche of Garden Court Chambers represented the family instructed by Gus Silverman of Irwin Mitchell Solicitors, and supported by INQUEST.

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The inquest into the death of Douglas Oak concluded at Bournemouth Coroners Court yesterday with Senior Coroner for Dorset Rachel Griffin stating that she would be issuing a wide ranging preventing Future Deaths report because of her concerns that further lives will be lost unless action is taken at a national level to improve training and the handling of persons suffering from acute behavioural disturbance (ABD).

Company director Douglas Oak, 35, came into contact with officers from Dorset Police near the junction of The Avenue and Dalkeith Road in Poole during the afternoon of 11 April, 2017. It was reported that he had been behaving erratically and walking in and out of traffic. Officers arrived and restrained him using handcuffs and leg straps after he jumped into the open door of a police car asking for help.

Officers told the court they quickly suspected Douglas was suffering from a medical emergency, later identified as ABD and asked for an ambulance to attend on the highest priority.

He was restrained by police officers for almost an hour and suffered a cardiac arrest before paramedics arrived. The court heard that restraint contributed to Douglas’ death. He was taken by ambulance to Poole General Hospital and admitted to the critical care unit but died the following morning.

Douglas’ parents instructed Gus Silverman of Irwin Mitchell and Patrick Roche of Garden Court Chambers to help investigate the events that unfolded in the lead up to his death and secure answers. Following the conclusion of the inquest, Dorset Police has agreed to pay undisclosed damages to the family whist denying liability.

A five-week inquest into Douglas’ death took place in Bournemouth before the Senior Coroner for Dorset, Rachel Griffin. The jury heard that whilst frontline police officers had been trained to recognise ABD, previously known as excited delirium, staff in both the police and ambulance control rooms had not been trained to recognise the term.  The call to the ambulance was allocated a 40 minute response time, whereas Dr Aw Yong, an Associate Specialist in Emergency Medicine and Medical Director at the Metropolitan Police Service, told the court that ambulances should aim to respond to cases of severe ABD within eight minutes.  The jury found that after Douglas went in cardiac arrest specially trained police officers failed to use a bag valve mask to provide ventilation during CPR. Expert evidence from paramedic expert Mark Faulkner demonstrated that such a mask should have been used.

The Senior Coroner confirmed she would be issuing a comprehensive Preventing Future Deaths report to the Secretary of State for Health, the Policing Minister and national policing and ambulance bodies highlighting the need for better training and guidance around ABD. Her recommendations will include the need for joint national guidance on the management of ABD by police and ambulance services, including the provision of sedation in pre-hospital treatment, transfers to hospital, and the categorisation of ABD calls; ensuring that all employees of police forces and ambulance trusts in England and Wales are trained in ABD and that such training is carried out annually.

Douglas’ parents, John and Christine, said after the inquest:

“These past two-and-a-half years have been the worst of our lives, having to cope with losing Douglas and then going through it all again day after day at the inquest.

“Over the last five weeks, we have sat in court and heard about gaps in training, the absence of de-escalation and calming techniques when officers first came into contact with our son, breakdowns in communication, and a failure to use medical equipment.  While some of the officers on the ground tried their best they were let down by a system that wasn’t capable of ensuring our son got the help that he needed when he needed it.

“While nothing will bring Douglas back, we are pleased that the Coroner will be issuing a report highlighting the fact that the lack of national guidance regarding acute behaviour disturbance is putting lives at risk.

“We hope this report will lead to urgent changes; we know that Douglas would want this too, and would not want any other families to lose their loved ones in these circumstances.

“He is missed every single day and wish, with all our hearts, that he was still with us.”

Gus Silverman, of Irwin Mitchell who represented the family alongside Patrick Roche of Garden Court Chambers, said after the hearing:

“For some time now coroners have been issuing reports following the deaths of those suffering from Acute Behavioural Disturbance.

“National ambulance and policing organisations should now work together as a matter of urgency to ensure that people displaying symptoms of ABD no longer face death as the result of restraint.

“Whilst some ambulance trusts have implemented their own policies regarding the treatment of ABD, Douglas’ tragic case illustrates that it is still very much a postcode lottery as to whether the correct treatment is received.  This cannot be right.”

Patrick Roche is a member of the Garden Court Chambers Civil Liberties Team.

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