A jury at the inquest into the death of 32 year old Paul Coker yesterday returned a critical verdict finding that lack of communication coupled with inadequate police training in identifying Paul's condition as a medical emergency contributed to his death.
The inquest opened on 11 January 2010 before HM Deputy Coroner for South London Selena Lynch, at Southwark Coroners Court.
Paul Coker died at Plumstead Police Station in the early hours of 6 August 2005 after being arrested at his girlfriend's home following a struggle with police officers who had been called to a domestic disturbance.
Giving evidence at Southwark Coroner's Court, Ms Chadwick told jurors her boyfriend had become "a bit paranoid" after taking cocaine and cannabis and that she wanted him to leave rather than see him in that state. Following a call made to the police, Ms Chadwick heard footsteps of a number of officers go to the room which Paul was refusing to leave. Eventually she heard him being taken away by officers. She told the jury, "he was saying, 'You are hurting me, I can't breathe, you are killing me.'"
The jury found that Paul was suffering from a form of excited delirium/acute behavioural disorder (ED/ABD) which can prove life-threatening unless treated immediately. The inquest heard extensive evidence on the varying ways in which police officers interpreted the training they received on ED/ABD. Although their training made it clear that where there was the slightest suspicion that someone may be suffering from ED/ABD the person should be treated as a medical emergency and taken to hospital immediately, there was nevertheless general confusion amongst the officers as to how many symptoms needed to be present for there to be a suspicion of ED/ABD and how to distinguish ED/ABD from ordinary violence.
Police officers did not recognise that Paul Coker was suffering from this condition, and the jury found that this was because of failures in police training, and their failure to communicate properly with each other and with the Forensic Medical Examiner (FME).
The inquest heard evidence about the FME's attendance at the police station, the information he received from the custody officers about Paul, and his decision to examine the officers first. It transpired during his evidence that the FME blamed the police for not giving him more information and the custody officers blamed the FME for not asking for more information. The evident lack of communication between the police and the FME played a critical role in Paul not receiving immediate medical care and treatment.
The inquest saw chilling CCTV footage from inside the cell showing Paul lying face-down on the floor for approximately 15 minutes, not moving, before being pronounced dead. The police did not allow the FME into the cell in case Paul attacked him and/or any of the officers. Despite Paul's rapidly deteriorating health, the FME was of the opinion that he was not a medical emergency.
The inquest heard that approximately five minutes after Mr Coker was pronounced dead an officer in the custody suite can be heard on the CCTV footage saying "you have to get one death in custody under your belt."
Counsel for the Coker family, Rajiv Menon, urged the coroner to make rule 43 recommendations on the following issues:
- Police training on excited delirium/acute behavioural disorder, particularly in relation to how to approach symptoms and the index of suspicion, needs to be clarified and improved;
- the system for risk assessment in police stations (in particular Form 57M) needs to be improved;
- a FME should assess whether a person is fit to be detained as soon as practicable after arriving at the police station and under no circumstances should they examine officers with minor injuries first;
- the system for the observation and treatment of those in custody deemed unfit to be detained needs to be improved;
- there should be at least one paramedic in every ambulance that responds to a call for assistance from the police, whether the call is from a police station or not;
- the system for grading of calls for an ambulance needs to be improved.
Deborah Coles, Co-Director of INQUEST, said:
Any perception that Metropolitan Police training has improved so that another death like that of Paul Coker would not happen today is grossly misconceived. Despite previous rule 43 reports made by coroners following other police restraint cases, including those made in 2004 following the inquest into the death of Roger Sylvester in 1999, Paul's death illustrates that little has changed. We await an urgent response from the Metropolitan Police and the Home Office as to what action will be taken on a local and national level as a result of the concerns raised by the coroner and the jury at this inquest to prevent further loss of life.
Paul's mother, Patricia Coker, said:
This verdict is a condemnation of the failures of the police and the police doctor to care properly for my son when he was clearly very ill and in need of urgent medical attention. Had Paul been recognised as a medical emergency and taken straight to hospital there was a very good chance he would have survived and been with us today.
Paul Coker's family was represented at the inquest by INQUEST Lawyers Group members Darren White of Deighton Guedella Solicitors and barristers Rajiv Menon and Kirsten Heaven of Garden Court Chambers.