Before Richard Travers, HM Senior Coroner for Surrey
Inquest opened 12 February
Resumed 8 May, following 5 week break
Concluded 5 July
Following thirteen weeks of evidence and a total of 48 hours and 53 minutes of deliberation, an inquest jury has today concluded that neglect contributed to the death of Terry Smith. They also found a serious failure to recognise the signs and symptoms of Excited Delirium as a medical emergency and noted the use of prolonged and excessive restraint. From Stanwell, Surrey, Terry was 33 when he died on 13 November 2013, following detention and restraint by Surrey Police.
On the evening of 12 November 2013 Terry was displaying increasingly distressed, strange and agitated behaviour. His family requested an ambulance. Two Emergency Medical Technicians (EMTs), who were employed by private firm ERS Medical, attended along with a police unit. The officers detained Terry under Section 136 of the Mental Health Act 1983. He was restrained at the scene on the ground by multiple officers, using handcuffs, leg restraints and a spit hood. He was taken to Staines Police Station where he continued to be restrained by five to six officers, before being moved into a police van where he stopped breathing. He was taken to hospital by ambulance and was pronounced dead at 9.20pm on 13 November 2013.
The inquest heard evidence from over 50 witnesses including police officers, EMTs, paramedics, the Forensic Medical Examiner (police doctor), police trainers and a variety of medical experts. The jury found Terry’s death was contributed to by neglect, and gave a narrative conclusion finding:
- A serious failure by those who owed duty of care to recognise signs and symptoms of medical emergency.
- A failure to carry out an adequate assessment at any stage.
- Inadequate training of those who owed a duty of care, with a serious failure to check their learning.
- Prolonged and excessive restraint and a failure to understand that the resistance to the restraint was leading to an ongoing depletion of oxygen and an increased level of adrenaline and that this was speeding up the effects of Excited Delirium in his body.
The jury also found Terry’s death was contributed to by Neglect, with the following contributory factors. Writing in a narrative conclusion that, the death was caused or more than minimally contributed to by the failure on the part of Surrey Police to:
- Ensure that all response and custody officers and staff were sufficiently trained in relation to Excited Delirium.
- Treat Terry as a medical emergency.
- Take Terry to hospital from Douglas Road.
- Assess sufficiently or at all his fitness to be detained at Staines Police Station prior to his detention there being authorised.
- Ensure that Terry was taken to the Accident and Emergency Department of the hospital, prior to 23.45 hours on 12 November 2013.
- Monitor and consider sufficiently or at all the length of time for which Terry was under restraint and his response to it, prior to 23.45 hours on 12 November 2013.
Central to this inquest was the controversial issue of Excited Delirium – a medical condition which has often been linked to deaths involving restraint, such as those in custody and detention settings. The exact causes of the condition are the subject of debate amongst medical experts. However, during the inquest the jury heard that police guidance and training, which has been in place for some years, made it clear that excited delirium carries the risk of death and should be treated as a medical emergency.
The patrol sergeant, PS David Richardson, told the other officers at the scene to be aware that Terry may have been suffering from excited delirium. Yet, instead of ensuring that Terry received immediate medical care, he directed that Terry should be taken to a police station and arrested for possession of drugs.
The custody sergeant at Staines Police Station, PS Andrew Jamieson, did not assess Terry’s condition before authorising his detention. During the inquest he denied having ever heard of the term Excited Delirium before that night. This was despite CCTV evidence which clearly showed him telling others more than once that he believed Terry had Excited Delirium and describing the symptoms. He claimed that he may have heard the term from a colleague or looked it up on the night, but this was contradicted by the CCTV evidence.
A number of the officers involved, including PS Richardson, claimed that they had not received training from Surrey Police that taught that Excited Delirium was to be treated as a medical emergency. Midway through the inquest, and after those officers had given their evidence, information from a 2007 guidance document was disclosed by Surrey Police that clearly stated that Excited Delirium was a medical emergency requiring immediate medical examination at hospital. As a result, the Coroner called a number of new witnesses including police trainers, senior officers – including the former Assistant Chief Constable, and other officers that had attended the training sessions.
The Forensic Medical Examiner Dr Abdi Aziz Ali, who was at the scene, gave evidence that, despite having carried out a cursory and inadequate assessment, he recognised that Terry’s condition was a medical emergency. Dr Ali admitted during questioning by the family’s legal representatives that he had lied to the Independent Police Complaints Commission (IPCC, now IOPC) investigators about the checks he had carried out. Dr Ali did not ask for the spit hood Terry was wearing to be lifted. The inquest heard evidence that spit hoods have the potential to impede breathing.
Dr Ali told officers that Terry should be taken to hospital, as he had a deep cut on his foot and a suspected drug overdose. He explained to the inquest that he assumed officers would know that he meant that it was a medical emergency, although he did not explicitly state this. Officers then decided that they should place Terry in a ‘body cuff’. The body cuff was a relatively new piece of equipment and officers struggled to fit it on, apparently because it had not been put away correctly after its last use. This caused further delays. In the meantime, no one had called an ambulance.
CCTV footage clearly showed Terry breathing irregularly throughout his time in the cell, and from around 11.50pm saying “I can’t breathe” on numerous occasions. The jury found that Terry had said he could not breathe no less than 13 times. He can also be heard pleading with the officers, stating “I can’t take the pain no more”. A number of officers who were there in the cell, inches from Terry as he shouted repeatedly that he could not breathe, denied at the inquest that they had any concerns that he might be having breathing difficulties.
Terry was eventually placed, still under restraint, in the back of a police van where he stopped breathing and went into cardiac arrest. An ambulance was called and attended shortly after. He was worked on by paramedics and taken to St. Peter’s hospital, where he died the following evening.
The jury heard that guidance says that officers should not, as a matter of general practice, confer with others before giving their accounts after a use of force incident. If the need arises to confer on issues other than their honestly held belief of the situation, they should make records detailing the conferring that took place in order to ensure transparency and maintain public confidence. Most of the officers involved in the incident wrote up their notes around six hours after Terry was taken to hospital, during which time they were in a briefing room discussing what had happened, and had met with a solicitor, police federation representative, and more senior officers. None of the officers made sufficient records about their conferring, despite this being required by the guidance. The jury heard that none of the officers recorded in their notebooks the fact that Terry had been saying that he could not breathe, despite accepting in evidence that this was a relevant factor that should have been recorded.
A medical expert appointed by the Coroner told the inquest that excited delirium can be treated effectively by administering a sedative. He was clear that Terry’s life could have been saved if he had been taken to A&E at any point before 11.30pm that night, highlighting how avoidable Terry’s death was.
Terry’s family said:
“We feel that we have had some justice. The jury identified that the state and in particular the police seriously failed Terry. We called an ambulance because it was obvious Terry needed medical help. Instead of treating him as a patient, the police treated him like a criminal. The treatment that Terry received from the police has caused us great distress. The manner in which he was restrained was barbaric. The type and nature of the restraint, and in particular the use of the spit hood, was beyond anything we expect to see in a civilised society. It was devastating to hear clear evidence that Terry could have survived if taken to hospital earlier. The police must be held to account for Terry’s death. Nothing will bring Terry back. We miss him every single day. All we can hope is that no other person dies in similar circumstances and no other family has to go through what we have.”
Deborah Coles, Director of INQUEST said:
“The deeply critical conclusions of this jury are reflective of the cruel and frightening ordeal Terry suffered, at the hands of those who owed him a duty of care. When his behaviour became worrying, Terry’s family knew he needed an ambulance. Instead Terry was met by police who, rather than seeing a vulnerable man in crisis, pursued, restrained, bound and hooded him then took him to a police station, not a hospital. They only called for an ambulance when it was too late.
Not only were Terry and his family failed on the day he died, they have been failed by the police response afterwards which has been one of lies, collusion and cover up.
This conclusion reaffirms what has been made clear in recent reviews as well as in police guidance: medical emergencies should not be treated as a criminal justice issue. Police officers should be better equipped to understand and enact this, as a priority over being equipped with yet more potentially dangerous restraint tools.”
The family’s solicitor, Nia Williams of Saunders Law said:
“Terry’s family called for an ambulance because they were concerned about his condition and thought he needed help. Instead Terry spent over two hours being restrained, including being held down by several police officers and with a spit hood over his face. Nobody lifted the spit hood to check his breathing, meaning that throughout this time nobody saw his face. Despite both the patrol sergeant and custody sergeant recognising he was showing the symptoms of Excited Delirium, no officer acted accordingly by getting him to hospital immediately.
The evasive manner in which officers gave their evidence throughout this lengthy inquest has been shocking. The sergeants claimed they had not received adequate training on Excited Delirium. Police officers that were stood over Terry in the cell as he repeatedly shouted “I can’t breathe” stated in court that at the time they had no concerns about his breathing, or that they did not take his complaints seriously. None of the officers adequately detailed in their statements that they had discussed the incident before writing up their statements or why they had done so.
We have also heard that medical professionals including the doctor on duty at the police station as well as the emergency medical technicians employed by a private ambulance service failed to give Terry the care he needed.
A catalogue of failures led to the loss of Terry’s life, which could have easily been prevented. We hope that today’s conclusion gives some relief to Terry’s family, who have been waiting for answers for over four and a half years. We now look to the relevant authorities to consider further action against those involved in Terry’s death.”