Jury find failings of East Midlands Ambulance Service and Derbyshire Constabulary contributed to the death of a seriously unwell man in their custody

Thursday 12 August 2010

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On 2 August, at the culmination of a four-week inquest into the death of Sean Hardy, a jury sitting before Her Majesty's Coroner for the Hundred of Scarsdale and High Peak of Derbyshire, Dr Robert Hunter, returned a highly critical narrative verdict finding that a number of failings by East Midlands Ambulance Service (EMAS) and Derbyshire Constabulary contributed to Sean's death.

On 6 December 2006 Sean made a 999 call and asked for an ambulance as he was having difficulties breathing. On arrival the ambulance crew could not gain access as Sean was unable to get to the door. The police were called to force entry and for approximately 20 minutes while they waited for the police, the ambulance crew made no attempt to gain entry. The police gained entry and saw Sean crawling along the floor as he was unable to get up. Sean was subject to a warrant for failure to attend probation meetings and so he was arrested. He was not examined in his flat by the ambulance crew but taken to an ambulance where he was allegedly examined. This was disputed during the inquest by Sean's family and it was suggested that the readings (some of which were accepted to be inaccurate) were fabricated. The original patient report form completed at the time could not be produced to the inquest as EMAS could not locate it, despite giving an undertaking to the IPCC in 2007 that it would be retained indefinitely. Personnel files containing relevant disciplinary records for the technician involved were also "lost". Sean was deemed by the ambulance crew to be "just intoxicated". Sean allegedly refused to go to hospital which the crew accepted, despite the fact that Sean appeared confused. Sean was taken into police custody and to Ripley police station. CCTV footage of the van dock in the police station showed Sean to be clearly unconscious on arrival at the station. Officers with care of Sean thought he was "acting-up" but were ordered by two custody sergeants to take Sean to hospital. The officers delayed for approximately 30 minutes, attempting to organise relief cover. They were at the end of their night shift and did not want to take Sean to hospital themselves as it would mean having to work extra hours. Sean was eventually taken to Alfreton police station (to pick up relief officers) but on arrival Sean went into cardiac arrest. During the time he was in police custody and while unconscious Sean was not placed in the recovery position at any stage, contrary to the officers' basic first aid training.

The jury found that Sean died of alcoholic ketoacidosis, complications of alcoholic ketoacidosis and complications of chronic alcoholism. In their narrative verdict the jury criticised the ambulance crew's unreasonable and inappropriate actions and remissions in not attempting to gain entry after arriving at Sean's house, the insufficiency of examination of Sean and his environment while he was in his flat, and the inaccuracy of the patient report form observations. The jury also stated that Sean did not have sufficient mental capacity to understand issues about going to hospital and that there was a failure to act in accordance with EMAS policy by not giving the bottom copy of the patient report form to Sean or the police. The jury found that the omissions of the ambulance crew contributed to Sean's death and that the failure to take Sean directly to hospital from his home was a gross failure to provide basic medical attention. In respect of the police officers, the jury found the belief that Sean was "acting-up" was initially reasonable, however, once they had done stimulus tests it should have been obvious that Sean was unwell. Further, that Sean should have been taken from Ripley police station to hospital immediately, that Sean's airway was not partially obstructed (despite expert evidence that it was), that it was appropriate to convey Sean to hospital in a police car rather than ambulance and in a seated position, that adequate and sufficient checks were made en route but that at Ripley custody suite the police seriously underestimated Sean's condition and this, as well as the delay, contributed to the cause of Sean's death. The jury found that this serious underestimation of Sean's condition and the delay in not taking Sean to hospital from Ripley police station was a gross failure to provide or procure Sean with basic medical attention.

Dr Hunter is intending to make a number of recommendations pursuant to rule 43 to both Derbyshire Constabulary and the National Police Improvement Agency on police training and basic first aid and to EMAS on introducing appropriate training on dealing with intoxicated persons, the safety and retention of original records, diversity training for clinical staff (as HM Coroner was of the view that the ambulance crew prejudged Sean due to the state of his flat and the area in which he lived), the need for a policy on how staff should respond to a death in EMAS custody and actions to be taken as regards paperwork, witness statements and securing exhibits.

Sean's partner and child were represented at the inquest by Kirsten Heaven of Garden Court Chambers, instructed by Claire Liptrot of Nelsons Solicitors. Sean's parents, brother and sisters were represented at the inquest by Sean Horstead of Garden Court Chambers, instructed by Fiona Borrill of Lester Morrill Solicitors.

To read the IPCC press release, click here.

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