Independent Investigation Final Report
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- Bu səhifədəki naviqasiya:
- Healthcare professional assessment
- Mark Trask
- PC Alison Huntley
- Barry Brackenborough
- PS Jason Francis
- PS Mark Whitehead
- PS Matt Gilbert
- Learning Report
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Conclusions
172. There are no concerns with the deployment of officers to find Mr Edwards. There was a large police response, necessary intelligence checks were carried out, and the welfare of the victim, Mr Edwards ’s children, and Ms Harrison was ensured.
173. Both Ms Harrison and Belinda Edwards had said they told officers that Mr Edwards had a tendency to vomit in his sleep. However, there is no evidence to show that this information was passed onto anybody in custody. The health care professional Ms Kells-Saunders stated that had she been provided with this information her medical assessment would not have been different. Although, in any event, if officers had been provided with this information, it would have been advisable for them to have informed the custody sergeant.
174. It is not been possible to establish whether Ms Harrison provided this information to PC Nailard who denied it was said to her, as there were no witnesses to the conversation.
175. It has been established that the four officers have denied that Belinda Edwards told them about this condition. It has been established that Ms Harrison told Belinda Edwards about what she had said to PC Nailard prior to Belinda Edwards providing her statement to the IPCC. However, in the absence of any independent witnesses, it has not been possible to conclude on the available evidence whether or not Belinda Edwards
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provided this information to the officers. Arrest
176. The officers that detained and searched Mr Edwards had been informed that an assault had taken place at Mrs Edwards’s address , that Mr Edwards was the suspect, and had been provided with a description of Mr Edwards. PC McNee, the arresting officer, therefore had reasonable grounds to suspect Mr Edwards had committed the offence of assault, and it was necessary to arrest Mr Edwards for the prompt and effective investigation of the assault allegation. He therefore had the power to arrest him under Section 24 of PACE.
177. Although Mr Edwards was not informed of the reasons for his arrest until he was placed in the back of the police van, it was clearly the officer’s intention to arrest him for the offence of assault prior to that. It is concluded that as soon as officers started to move Mr Edwards out of the bushes behind Barclays Bank, they were affecting his lawful arrest.
178. Force was used by officers when they moved Mr Edwards from the bushes, placed him on the ground, and handcuffed him. Under Section 3 of the Criminal Law Act 1967 officers are entitled to use such force as is reasonable in the circumstances in affecting the lawful arrest of offenders or suspected offenders. When determining whether the force used was reasonable it needs to be considered whether the force was lawful, necessary and proportionate.
179. Firstly, as stated, it has been determined that the officers were lawfully exercising their power of arrest pursuant to Section 24 of PACE because they had reasonable grounds to believe that an offence had been committed by Mr Edwards and that it was necessary to arrest him.
180. When determining whether the force was necessary and proportionate it is necessary to consider the level of threat Mr Edwards posed. Based on the available evidence, the threat was that he may have been violent towards the officers or members of the public. This was because he was
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wanted in connection with an allegation of assault, had warning markers for violence and carrying a knife, was suspected of being in possession of a knife taken from his estranged wives house, and when approached by officers he failed to show his hands as requested. It is concluded it was necessary for officers to use force to reduce the threat posed by Mr Edwards. It is also concluded that the force used to detain Mr Edwards, by placing him on the ground and handcuffing him, was proportionate in the circumstances to the threat posed.
181. Under Section 32 of PACE a constable may search an arrested person, in any case where the person to be searched has been arrested at a place other than a police station, if the constable has reasonable grounds for believing that the arrested person may present a danger to himself or others. It is concluded, on the basis of the evidence available, the search was lawful as the officers had reasonable grounds to believe Mr Edwards may have presented a danger to others because he was suspected of having committed an assault, was not complying with the officer’s instructions, and it was suspected he was in possession of a knife.
182. Some force was then used by officers to keep Mr Edwards detained on the floor whilst waiting for the police van to arrive, and then in lifting Mr Edwards up from the floor and placing him into the van to take him to Bury St Edmunds police station. As the officers were still affecting Mr Edwards
’s arrest at this stage and he was actively resisting, the officers still had a power under Section 3 of the Criminal Law Act 1967 to use reasonable force. It is concluded, on the basis of the evidence available that the force used was necessary and proportionate, firstly to reduce the threat to the officers posed by Mr Edwards when waiting for the van, and then actually placing Mr Edwards into the van which was necessary to take him to Bury St Edmunds police station.
183. Mr Edwards was informed of his arrest when he was placed in the back of the police van. Section 28 of PACE states that where a person is arrested, otherwise than by being informed that he is under arrest, the IPCC Final Report Mr Robert Edwards
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arrest is not lawful unless the person arrested is informed that he is under arrest as soon as is practicable after his arrest. Given that Mr Edwards had been described as actively resisting the officer ’ s attempts to restrain him, and kicking out at them, it is concluded that it would not have been practicable to have informed him of his arrest until he was placed into the police van when the officers were no longer having to restrain him.
184. The fact that no injuries were identified when Mr Edwards was brought into custody, and the post mortem found no evidence of assault or restraint, supports the finding that the force used by officers in detaining Mr Edwards was not excessive.
185. The decision to take Mr Edwards to Bury St Edmunds police station instead of a hospital was appropriate in the circumstances. He did not meet the criteria for immediate referral to hospital as set out in the ACPO Guidance on the Safer Detention and Handling of Person on Police Custody in that there was no evidence to suggest he was; drunk and incapable, had a head injury, serious injury, or other condition that required urgent medical attention, known to have been unconscious or had swallowed or packed drugs or taken a drugs overdose.
186.
There is discrepancy over Mr Edwards’ s condition when examined by Ms Kells-Saunders. Specifically, whether he was snoring and whether he provided appropriate responses to the questions he was asked. The CCTV from the cell does not help clarify what responses were given, as there is no microphone in the cell and therefore no audio. This is therefore a question of whether the account of Ms Kells-Saunders and PS Francis, or Mr Trask is preferred. The medical notes Ms Kells- Saunders made at the time of her assessment give weight to her account, but PS Francis’ s comment during his handover to PS Whitehead that Mr Edwards was roused
slightly undermines his own account. However, applying the balance of probabilities, it is considered
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more likely than not that Mr Edwards was roused as described by Ms Kells-Saunders. This is due to the written record she made at the time, and that her account is somewhat supported by PS Francis.
187. Ms Kells-Saunders did not see any vomit during her examination, but did notice some saliva around his mouth which came from his retching. Mr Trask informed PS Francis, after his first cell visit, that Mr Edwards had been a bit sick. It is concluded it is more likely than not that the vomit Mr Trask saw was this saliva.
188. Mr Trask’s decision to call the healthcare professional before being asked showed good initiative, and saved time in getting Mr Edwards medically assessed.
189. During Mr Trask’s first check, he did not rouse Mr Edwards in accordance with PACE Annex H because Mr Edwards failed to respond to any of Mr Trask’s verbal commands, and the only response Mr Trask got was that he felt Mr Edwards tighten up when he shook him. A detainee needs to be able to respond appropriately to the commands set out in Annex H, and if a detainee fails to do so a healthcare professional or ambulance should be called. Mr Trask readily acknowledged that Mr Edwards did not rouse properly. However, a healthcare professional had already been called, and he took the correct action by notifying PS Francis straight away.
190. There is a discrepancy as to whether the second visit to Mr Edwards was actually another check by Mr Trask, or part of his handover to PC Huntley. Given the check was conducted only fifteen minutes after the healthcare professional assessment, and that it took place at the time of Mr Trask’s handover, it is considered more likely that not that it was part of his handover to PC Huntley. In view of this Mr Trask need not have recorded this visit as a rousing check on Mr Edwards’s custody record.
191. It is concluded that when Mr Trask informed PC Huntley that Mr IPCC Final Report Mr Robert Edwards
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Edwards
’s condition was exactly the same as when the healthcare professional saw him, he was not providing an accurate picture of how Mr Edwards had been. During the joint cell visit by Mr Trask and PC Huntley, Mr Edwards was snoring, did not respond to any of Mr Trask’s commands, and the only response when he was shaken was him tightening up. In contrast however, Mr Edwards was not snoring during the healthcare professional assessment, and Ms Kells-Saunders had managed to get some verbal responses to her commands.
192. It is concluded that it is more likely than not that Mr Trask did not breach the Police Staff ‘Responsibilities And Obligations - General Rules on Behaviour and Conduct’ . The visit to Mr Edwards was part of his handover to PC Huntley and not a rousing check as indicated by the custody record. However it is recommended that advice is given to Mr Trask around the importance of accurately providing information about a detainee’s condition during a handover.
PC Alison Huntley
193. During PC Huntley’s cell check at 11.03pm, Mr Edwards was not roused in accordance with Annex H. He did not respond to PC Huntley’s command to ‘open your eyes’ or any of the other verbal commands she used. He was also snoring which, as explained in the ACPO Guidance on the Safer Detention and Handling of persons in Police Custody, can be a significant indicator of risk. The only response PC Huntley received was Mr Edwards pulling away from her. PC Huntley should have reported to the custody sergeant that Mr Edwards could not be roused, and a healthcare professional or ambulance should have been called.
194. PC Huntley’s entry on Mr Edwards’ s custody record in itself is evidence that Mr Edwards had not been roused. PC Huntley’s explanation that the resistance Mr Edwards showed to her shaking him, and her assumption that he was refusing to respond verbally was an incorrect interpretation on the rousal procedure, something which she had been trained on. Rousing requires that a detainee needs to be able to respond IPCC Final Report Mr Robert Edwards
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appropriately to the commands set out in PACE Code C Annex H. 195. It is considered likely that there was some confusion about Mr Edwards’s condition following the handover from Mr Trask, which led PC Huntley to falsely believe the healthcare professional had not been able to get responses to her verbal commands, and that Mr Edwards had been snoring during the assessment. Although this may have impacted upon PC Huntley’s assessment of Mr Edwards during her cell visit , she was still aware of Annex H, and had been trained in safer detention. It is therefore concluded that it is more likely than not that that PC Huntley has a case to answer for breaching the standards of professional behaviour for not taking the necessary action when Mr Edwards could not be roused in accordance with Annex H.
196. The allegation against PC Huntley on her Regulation 14a notice was for gross misconduct. However, after reviewing her account it is evident that she did make some attempts to rouse Mr Edwards in accordance with Annex H, some confusion may have arisen about Mr Edwards ’s
condition following the handover from Mr Trask, and there is no evidence to show her omission was deliberate or malicious. It is therefore concluded that the case to answer is for misconduct.
197.
During Mr Brackenborough’s first cell visit, Mr Edwards was not roused in accordance with Annex H as he did not respond to Mr Brackenborough’s commands in any meaningful way . The only response he received was Mr Edwards mumbling/murmuring when he asked him how he was. Mr Brackenborough did not ask any of the specific questions set out in Annex H such as ‘what’s your name?’ ‘ Where do you live ’, or any of the commands such as ‘ lift one arm! ’
198. Mr Edwards was snoring during this first cell visit which can be a significant indicator of risk. The ACPO Guidance on the Safer Detention and Handling of Persons in Police Custody 2006 states that when someone is snoring they should be roused and checked at least every
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thirty minutes until they are talking coherently. The IPCC interpretation of this guidance is that the person should be talking coherently on every visit, not that the rousing regime stays in place until they are talking coherently. On the first visit the evidence shows that Mr Edwards was certainly not talking coherently. Mr Brackenborough’s response in interview that you cannot get someone in that state talking coherently is an incorrect interpretation of the rousing regime and Annex H.
199. On his second visit, Mr Edwards again did not rouse in accordance with Annex H as he did not respond to Mr Brackenborough’s commands in any meaningful way. Mr Edwards mumbling ‘ OK ’ did not represent an appropriate response to Mr Brackenborough’s questions , and again Mr Brackenborough did not ask any of the specific questions or give commands set out in Annex H.
200. Mr Brackenborough said he did not notice any vomit on the floor of the cell during this visit, although the CCTV showed that a pool of liquid had started to form around Mr Edwards’ s head. It is concluded that if he had conducted a more thorough check, it is likely that he would have seen this.
Annex H and had started snoring again, which Mr Brackenborough described as being raspier than before. Mr Edwards did not respond to any initial verbal commands from Mr Brackenborough, then after being shaken only mumbled ‘ yeah ’ which
was not an adequate response, and did not show he was talking coherently.
202. Mr Brackenborough stated he did not see vomit on the floor around Mr Edwards, although during the check said he had noticed some liquid which looked more like saliva. The CCTV from the cell shows the pool of liquid around Mr Edward’s head had grown.
203. Mr Brackenborough has explained he had a number of concerns about Mr Edwards following this cell visit, notably that his condition had deteriorated and he had become more difficult to rouse. However, there
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is a discrepancy over whether Mr Brackenborough then told PS Francis about his concerns following this cell check. Mr Brackenborough states he did, PS Francis said he did not remember.
204.
Mr Brackenborough’s com ment recorded on the CCTV at 1.59am where he said to PC Huntley ‘that’s why I said to Jason, at what point is difficult difficult? ’ appears to relate to an earlier conversation with PS Francis, along similar lines to that which he had described. The CCTV does show that Mr Brackenborough had a conversation with PS Francis following his cell check, albeit there is no audio recording of this. These both add weight to his account, and it is concluded it is more likely than not the conversation with PS Francis did take place. It is concluded that Mr Brackenborough took the correct action by informing PS Francis of his concerns.
205. Mr Brackenborough has had a lot of experience in custody, was a custody officer prior to becoming a detention officer, and has had training in safer detention. The comment Mr Brackenborough made in the detention room where he said ‘I’ll shout in and if he goes “eh” that
rouse Mr Edwards in accordance with Annex H. His explanation in interview that he must have been joking is not credible given that the evidence shows his first two checks seemed to be carried out in exactly the same way as described in his comment.
206. It is concluded that it is more likely than not that Mr Brackenborough ’s
conduct fell below the Police Staff ‘Responsibilities and Obligations- General Rules on Behaviour and Conduct’ for not rousing Mr Edwards in accordance with Annex H on his first two cell visits. When considering his conduct it is recognised that there were serious potential implications of failing to correctly rouse Mr Edwards, and take the necessary action in relation to the responses received from him. It is also recognised that there is some evidence to support the finding that Mr Brackenborough deliberately did not rouse Mr Edwards in accordance with Annex H. It is therefore concluded that there is a case to answer for gross misconduct. IPCC Final Report Mr Robert Edwards
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PS Jason Francis
207. It is concluded PS Francis carried out the necessary checks on Mr Edwards when he was brought into custody. Although Mr Edwards was obviously heavily intoxicated, he could answer some questions, and was able to walk with some support. It is concluded therefore that Mr Edw
ards was not drunk and incapable, and PS Francis’ s decision to place Mr Edwards straight into a cell, pending a medical assessment to determine his fitness to be detained, was appropriate in the circumstances.
208. PS Francis, whilst he was custody sergeant, should have taken more action to ensure he was satisfied with the checks carried out on Mr Edwards. In interview he explained that if he had seen the checks by Mr Trask and PC Huntley he would not have been happy they were proper rousing checks. He accepted that he should have looked at the entries on the custody record and did not know why he did not. He accepted that it was not a busy night in custody when these checks were carried out, nobody else was on level 2 rousing checks at that time, and he would have had an opportunity to look at the custody record if he wanted.
209. It is considered more likely than not that following his handover to PS Whitehead, he became an extra resource to help out in custody as described in the email from Inspector Zoe Finn. This is also supported by PS Whitehead’s entry on Mr Edwards’s custody record to say that he was now the custody officer which is consistent with the force’s custody handover procedure. However, if PS Francis was not the custody sergeant responsible for Mr Edwards following his handover to PS Whitehead, he should have brought Mr Brackenborough’s concerns about Mr Edwards’s welfare to the attention of PS Whitehead. The information Mr Brackenborough provided to PS Francis showed a clear deterioration in Mr Edwards’ s condition. It had been recognised that he was difficult to rouse. If Ms Kells- Saunders’ s advice had been followed, and the guidance given in Annex H followed, Mr Edwards should have
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been taken to A&E at this stage. 210. PS Francis’ s comment, during the conversation recorded in the custody room that Mr Edwards was ‘ alright really ’ was clearly incorrect. Mr Edwards sweating heavily was an obvious deterioration in his condition, and he knew that Mr Edwards had not been sweating heavily before. This was another opportunity for PS Francis to obtain medical assistance, which would have been very easy as Dr Dorsett was just arriving in custody, or he could have explained to PS Whitehead that there had been deterioration in Mr Edward s’ s condition. 211. It is concluded that it is more likely than not that PS Francis has breached the standards of professional behaviour by failing to ensure the rousing regime in place was being adhered to whilst he was responsible for Mr Edwards, and for failing to take any action when he was notified of a decline in Mr Edwards ’s condition. This situation is exacerbated by the fact the PS Francis had previous knowledge of Mr Edwards being unwell in custody and subsequently going to hospital. Due to the serious potential implications of this, and that clear instructions had been given by the healthcare professional, it is concluded that there is a case to answer for gross misconduct.
212. It is concluded that PS Whitehead should have taken over responsibility for Mr Edwards following the handover from PS Francis. He should have conducted cell checks in accordance with policy, and he should have reviewed the entries on the custody record to verify the observation routine in place. However, Inspector Finn has explained that the division of responsibilities between custody sergeants was a grey area at the time. It is considered that it is possible that PS Whitehead interpreted the s ergeant’s responsibilities in the way he has described, that PS Francis and PS Gilbert were responsible for the earlier detainees until they finished their shifts.
213. PS Whitehead was present for the conversation in the custody room IPCC Final Report Mr Robert Edwards
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where Mr Brackenborough explained that Mr Edwards was sweating. It is concluded that PS Whitehead incorrectly assumed there had been no deterioration in Mr Edwards’s condition as he had not been informed previously that Mr Edwards had been sweating heavily. It is concluded that he should have queried this as it was clear nobody was intending to take any action at that time.
214. It is concluded that it is more likely than not that PS Whitehead did not breach the standards of professional behaviour because of the confusion that may have arisen regarding the division of responsibilities between sergeants. However, it is recommended that PS Whitehead should be given advice about being more proactive when concerns about a detainee come to light, and not just assume someone else will deal with it. PS Whitehead was also aware that Mr Edwards had previously been unwell whilst in custody and been admitted to hospital.
215. PS Gilbert did not have much involvement with Mr Edwards, and according to the practice in place described by Inspector Finn, would not have been directly responsible for him as he was not the sergeant that booked him in. As he was not the sergeant who booked Mr Edwards in, or who took over from PS Francis, it is not considered unreasonable for him to not have in trusively inspected Mr Edwards’ s custody record, and to assume the rousing regime was being implemented and overseen by PS Francis and PS Whitehead.
216. PS Gilbert was present for the conversation in the custody room where Mr Brackenborough explained that Mr Edwards was sweating. He has stated that he did not have any concerns about Mr Edwards at that time. However, Mr Brackenborough’s comments were clearly raising a concern about Mr Edwards’s condition at that time, and it is concluded it would have been reasonable for him to have realised that. Although it is concluded that it is more likely than not that PS Gilbert did not breach the standards of professional behaviour due to his limited involvement IPCC Final Report Mr Robert Edwards
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with Mr Edwards, it is recommended that he should also be given advice about being more proactive when concerns about a detainee come to light. PS Gilbert was also aware that Mr Edwards had previously been unwell whilst in custody and been admitted to hospital.
Learning Report 217. There is no Learning Report for this investigation. However, it is very concerning that neither PS Francis nor PS Whitehead thought they were taking responsibility for Mr Edwards following the handover. As Inspector Finn has explained, this grey area around responsibilities led to the creation of a ‘suite supervisor’ in the new policy which has been implemented for the new Prisoner Investigation Centres. The new policy states that where more than one custody officer is on duty, the designated ‘ suite s upervisor’ is responsible fo r the welfare of the detainees. All of the Prisoner Investigation Centres in Suffolk are now operational and using the new policy, and all of the old custody suites have been closed. This means there should no longer be any ambiguity over who is responsible for detainees.
Adam Stacey
Lead Investigator, IPCC
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