Preventing Deaths in Police Custody

Lessons Learned

http://vimeo.com/36009007

Excited delerium(5)

Drug / alcohol overdose(2)

Gastrointestinal disease(1)

CNS disease(1)

Circulatory(1)

External injuries(1)

Asphyxiation(1)

Poisoning(1)

Awaited / no PM(2)

Deaths 1998/99 – 2008/09

Drugs 120

Restraint87

74 48 61

Drugs 120

Alcohol 184

Mental Health58

53106

46

1411

10

23

Alcohol 184 Restraint

87

Drugs120

106

44 30

2014 26

27

Alcohol

Alcohol metabolism

Blood alcohol & behaviour<50 not obvious, driving skills deteriorate

50 – 100 ‘dizzy and delightful’

bravado, slurred speech

100 – 200 ‘drunk and disorderly’

staggering gait, uncooperative

200 – 300 ‘dead drunk’ ‘mortal’ vomiting, incontinence

300 – 400 coma, impaired respiration, loss of reflexes

>400 ‘devil’s disciple’ death

Alcohol

?

DRUGS

Benzodiazepines – dilated pupils, respiratory depression. Withdrawal seizures.

Opiates e.g. Heroin - nausea, vomiting, pinpoint pupils, eyelids closing, respiratory depression, lethargy, drowsiness and difficulty to rouse, and loss of consciousness

Cannabis - anxiety, hallucinations, and loss of consciousness

Cocaine - agitation, dilated pupils, seizures, raised body temperature, fast pulse, and chest pains. Irregular heart beats may occur.

Amphetamines - nausea, vomiting, dilated pupils, fast pulse, sweating and seizures

‘Legal highs’

BEWARE EXCITED DELERIUM

Excited deleriumPain tolerance

Raised respiratory rate

Sweating

Agitation

Hyperthermia

Non-compliance

Lack of tiring

Unusual strength

Inappropriate clothing

Attraction to reflection

RestraintPositional asphyxia

Excited delerium

Post arrest peril

Mental Health

Mental Health (Care and Treatment) (Scotland) Act 2003

Meaning of “place of safety”

In this Part of this Act, “place of safety” means—

(a)

a hospital;

(b)

premises which are used for the purpose of providing a care home service (as defined in section 2(3) of the Regulation of Care (Scotland) Act 2001 (asp 8)); or

(c)

any other suitable place (other than a police station) the occupier of which is willing temporarily to receive mentally disordered persons.

Suicide risksSerious violent or sexual crime against family

member

Public interest or public shame

First experience of custody

Anniversaries and key dates

Substance misuse or detox including alcohol

Additional charges

THE FATAL ACCIDENTS AND SUDDEN DEATHS INQUIRY (SCOTLAND)

ACT 1976

Case studiesAlan Irvine

Alexander Ogg Wylie

Angela Smith

Angus Malone

Daryl Shearer

Catherine Wingate

Gerard McNally

Kristoffer Batt

Martin Jamieson

Phillip Duffy

Robert Shreenan

Case studiesAlan Irvine

Died GRI 22/08/10

0435 H

Naprophyne lignocaine and cocaine intoxication

Non avoidable

No systemic defects

Case study Alexander Ogg Wylie

Died Ninewells 27/12/09

Quadrangle Bell St

Atherosclerosis

Minor blunt force injuries

POs & medics did their jobs

Not preventable

No systemic defects

Case study Angela Smith

Died 22/12/09

St Leonard’s Police Station

Drugs related arrest

Withdrawal

1(a) Coronary arrythmia

1(b) Myocardial fibrosis & emphysema

1(c) Misuse of cocaine & opiates

Observations insufficient

Care planning

Reviews

Integration of nursing

Case study Angus Malone

Died 13/08/07

Dunfermaline Police Station

Hidden package

Strip search

Cell search

Communications failures

Failure to examine

Case study Daryl Shearer

Died 27/10/08

Dingwall Police Station

Head & neck trauma

DHC & BDZ intoxication

Refrain from fighting

Refrain from abusing controlled drugs

Rx administration

Communications

Head injury advice

Case study Gerard McNally

Died 25/05/12

Raigmore Hospital Inverness

Phosphine toxicity

Not preventable

No systemic defects

Case study Kristoffer Batt

Died 28/11/07

Cell 11 Police HQ West Bell St Dundee

Heroin & Diaepam

Full body search

Past substance history

Vulnerability checks

Light/buzzer

Case study Martin Jamieson

Died 21/05/2008

Monklands Hospital

Methadone & Olanzapine intoxication

Risk assessment

Communication

Mentoring

Case study Phillip Duffy

Died 24/10/2010

Crosshouse Hospital

Head Injury as a result of a fall

Not preventable

Case study Robert Shreenan

Died 24/10/2010

Cell 17 Clydebank Police Office

Plastic bag asphyxia

Case study Catherine Wingate

9/10/2009

Mill Street Paisley

Cardiac failure

LVH

Drug intoxication

Hyperthyroidism

Police casualty surgeon not asked to assess