Edir DA Costa
27 Jun 2019 · Coroner Nadia Persaud · London (East)
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of mandatory Emergency Life Support training among police officers
“not all police officers are up to date with mandatory Emergency Life Support training”
2. absence of designated safety officer oversight in street restraint
“safety officer had taken control of the restraint or that one officer was taking the lead in communicating with Mr [name redacted] and/or monitoring his condition”
3. high choking risk from plastic bags placed in mouth
“Placing plastic bags in the mouth raises a very high risk of choking.”
4. CS spray use with mouth contents increasing airway obstruction risk
“use of CS spray, when a person has something in their mouth, could increase the risk of a complete airway obstruction”
5. missed recognition of agonal breaths by officers
“agonal breaths were likely to have been missed”
6. communication failures to London Ambulance Service
“errors were made in communicating information to the LAS”
Linked reports
Closely relatedConfidence 0.90 · high
This report
“Evidence was heard at the Inquest that errors were made in communicating information to the LAS.”
Later report
“The police officer did not pass on this crucial account to the emergency ambulance crew who transported Ms [name redacted] to hospital, nor to any of the doctors or nurses at the hospital.”
Responses
2019-0211-Response-by-Metropolitan-Police.pdf ↗· Metropolitan Police
Stated action · April 2020
“request that the working group, driven by Met training, review the attendance of officers at mandatory ELS training and review the systems in place for supervisors to monitor attendance”
Stated action · October 2019
“The MPS are requested to review the training provided to staff in relation to the role of the safety officer in a street setting and to consider whether a reminder of the importance of the safety officer role, in the street setting, should be issued to staff (by way of bulletin or otherwise)”
Stated action · October 2019
“Future restraint lessons will reference the revised Module 12 of the National Personal Safety Manual (NPSM) which was presented by Inspector Collett during the Inquest as the final draft”
Stated action
“The MPS is requested to review the guidance and procedures in place for officers, in relation to the use of CS spray where a person is believed to be holding items in their mouth”