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Inquests – Concluded Cases

Inquests – Concluded Cases

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Nadeem Khan (Dean Khan) – Death in custody

Dean died on the 30th June 2007 having been arrested and taken into custody at Burnley Police Station.
When the Police arrived on the scene Dean was arrested, handcuffed and restrained.  An ambulance arrived at the scene but Dean was not examined.  He was then transferred to Burnley Police Station where he was restrained in a cell, whereupon he collapsed and died.
The family said the following at the conclusion of the inquest:

“After nearly three long years, we have finally been given the opportunity to hear evidence surrounding the death of our brother. As a family, we have always had concerns over the events that led to Dean’s death. In particular, the amount of force used by the police in detaining Dean, the period of time he was restrained for, and most importantly, the apparent failure to recognise the condition Excited Delirium and deal with Dean as a medical emergency.
“It still concerns us greatly as a family that after two weeks of evidence and after the death of our brother, most of the officers giving evidence in court still refused to acknowledge that lessons could be learnt. They still maintained that if presented with the same set of circumstances, they would treat Dean in exactly the same way. Given the fact that a young man has dies in their care, we are deeply shocked and saddened by this attitude”.

Following the jury’s verdict, the Coroner confirmed he would be making a rule 43 recommendation to the Chief Constable of Lancashire Constabulary in respect of the lack of training in dealing with Excited Delirium in their force.

Paul Davies – Death in police custody 

Paul Stephen Davies died as a result of an accident and the cause of death was contributed to by neglect. At 12:25 am on 28th September 2006, the deceased was pronounced dead at the Princess of Wales Hospital in Bridgend.

On 26th September 2006 between 07:30am and 07:42am, the deceased Paul Stephen Davies swallowed a package which became lodged in his airway (at an indeterminate point within this time range) during the execution of a drugs warrant.

The briefing was inadequate due to the gross failure of the intelligence systems in place at the time.

There was a lack of training provided to officers for

  • the forced search of the mouth of a detained person in a non-custodial setting
  • the control and restraint of a detained person in circumstances where an item is seen to be placed in the mouth

Paul Stephen Davies was not adequately controlled or monitored in the sitting room when officers arrived at (address).
Appropriate and timely action was taken by officers in seeking medical assistance for Paul Stephen Davies.
The coroner, Mr Peter Maddox, stated that he would use his rule 43 powers to write to the chief constable of South Wales Police and the other associated bodies to express his concerns of the lack of training offered to police officers dealing with this situation.
Emmanuel Buyoya – Death at HMP Parc, South Wales

Mr Buyoya was 20 years old when he died. Mr Buyoya appeared at Cardiff’s Magistrate’s Court on 23 December 2005 where he was charged remanded to HMP and YOI Parc in Bridgend.


“We, the jury, have unanimously agreed that Mr Emmanuel Buyoya, on 29th June 2006, took his own life whilst the balance of his mind was disturbed.

“Emmanuel Buyoya was received on remand at Parc Prison on 23rd December 2005 for alleged offences. During his time at Parc, he was moved to the segregation unit on two occasions, the second occasion lasting from 23rd March 2006 until his death on 29th June 2006. We feel that this was a conside4rable length of time for a young and venerable person to be in segregation, but unfortunately, this was the only option available o Emmanuel at that time. We also feel that his mental health deteriorated to such an extent, it contributed to him taking his own life. We also feel that the documentation and communication of Emmanuel’s everyday behaviour, such as his violent outbursts and sometimes bizarre behaviours, should have been more closely monitored and recorded more accurately, and this was a missed opportunity for a better and more relevant care plan to have been put in place for the wellbeing of Emmanuel”.

The coroner intends to make rule 43 recommendations in respect of there not being an establishment in Wales that can adequately care for vulnerable youths similar to Emmanuel.


Lisa Marley – Death at HMP Styal, Cheshire

The jury found that Miss Marley’s death was caused by a “failure to ensure awareness of accurately reporting and act on all events which could be significant for a prisoner at high risk of self harm”.
The jury criticised the prison for failing to provide adequate mental health training for staff working on the Keller Unit – a clear breach of the unit’s own policy. The Coroner also noted that despite her complex needs, Miss Marley only had ‘fleeting contact’ with a mental health professional during her time at HMP Styal, and also that the Keller Unit “fell far short of its operating philosophy of providing a multi disciplinary approach”.
The Coroner intends to make a rule 43 recommendation for HMP Styal to carry out regular inspections of cells on the Keller for ligature points; to devise an electronic system to record ACCT observations; to require staff to have mental health awareness training; to provide a Registered Mental Health Nurse seven days a week; and to ensure that ACCT reviews are multidisciplinary.
The Coroner noted that :

“At any one time, the Keller unit is likely to hold some of the most damaged members of HMP Styal’s prison population, most if not all suffering from one form of mental illness or another. A sense of injustice and resentment fostered through an unequal operation of the system is likely to prove counter productive. Urgent steps need to be taken to ensure a universal understanding and consistent application thereof”.


Mitchell John Turner – Death at Forest Bank Prison

Mitchell was found hanging from the hinge of his cell door at Forest Bank on the 15th July 2007. The jury heard four days of evidence from staff at Forest Bank, Paramedics and the pathologist.
After hearing all the evidence, the jury determined that Mitchell dies in the care of Forest Bank. On a number of occasions, Mitchell demonstrated a risk of self harm and appropriate precautions were not taken by the prison to negate this risk.


Terrance John Madden – Death in Custody

The jury have returned their verdict following the Inquest into the Death of Terrence John Madden.

The jury found that Mr Madden was experiencing severe alcohol withdrawal symptoms and that although prison staff recognised that his condition was deteriorating and that he was becoming more confused and distressed, he received no further medical intervention before he was found in his cell having sustained a serious head injury.

The jury had heard evidence that non of the healthcare staff in prison had had any specific training in the assessment and treatment of alcohol withdrawal. Staff gave evidence that although Mr Madden was suffering from auditory and visual hallucinations and he was plucking imaginary objects off the walls in his cell, this behaviour was normal for prison inmates undergoing alcohol withdrawal at HMP Liverpool.

The jury found that the significances in his deteriorating condition had not been appreciated by the healthcare staff.

Following his injury, Mr Madden was taken to University Hospital Aintree where there was a delay in his treatment, he became unconscious and died in Ormskirk Hospital on the 20th March 2005.

Petra Blanksby – Womens Death in Prison

Farleys Solicitors represented the family of Petra Blanksby a young woman who died in HMP New Hall prison.

Petra had a long history of self-harming and had been arrested following an attempt to kill herself by setting her bed on fire.  Whilst an inmate at HMP New Hall for 130 days she self-harmed on 92 occasions. She was described by one prison officer as a ‘death in custody waiting to happen’.

This case highlighted the issue of the lack of suitable places for young women who self-harm and following the Inquest, the Coroner indicated his intention to write subject to Rule 43 of the Coroners Rules to both the Prison Service and the Department of Health.

Gareth Price – Juvenile Death

Farleys acted for the family of Gareth Price a 16 year old who died in HMP Lancaster Farms. The Inquest lasted 3 months and evidence was heard from over 60 witnesses.  Having heard all the evidence the jury returned a detailed narrative verdict which included some of the following comments:-

  • County Durham Engagement Service (CDES) took the decision to derogate from their National Standards, however failed to communicate this decision adequately to key agencies resulting  in a poor standard of service being delivered.
  • There was a failure by CDES to engage in meetings, in particular Gareths initial remand planning meeting. Documentation was incomplete and there were inappropriate assessments and only intermittent communication with Gareths family.
  • The jury found that there was a serious omission in that incidents of Gareths self harm were not communicated to the family and other agencies.
    The visiting Psychiatrist who assessed Gareth in prison should have ensured that the contents of her report were shared with other agencies instead of anticipating that they would be.
  • The Prison Psychologists Report was not dealt with adequately, the report contained important information regarding Gareths self harm and was sent via the Prison internal mail. However the report did not reach the Prison Governor who had requested the same.
  • The Personal Officer system within the Prison was ineffective.
  • After 3 incidents of self harm Gareth was not seen by a qualified health practitioner.
  • The jury found that the Youth Offending Team of Lancashire County Council  employed untrained temporary staff, had confused lines of management and unclear job descriptions. Paperwork was not always completed correctly or on time, record keeping was poor and communication between agencies was haphazard. The overall running of the department was intermittent and casual.

In conclusion the jury stated that, “the complexity of this case and the evidence heard the jury finds that all agencies dealing with Gareth Price provided a most inadequate and negative input to his needs and ultimately contributed to his death.”
Kurt Howard – Death in a Psychiatric Hospital

Six years after he died the Inquest recently concluded into the death of Kurt Howard who died in Cefn Coed Hospital, Swansea.

The Inquest lasted 5 weeks and amongst their findings the jury concerned that,

  • The care plan and risk assessment in relation to Kurt were inadequately completed.
  • There was a lack of communication and training between the hospital staff.
  • Kurt was subject to an excessive and prolonged restraint in the prone position.
  • There was a delay in the staff calling the Ambulance.
  • The environment that the restraint took place was inadequate and unsuitable.

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