A two-week inquest at the end of January recorded a detailed narrative verdict critical of the care that 28-year-old Andrew Jordan, a Guyanese man who had a history of schizophrenia, received from police, mental health officials and ambulance service staff in south-east London.
Andrew’s mental health problems had begun in 1999 when he returned to England after a family holiday in Guyana. His wife was refused entry due to a problem with her visa. Throughout this period, the stress of not knowing if his wife would get entry clearance caused his mental health to deteriorate.
On the afternoon of 7 October 2003, Andrew, the father of a young girl, died after being restrained by up to five police officers and a mental health team from Oxleas Primary Care Trust. The mental health team, including one doctor, was planning to take Andrew for assessment at the Woodlands mental health unit of Queen Mary’s Hospital, Sidcup, because of concerns that he had stopped taking his medication.
At the inquest it emerged that Andrew refused to allow the mental health team to enter his house in Erith, south-east London, and police officers were called to persuade him to open the door. Two police officers forced their way in after claiming to hear Andrew saying ‘You will see blood. Do you want blood?’ According to officers, Andrew grabbed PC Terry Fearn around the neck and was then restrained with the help of the other police officer, PC Lautier, and the mental health team. Police reinforcements were also called – four police cars and a police van with a total of eleven other officers, most of whom were inexperienced probationers, arrived at the scene to help restrain Andrew (thirteen police officers in total). During the struggle, PC Fearn was bitten on the arm and Andrew was punched several times on his forehead by the same PC. Eventually, police handcuffed Andrew and he was restrained for at least ten minutes as he knelt on the floor with his chest pressed against the sofa. The police attempted to stand Andrew up and were unable to do so as he was limp and floppy. He was then carried from the house and placed belly-down on a stretcher and then strapped (across legs and chest) to a trolley and taken to a waiting ambulance – he remained in the face-down prone position with his hands cuffed behind his back.
As he was placed in the ambulance, accompanied by three police officers and the ambulance crew, he suffered a fit. The crew assumed he was hyperventilating and failed to provide oxygen. Andrew’s hands were uncuffed some point before the ambulance stopped to check on his condition. Fourteen minutes later, the ambulance stopped again after it was discovered that Andrew was not breathing and his lips had turned blue; it was then decided that Andrew had died. The ambulance then travelled to Queen Mary’s Hospital where he was officially pronounced dead at 2.15pm.
Nine months after Andrew’s death, on 23 September, his mother, Theresa, 50, who was disabled and had a heart condition, took her own life. Her family said that she was unable to cope with her son’s death and was upset that the family had been unable to bury him as various post-mortems were being carried out. On 5 October 2004, mother and son were cremated together.
The inquest jury recorded a narrative verdict, which found that:
- A contributory factor in Andrew’s death was the lack of communication between all services as to his condition;
- Deficiencies in training on positional asphyxia amongst some of the medical staff was detrimental to the treatment that Mr Jordan received;
- Mr Jordan died in part because asphyxia caused by prolonged restraint was not subsequently treated.
Evidence from the inquest
One pathologist, Dr Chapman, told the inquest that he could find no obvious cause for Andrew’s death. However, there were cuts and bruises, with the most extensive area of bruising being in the middle of Andrew’s back where it was deep and internal. This bruising was consistent with either a blow or pressure from a knee during restraint. Cuts and bruises to his face were consistent with punches. Chapman gave the cause of death as cardio-respiratory arrest following struggle and restraint, with a secondary factor being Andrew’s paranoid schizophrenia.
Another pathologist, Dr David Rouse, employed by the Police Federation on behalf of the police officers involved in Andrew’s death, agreed with Dr Chapman’s findings and the interpretation of the causes of Andrew’s injuries’ but disagreed with Dr Chapman’s conclusions. He gave the cause of death as sudden death following restraint with agitation and schizophrenia, with a secondary factor being diabetes.
The pathologist, Professor Jack Crane, who examined Andrew’s body on behalf of his family, also agreed with Dr Chapman’s initial findings, but found that the cause of Andrew’s death was positional asphyxia due to struggle and restraint, commenting, ‘I would not include schizophrenia in the reasons for death. He did not die because of schizophrenia. It was not a natural death and it was not a sudden death.’ He also said that, had Andrew been put on his side in his house, there was every chance that he could have survived. His breathing problems had been caused by exhaustion because of struggling with police officers, obesity, being kept face down and having his hands cuffed behind his back.
Evidence on policing
Police officers denied exerting pressure on Andrew’s back and officers claimed to have warned ambulance staff about the dangers of positional asphyxia and, allegedly, warned them against placing Andrew on his front with his hands cuffed in the ambulance. Though police officers had been trained in positional asphyxia, Andrew was kept in a semi-prone position, kneeling, chest over sofa, for at least ten minutes. (Positional asphyxia can set in after 4-7 minutes.) Four officers restrained Andrew despite him already being in Kwik-cuffs, which are designed for a single officer to easily control a detained person. Three police officers told the inquest that the ambulance technician ignored their concerns about Andrew – that he was cold and that his breathing was irregular.
Evidence on medical support
In a written statement, Mark Robertson, a paramedic who drove the ambulance that took Andrew to hospital, claimed that his colleague, Daniel Gaze, a medical emergency technician, had given Andrew oxygen but, when giving evidence, accepted that it might not have happened. He also agreed that he was wrong to drive the ambulance, as he was a paramedic who was far better qualified medically than his technician Daniel Gaze. Mark Robertson, who apparently failed to get doctors at the scene to examine Andrew, also agreed that had Andrew been given oxygen earlier he might have survived. Both Daniel Gaze and Mark Robertson denied any conversation in which they were warned about the dangers of positional asphyxia. They said that the first time they heard the phrase positional asphyxia was when they were at the hospital after Andrew had died. It was also found that even after two and a half years since Andrew’s death, London Ambulance Service crews are not systematically trained in positional asphyxia. Daniel Gaze also admitted to using the term ‘a nutter’, when he was told he was to attend a possible sectioning of a psychiatric patient.
After the inquest, London Ambulance Service (LAS) director of operations Martin Flaherty accepted that there were ‘things our crew should have done differently when caring for Mr Jordan’. He also revealed that LAS would be amending its clinical guidelines and training on the dangers of positional asphyxiation.
Responses to the verdict
After the verdict, Andrew’s family commented: ‘We are very pleased with the verdict that the jury has returned. However, nothing will bring Andrew back. He leaves behind a grieving family including his young daughter. We, as a family, feel vindicated for our belief that the authorities, including the Metropolitan police, Oxleas mental health trust, and London Ambulance Service failed Andrew. We just hope that lessons are learnt from Andrew’s death and no other family has to go through what we have been going through for the last two and a half years. We still have never heard one of those authorities say sorry for what they did to Andrew.’ Andrew’s family is considering a civil action against the three agencies involved in his death.
Deborah Coles, co-director of INQUEST, commented: ‘The inquest has heard very disturbing evidence about the treatment and care of a mentally ill man in police custody. This case once again raises serious concerns about the ongoing dangers of current police restraint methods, especially where prolonged and dangerous use of the prone position occurs. It is a damning indictment of the failure of state agencies to learn the lessons of previous deaths.’
Susie Yau, of Fisher Meredith, who represented Andrew’s family, told IRR news: ‘What happened to Andrew was a tragedy. We must remember that Andrew was not a criminal and was not under arrest. He was a young man suffering from a serious mental illness and was, in fact, in need of help. We hope that all the agencies ensconced with the care of Andrew will review their training policies and procedures, with regard to dealing with the most vulnerable members of our society.’
Following the inquest, the coroner has written to the agencies involved to raise concerns about the way Andrew was treated. The coroner has made the following recommendations:
- Mental health care staff should be trained in the recognition and treatment of positional asphyxia. This includes psychiatrists (whether in training or fully accredited), registered mental nurses and approved social workers, as well as doctors approved under s12 of the Mental Health Act to carry out assessments;
- The ambulance service on a national level, and not just LAS, should also be trained in positional asphyxia;
- Where two emergency services (i.e. police and ambulance) are involved in carrying out a mental health assessment, consideration should be given as to how they are to jointly manage the patient and to ensure that communication is clear;
- The Metropolitan police training manual should make clear the position in which to hold someone who has been brought under control. Dr Richard Shepherd, a forensic pathologist, revealed that when he recommended that a person be brought to their knees, he meant kneeling in an upright position. The police officers in this case, on the other hand, thought that the position in which they restrained Andrew was compliant with current guidance, given that he was on his knees (although his torso was over the sofa);
- Oxleas NHS trust should draw attention to this case in leading professional journals in order that care staff become aware of the risks of positional asphyxia.