This media release was written by Irwin Mitchell.

Before HM Senior Coroner Rachel Griffin
Bournemouth Coroner’s Court
16 September - 22 October 2019

The parents of a man from Poole who died hours after being restrained by police have spoken out following the conclusion of an inquest which highlighted a need for improvements in training for ambulance staff and police officers.

Company director Douglas Oak, 35, came into contact with officers from Dorset Police near the junction of The Avenue and Dalkeith Road in Poole during the afternoon of 11 April, 2017. It was reported that he had been behaving erratically and walking in and out of traffic. Officers arrived and restrained him using handcuffs and leg straps after he jumped into the open door of a police car asking for help. 

Officers told the court they quickly suspected Douglas was suffering from a medical emergency, later identified as acute behavioural disturbance (ABD) and asked for an ambulance to attend on the highest priority. 

He was restrained by police officers for almost an hour and suffered a cardiac arrest before paramedics arrived. The court heard that restraint contributed to Douglas’ death. He was taken by ambulance to Poole General Hospital and admitted to the critical care unit but died the following morning.

Douglas’ parents instructed specialist lawyers at Irwin Mitchell and Garden Court Chambers to help investigate the events that unfolded in the lead up to his death and secure answers. Following the conclusion of the inquest the law firm has revealed that Dorset Police has agreed to pay undisclosed damages to the family whist denying liability.

A five-week inquest into Douglas’ death took place in Bournemouth before the Senior Coroner for Dorset, Rachel Griffin, and concluded this week. The jury heard that whilst frontline police officers had been trained to recognise ABD, previously known as excited delirium, staff in both the police and ambulance control rooms had not been trained to recognise the term.  The call to the ambulance was allocated a 40 minute response time, whereas Dr Aw Yong, an Associate Specialist in Emergency Medicine and Medical Director at the Metropolitan Police Service, told the court that ambulances should aim to respond to cases of severe ABD within eight minutes.  The jury found that after Douglas went in cardiac arrest specially trained police officers failed to use a bag valve mask to provide ventilation during CPR, although they couldn’t say whether this contributed to his death.

The Senior Coroner confirmed she would be issuing a wide ranging Preventing Future Deaths report to national policing and ambulance bodies highlighting the need for better training and guidance around ABD.

Douglas’ parents, John and Christine, said after the inquest: “These past two-and-a-half years have been the worst of our lives, having to cope with losing Douglas and then going through it all again day after day at the inquest.

“Over the last five weeks, we have sat in court and heard about gaps in training, the absence of de-escalation and calming techniques when officers first came into contact with our son, breakdowns in communication, and a failure to use medical equipment.  While some of the officers on the ground tried their best they were let down by a system that wasn’t capable of ensuring our son got the help that he needed when he needed it.

“While nothing will bring Douglas back, we are pleased that the Coroner will be issuing a report highlighting the fact that the lack of national guidance regarding acute behaviour disturbance is putting lives at risk. 

“We hope this report will lead to urgent changes; we know that Douglas would want this too, and would not want any other families to lose their loved ones in these circumstances.

“He is missed every single day and wish, with all our hearts, that he was still with us.”

Gus Silverman, of Irwin Mitchell who represented the family alongside Patrick Roche of Garden Court Chambers, said after the hearing: “For some time now coroners have been issuing reports following the deaths of those suffering from Acute Behavioural Disturbance. 

“National ambulance and policing organisations should now work together as a matter of urgency to ensure that people displaying symptoms of ABD no longer face death as the result of restraint.

“Whilst some ambulance trusts have implemented their own policies regarding the treatment of ABD, Douglas’ tragic case illustrates that it is still very much a postcode lottery as to whether the correct treatment is received.  This cannot be right.”

Anita Sharma, Senior Caseworker at the charity inquest which has been working with the Oak family said:

“The findings of this inquest demonstrate the urgent need for a national oversight mechanism, to collate and implement recommendations following deaths.  Douglas is one of many to have died arising from a lack of understanding of ABD.  We have seen inquest after inquest giving rise to the same issues on a local and national level over a number of years. Without a Government resourced and committed mechanism of learning we will continue to see people in crisis die in similar circumstances”

The jury recorded a narrative conclusion, finding that Douglas died as a result of the combined effects of acute-on-chronic cocaine intoxication, excitement, exertion, restraint and hyperthermia with terminal bronchopneumonia.

Background

Douglas Oak was born in Boscombe and grew up in the Bournemouth and Poole area.  At the time of his death he was the director of a company specialising in bespoke Company Software Design.  In a statement read to the inquest his mother, Christine Oak, described her son as “a gifted, genuine, kind and gentle person, who showed love, generosity and compassion to everyone. His fun-loving nature, and gorgeous smile coupled with his enthusiastic personality was infectious.”

 

‘Massive paranoid attack’

The inquest heard that at around 3.30pm on 11 April, 2017, Douglas’ neighbours heard him shouting for help outside of the house near Poole, Dorset, where he had been living temporarily with his parents who were on holiday in Portugal at the time. 

Giving evidence to the inquest one of the neighbours, Duncan Sutherland said that Douglas was barefoot and “standing in the middle of the road and appeared very distressed and frightened.”  Mr Sutherland and other neighbours tried to speak to calm Douglas down but he seemed delusional and paranoid. 

One of the neighbours said “He was particularly frightened of going near the hedges, gates and shadows. I heard Douglas say, ‘can't you see them, they're in the shadows trying to kill me’”  Mr Sutherland said that Douglas “was not aggressive at all, but was extremely agitated and appeared terrified.”

Another neighbour, Karen Gore, told the inquest that she called 999 at 4.09pm and asked for the police and ambulance to attend.  In a recording of the call played in court Ms Gore was heard to say that Douglas was having a “massive paranoid attack running around in the road … he’s just incredibly disturbed and I think he might hurt himself.”  When the Dorset Police operator asked Ms Gore if she thought an ambulance was needed as well as the police she said that it was. However, the court heard that this message wasn’t passed to the ambulance control room. 

 

No training for police control room staff in ‘Acute Behavioural Disturbance’

The police operator told the inquest that at the time police control room staff had not been trained to recognise the signs of a condition called ‘Acute Behavioural Disturbance’ (ABD) or the fact that it was a medical emergency due to the risk of cardiac arrest.

Mark Faulkner, an Advanced Paramedic Practitioner with the London Ambulance Service and an expert on ABD told the court that Douglas was presenting with “textbook” symptoms of the condition.  The court heard that in 2015 Dorset Police had trained its police officers, but not its control room staff, that individuals suspected of suffering from ABD must be “treated as a medical emergency”. 

In a statement to the inquest the police operator said she was now trained in ABD and “would certainly start to link the described behaviour to the medical condition and how serious it is” and that, if she had been trained at the time, she would have “flagged it early on” for the South Western Ambulance Service Trust (SWAST) to consider deploying an ambulance.  Mr Faulkner told the inquest “I can find no obvious reason as to why the call was not passed to SWAST following the initial call to the police.”

The inquest heard that at around 4.20pm, PC Steven Donaldson and PC Simon Young arrived in a police car at The Avenue, near the junction with Dalkeith Road, and saw Douglas running “erratically down the centre of the road”.  PC Young told the court that he stepped out of the car and Douglas ran around him before jumping into the passenger seat.  PC Donaldson recalled “I believe he was saying something similar to “they are after me, they are going to kill me, I have done something”.”  A passer-by, Rose-Ellen Toon, told the inquest that Douglas looked “frightened” when she looked at him through the window of the police car. 

‘Forced’ out of car

Responding to questions from the Coroner PC Donaldson admitted shouting “get him out of the f**king car” and both officers described forcing Douglas out of the vehicle and on to the road where they put him in handcuffs. Both officers told the court that neither of them attempted to calm Douglas or use any “de-escalation” and calming techniques before forcing him out of the passenger-side door. 

PC Young told the inquest that after placing Douglas in handcuffs he saw the 35-year-old was “sweating a lot, he was red in the face, he felt very hot to touch and he was breathing very heavily. It was at this point it dawned on me that this was potentially a medical emergency”.  Both officers confirmed they had recently been trained in ABD and knew that sufferers had to be taken to hospital as soon as possible.  The inquest heard that PC Young radioed the Dorset Police control room stating “I think it is a medical episode” and asked for an ambulance.

The court heard how more officers arrived and helped to move Douglas off the road on to a grass verge.  However, he continued to be distressed and police restrained him on his back, at first using handcuffs and leg restraints but later with one officer holding each of his limbs.  Ms Gore told the court that Douglas “was still thrashing about and moving all the time, I don't think he knew that it was the police officers who were holding him. There appeared to be something going on in his head that wasn't reality and he was fighting against that.”  PC Mike Constable told the inquest that at one point Douglas asked “is this real?”  The officer told him that it was real and tried to reassure him.

“I was devastated to see another police car arrive”

The court heard that officers radioed through a string of further requests for an ambulance as they were grew increasingly concerned about Douglas’ deteriorating condition. 

At around 4.23pm PC Young radioed the police control room asking again for an ambulance, this time “on the hurry up”.  When asked by the family’s barrister, Patrick Roche of Garden Court Chambers, “is there any higher level than ‘on the hurry up’” PC Donaldson responded “no it’s as urgent as it gets” and that “as a police officer if I request ‘on the hurry up’ I want it there within minutes, as soon as possible”. PC Young did not tell the police control room that Douglas might be displaying symptoms of ABD because neither he nor PC Donaldson could remember the name of the condition.

The court heard that when the police control room told one of the officers that they were “struggling” to get a reply from the ambulance service, one officer at the scene radioed back “I am going to say this is a priority at this point”. The jury was told that the police control room then gave up trying to reach the ambulance control room via the ‘direct line’ and had to resort to calling 999 in order to get through. 

PC Young told the court at one point “I heard sirens approaching and quickly got up to flag down what I expected to be the ambulance. I was devastated to see another police car arrive.”

No training in ‘ABD’ for ambulance staff

When the police control room first made contact with the ambulance control room, 11 minutes after the officers had first asked for an ambulance, at around 4.34pm, the inquest heard that neither the police nor the ambulance operators understood what ‘ABD’ meant.  A transcript read out in court revealed that the ambulance control room thought it was the name of a drug and graded the call ‘category 3’, meaning that an ambulance would aim to respond within 40 minutes.  Dr Aw Yong, an Associate Specialist in Emergency Medicine and Medical Director at the Metropolitan Police Service, told the court that ambulances should aim to respond to cases of severe ABD within eight minutes.  Mr Faulkner told the inquest that “I would suggest that by 2017 ambulance services should have been aware of the risks of ABD and had polices in place to guide and support staff.”

The court heard that at 4.44pm PC Mike Constable radioed to confirm that firearms officers, who had been asked to attend due to their advanced life support training, had arrived and agreed the situation was a medical emergency.  In a transcript read to the court PC Constable told the Dorset Police control room that “this chap’s possibly going into cardiac arrest soon” and requested “a bit of priority with ambo”.  None of this information was passed onto the ambulance control room.

Officer “cannot explain” why medical mask not used

At around 5.12pm the ambulance control room received a further 999 call from the police control room advising that Douglas had “stopped breathing” and the call upgraded to the highest priority.  It was later confirmed that Douglas had suffered a heart attack. Officers started chest compressions but failed to use the ‘bag valve mask’ in their kit bag to push air into Douglas’ lungs.

A firearms officer who had been trained in this technique, PC Hayley Crawford, told the court “I cannot explain how this was missed, but can only assume that this was overlooked due to the stress and fatigue that I was feeling after I had been involved in restraining the male for a prolonged period” and that she had “taken a huge amount of learning from this incident for a number of reasons.” 

In a report provided to the court Dr Jasmeet Soar, a former chair of the UK Resuscitation Council, explained that if officers had used the bag valve mask “this would have provided Mr Oak with a meaningfully better prospect of survival even if the ambulance crew arrived when they actually did.”

PC Young told the inquest “I have never had such a critical incident whereby an ambulance has been called and taken what felt like an hour to attend.”

Soon after the ambulance control room was told that Douglas had “stopped breathing” the first of two ambulances arrived at the scene, around 56 minutes after one was requested over the police radio.  Dr Soar’s report to the court concluded that “had the ambulance crew arrived prior to the cardiac arrest, on the balance of probabilities Mr Oak would have had a meaningfully better prospect of survival.”

The inquest heard that Dorset Police started to train police control room staff two months after Douglas’ death. SWAST did not start training its staff until over 18 months after his death.

Poole General Hospital

Paramedics transferred Douglas to Poole General Hospital.  He never regained consciousness and died the following day with his family by his side.

Pathologist Dr Basil Purdue told the court that the medical cause of death was the combined effects of acute-on-chronic cocaine intoxication, excitement, exertion, restraint and hyperthermia with terminal bronchopneumonia.

Mrs Oak told the inquest that Douglas was “a deeply loved son, brother, brother-in-law, uncle, nephew and a friend to all who knew him. This world is far worse off without our lovely son. He was truly one of a kind.”

 

Lack of national guidance for ambulance trusts

The inquest was told that in 2015 the Royal College of Emergency Medicine issued guidance stating that Acute Behavioural Disturbance, formerly known as excited delirium, was “a medical emergency” and that “Sedation (rapid tranquilisation) will be required to facilitate rapid intervention and institution of potentially lifesaving treatments if an individual displaying ABD fails to respond to de-escalation techniques.”  The court heard that in the North West and London ambulance areas advanced paramedics are able to deliver sedation to patients suffering from ABD but that in the South Western Ambulance Trust area this option is not available. 

In July 2015 the Association of Ambulance Chief Executives (AACE) responded to a Preventing Future Deaths report issued by a coroner in Birmingham following the death of 29-year-old Kingsley Burrell after suffering from ABD symptoms.  The AACE told the coroner in that case that it had “established that not all trusts comprehensively incorporate education to their staff around ABD” and that it had “made a recommendation to the National Education Network for Ambulance Services leads (NENAS) that each trust considers including, if not completed already, the education of front line staff and control room staff in acute behavioural disturbance to raise awareness of the condition and how it can present in a patient.” Several witnesses gave evidence about the lack of national guidance on how patients suffering from ABD should be treated by ambulance trusts.

ENDS

Notes to Editors

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