National review needed, says coroner at inquest of Philmore Mills, 57, who died after being handcuffed with face to the floor at hospital.
8 MARCH 2016 | BY Lisa O'Carroll FOR THE GUARDIAN
A senior coroner has called for a national review of police use of restraints after an inquest jury found a decision to restrain a 57-year-old man suffering from lung cancer and pneumonia in hospital contributed to his death.
The verdict follows a four-year battle for justice by the family of Philmore Mills, who died in hospital in 2011. After a four-week inquest at Reading coroner’s court, the jury ruled that a police decision to take the seriously ill father to the ground and handcuff him with his face to the floor was a contributory factor in his death moments later.Mills’s death was caused by “cardiorespiratory collapse due to hypoxia [shortage of oxygen to the brain] due to the severe lung and heart disease in association with restraint” used by officers, the jury found.
Jurors said lack of oxygen “for a significant period of time” led to his “agitated” state and there had been “lack of medical support” at that time.
Mills had been admitted to Wexham Park hospital on 21 December 2011 with a chest infection and an irregular heartbeat. His condition worsened over the course of a week and on Boxing Day, when his family paid a visit, Mills was wearing an oxygen mask.
The jury found that nurses “panicked” when Mills woke in the early hours of 27 December and got out of bed. He had become confused and was shouting at staff. After failing to summon doctors, the nurses called on police for assistance.
The inquest heard that the process of placing him into the prone position, face to the floor, lasted less than one minute and the effort to move him back to his bed took less than 30 seconds.
There was “inadequate” communication between the officers and Mills, and no discussion between police and nursing staff on a course of action following restraint, the jury found.
The police had asked two security guards for assistance in cuffing Mills and the jury heard that one officer had yelled “get off” to a security guard who was claimed to be kneeling on the patient.
One expert witness, Kevin Gournay, the emeritus professor at the Institute of Psychiatry, told the inquest it is well known that placing any pressure on the back while someone is in the prone position is dangerous because it can compromise breathing. But the jury found the “evidence does not allow us to determine whether a knee was used or not”.
A damning hospital report, obtained by the Guardian, shows multiple failures on the night of Mills’s death. Frimley Health NHS foundation trust, which took over Wexham Park in 2014, concluded that the patient’s confusion was “dealt with as a security emergency rather than as a medical emergency”.
It also found nurses had failed to make half-hourly observations, as required by hospital policy, when his health deteriorated.
The inquest heard that when Mills’s daughter, Rachel Gumbs, left the hospital between 7pm and 8pm after visiting her father, “he seemed OK but a little tired”. Hours later she got a call to say he “had had a turn” and she should return to the hospital. Initially Gumbs was told by the hospital that her father had died of a heart attack. It was not until the family arrived at the hospital that they learned he had died following restraint.
Their suspicions were immediately raised when the first people to greet them in the family room at the hospital were representatives of the Independent Police Complaints Commission (IPCC).
An initial postmortem was conducted by the hospital but the evidence of bruising on Mills’s body only became visible in a second postmortem, commissioned by the family. The independent pathologist Deryk James then found seven areas of “bruising to the side of the chest and back which may have been caused by restraining”.
The senior coroner Peter Bedford called for a review of police training in relation to the risks associated with the “take-down” process.
He said Thames Valley police training makes officers aware of certain risks in the restraint procedure such as broken bones. “What it does not include is the risk of death. It seems to me if that was adopted as part of the training that would focus the officer’s mind,” said Bedford.
He added that the omission of risk of death may be something all police forces need to consider. “It may not be limited to Thames Valley police, but it could be a national issue,” he said.
Two police officers were cleared of breaching professional standards over Mills’s death at a misconduct hearing in 2015, while the Crown Prosecution Service ruled there was insufficient evidence to bring charges over Mills’s death. But the verdict paves the way for a potential civil action by the family against Wexham Park hospital, the security firm, CP Plus, and Thames Valley police.
In a statement the family said it had been four “stressful years” to get to this point. They said they had “listened to four weeks of evidence about how events unfolded like a car crash in slow motion … Yet we are none the wiser as to how a seriously ill man with pneumonia, heart and lung disease, lung cancer and blood clots in his lungs could have been allowed to die under police restraint on the floor of a respiratory ward.”
They said it was “shocking that neither the nurses, security staff or police officers spoke to each other before restraining him” and noted that “none of the witnesses accepted responsibility for the death of our father and grandfather”.
“No family should have to go through what we have gone through. We hope that all those involved will reflect on their actions and that lessons will be learned.”
The charity Inquest said the Mills case raised serious questions about the lack training of nurses and security staff. The inquest concluded the day the IPCC revealed concerns in a report about the use of force by police particularly on the vulnerable.
Deborah Coles, director of the charity Inquest said: “This is not an isolated case and that time and again following critical inquest findings the police are warned about the dangers of restraint and yet the deaths continue.
“Philmore Mills was a vulnerable and seriously ill black man in need of help and yes he was failed by those should have been there to protect and care for him,” she said.