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You are here: BAILII >> Databases >> Scottish Sheriff Court Decisions >> INQUIRY UNDER THE FATAL ACCIDENTS AND INQUIRIES (SCOTLAND) ACT 1976 INTO THE SUDDEN DEATH OF ROBERT SHREENAN [2011] ScotSC 83 (18 April 2011)
URL: http://www.bailii.org/scot/cases/ScotSC/2011/83.html
Cite as: [2011] ScotSC 83
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2011 FAI 19
Sheriffdom of North Strathclyde at Dumbarton
Fatal Accident Inquiry
Under
Fatal Accident and Sudden Deaths Inquiry (Scotland) Act 1976
DETERMINATION
By
SHERIFF M S MACTAGGART
Following an Inquiry at Dumbarton Sheriff Court into the circumstances of the death of
ROBERT SHREENAN
B548/10
Dumbarton, 18 April 2011
The Sheriff, having resumed consideration of the cause, DETERMINES in terms of section 6 of the Fatal Accident and Sudden Deaths (Scotland) Act 1976:-
(a) In terms of section 6 (1) (a) of said Act that Robert Shreenan (born 9th January 1960) and ordinarily resident at 11 Apple Close, Blackburn, died on 14th July 2008 at an indeterminate time after 18.15 hours and before 18.45 hours. The place of death was Cell 17, Clydebank Police Office, Montrose Street, Clydebank.
(b) In terms of section 6 (1) (b) of said Act that the cause of death was plastic bag asphyxia.
(c) In terms of section 6 (1) (c) reasonable precautions whereby the death of Robert Shreenan might have been avoided are:-
(i) if the officers of Reliance Custodial Services transferring the said Robert Shreenan had ensured that the plastic bag given to him to be sick into was retrieved from him;
(ii) if the officers of Reliance Custodial Services transferring the said Robert Shreenan had informed the custody officers at Clydebank Police Office that the said Robert Shreenan had been provided with a plastic bag to be sick into and said bag had not been retrieved from him.
(d) In terms of section 6 (1) (d) there are no defects in any system of working which contributed to the death of the said Robert Shreenan.
(e) In terms of section 6 (1) (e) there were and are no other facts which are relevant to the circumstances of the death of the said Robert Shreenan.
Finds in Fact:
1. Robert Shreenan was born on 9 January 1960. He died on 14 July 2008, aged 48.
At the time of his death Robert Shreenan was ordinarily resident at 11 Apple Close, Blackburn. He resided there with his partner Carol Sutherland.
2. A petition warrant was granted at Dumbarton Sheriff Court on 13 May 2008 for the arrest of Robert Shreenan. This warrant related to charges of (i) attempted assault; (ii) lewd and libidinous practices and behaviour; and (iii) a contravention of the Criminal Law (Consolidation) (Scotland) Act 1995 section 6. A further warrant was granted at Dumbarton Sheriff Court on 19 May 2008 for the arrest of Robert Shreenan. This warrant related to a charge of contravention of the Criminal Procedure (Scotland) Act 1995 section 102A.
3. Robert Shreenan had previously spent time in custody.
4. On Monday 14 July 2008 at or about 0630 hours Robert Shreenan was arrested on said petition warrants at his home address at 11 Apple Close, Blackburn by PC Mark Emmett and PC Jonathan Hulton, both officers of Lancashire Constabulary and conveyed by them directly to Blackburn Police Office.
5. Robert Shreenan was searched by said constables prior to being placed in the police vehicle. He was searched again at Blackburn Police office.
6. Robert Shreenan was detained at Blackburn Police office at around 0645 hours. His arrest and detention were lawful.
7. On arrival at Blackburn Police Office at 0645 hours Robert Shreenan was processed as an arrested person by Sergeant Marshall Seddon.
8. Robert Shreenan's property upon his detention consisted of cigarettes, a lighter, trainers, a walking stick and a medical tag.
9. Robert Shreenan advised Sergeant Seddon that he had medical problems with his legs, that he had a punctured lung and that he was on prescribed medication. Mr Shreenan had a splint on his wrist. Sergeant Seddon arranged for Robert Shreenan to be examined by a nurse from Medacs (an external health care company).
10. Initially upon processing Robert Shreenan, Sergeant Seddon ordered fifteen minute checks and then half-hourly checks to be made on him. Sergeant Seddon assessed this as necessary as he had concerns about Mr Shreenan's medical condition.
11. Robert Shreenan was examined by Nurse Tracy Moorby at 0830 hours. He vomited a little in her presence. He complained of back pain and advised her that he had recently suffered a punctured lung. He was seen to be shaking and admitted having an alcohol problem. She prescribed him Buccastem to be taken immediately to alleviate the nausea and prescribed Diazepam, Dihydrocodeine and Co-codamol to be taken immediately and then later in the day at 1500 hours and 2100 hours. Diazapam is a drug prescribed to alleviate the symptoms associated with alcohol withdrawal. Dyhydrocodeine is an opiate pain-killer. Co-codamol is a pain killer.
12. Robert Shreenan was checked in his cell at half- hourly intervals from 0929 hours until discharged into the custody of officers from Reliance Custodial Services at 1145 hours.
13. Custody officers from Reliance Custodial Services, namely Margaret Maider and Gary Dewar attended at Blackburn Police Officer at 1145 hours to collect the said Robert Shreenen for transfer to Clydebank Police Office. Robert Shreenan was searched and wanded by Reliance officers and placed in a cell in the rear of the van.
14. The medication prescribed for Robert Shreenan by Nurse Moorby was not given to Reliance officers and was not placed within Mr Shreenan's property.
15. A record of Robert Shreenan's custody at Blackburn Police Office was completed and handed to Reliance Officers together with a Personal Escort Record (PER).
16. As at 14 July 2008 the only bags in use on Reliance vans were clear plastic non-perforated bags, normally used as property bags.
17. Since in or around 15 July 2008 small paper sick bags have been available for use on Reliance vans.
18. Robert Shreenan was not given a comfort break whilst in transit with Reliance Custodial Services.
19. Whilst in transit Mr Shreenan was checked at least every 30 minutes by the Reliance Officer Margaret Maider. At 1430 hours he was sick and this was noted on the PER form by Officer Maider. She passed him a newspaper under the door of his cell to be placed by him on the floor. Custody officer Maider advised her control office of this and was told to keep an eye on Robert Shreenan.
20. The Reliance vehicle being used to transfer Robert Shreenan developed a slow puncture and the transfer of the prisoners on board to an alternative van was arranged to take place at the first available secure unit, being Airdrie Sheriff Court.
21. The van carrying Robert Shreenan arrived at Airdrie Sheriff Court at 1500 hours. Robert Shreenan was transferred to Reliance van number 546 which was staffed by custody officers Norma Scott and John McKenzie.
22. Custody officer Margaret Maider advised Custody officer Norma Scott that Robert Shreenan had been sick during the initial part of the journey. Prior to leaving Airdrie Sheriff Court, Custody officer Scott gave Robert Shreenan a clear plastic property bag for him to use if he was sick again. It is unclear whether this bag was offered to Mr Shreenan or whether he requested it.
23. Van number 546 made three scheduled stops at secure units, being Stewart Street Police Office Glasgow, Kilmarnock Police Office and Clydebank Police Office. Custody officer Scott drove the vehicle to Glasgow and Kilmarnock and Custody Officer McKenzie drove from Kilmarnock to Clydebank.
24. During the journey from Airdrie Sheriff Court to Clydebank Police Office Robert Shreenan was checked at 1525 hours, 1550 hours, 1615 hours, 1650 hours and 1715 hours.
25. Custody Officer McKenzie was aware that Robert Shreenan had been given a clear plastic property bag by Custody Officer Scott.
26. The provision of a clear plastic property bag to Mr Shreenan was not noted on the PER form by either Custody Officer Scott or Custody Officer McKenzie.
27. The clear plastic property bag was not retrieved from Mr Shreenan by Custody Officer Scott or Custody Officer McKenzie. The bag was not left on the vehicle by Mr Shreenan.
28. Mr Shreenan arrived at Clydebank Police Office at 1745 hours. Custody Officer McKenzie took Mr Shreenan, his property and his PER form into Clydebank Police Office. He did not advise custody officers at Clydebank PO that RS had been given a plastic bag and that this has not been retrieved from him.
29. Mr Shreenan deliberately concealed the plastic property bag given to him by Custody Officer Scott about his body in an attempt to prevent detection.
30. Mr Shreenan's detention at Clydebank Police Office was supervised by Sergeant Graeme Spence. A Police National Computer check had been carried out on Mr Shreenan prior to his arrival at Clydebank. This did not indicate any risk factors relative to Mr Shreenan.
31. Mr Shreenan was searched at Clydebank Police Office by PC Gavin Murray under the supervision of Sergeant Spence. Sergeant Spence instructed a pat down search of Mr Shreenan.
32. In carrying out the pat down search of Mr Shreenan, PC Murray did not pat down his chest area, inside his legs, under his arms or his groin area. The search did not detect the plastic bag.
33. There was nothing in the information available to Sergeant Spence regarding Mr Shreenan to indicate that he posed a risk to himself or others nor that he merited a strip or intimate search.
34. In all the circumstances the search of Mr Shreenan at Clydebank Police Office was a reasonable one.
35. Mr Shreenan was placed in cell number 17 at Clydebank Police Office by PC Murray at approximately 1815 hours. He was the only occupant of the cell. He was provided with water.
36. Mr Shreenan was to be checked hourly in line with normal practice and procedure.
37. Civilian Custody Officer John McRae checked on Mr Shreenan at approximately 1845 hours with a view to offering him a meal. Mr Shreenan was found with a plastic bag over his head and two socks tied around his neck. The plastic bag was the one given to him by Reliance Officer Norma Scott. The socks were his own.
38. Emergency CPR was commenced within seconds of discovering Mr Shreenan's body by Sergeant Spence and Custody Officer McRae. Emergency services were called immediately.
39. Rapid Response Paramedic Sheila Parr arrived at Clydebank Police Officer within seven minutes of receiving the call to attend there and continued CPR procedures. Ambulance crew arrived within twelve minutes of receiving the call to attend. CPR continued both within Clydebank Police Office and within the ambulance transferring Mr Shreenan to Western Infirmary, Glasgow.
40. Mr Shreenan was pronounced dead at Western Infirmary Glasgow at 1938 hours.
41. Every effort was made by custody staff at Clydebank Police Office and by emergency services to save Mr Shreenan's life.
42. A Post Mortem examination of the body of Robert Shreenan was conducted at the City Mortuary, Glasgow on 18 July 2008 by Julie McAdam, Forensic Pathologist, Department of Medicine and Science, University of Glasgow. The conclusion of said examination was that the cause of death was presumed plastic bag asphyxia.
43. The cause of death was plastic bag asphyxia.
44. Robert Shreenan took his own life by placing a plastic bag over his head and securing same by a ligature made from his socks.
Note:
This is an Inquiry into the circumstances of the death of Mr Robert Shreenan whilst in police custody at Clydebank Police Office on 14 July 2008. The purpose of this Fatal Accident Inquiry is to establish the facts surrounding the death of Mr Robert Shreenan. It is not the purpose of this Inquiry to apportion blame.
The Inquiry heard evidence and submissions over six days in total. The Crown were represented by Ms S McDermid, Mr Shreenan's mother was represented by Ms L Bain, Strathclyde Police were represented by Ms C Martin and Reliance Custodial Services were represented by Mr D Batchelor. I am extremely grateful to each of them for their sensitive but thorough examination of witnesses and exploration of relevant facts. I am also grateful to them for their careful and detailed submissions.
The Inquiry heard evidence from the following witnesses:-
· Carol Sutherland;
· PC Mark Emmett;
· Sergeant Marshall Seddon;
· Christine Balmer;
· Margaret Maider;
· Jean Gorrian;
· Gary Dewar;
· Norma Scott;
· Sheila Parr;
· Stephen Taylor;
· John McKenzie;
· PC Gavin Murray;
· PC Steven Smith;
· Sergeant Graeme Spence;
· John McRae;
· Gary Mitchell;
· Grant Adams;
· George Kidd;
· Sergeant Malcolm Cowie;
· Tracy Moorby;
· Inspector David George Croll; and
· Professor Anthony Busitill.
The Crown and agents entered into a Joint Minute of Admissions which forms production number 40.
For ease of reading and understanding I have divided this note into the following sections:-
History:-
(1) Petition warrants for the arrest of Mr Robert Shreenan were issued at Dumbarton Sheriff Court on 13 and 19 May 2008. The first warrant related to charges of attempted assault; lewd and libidinous practices and behaviour; and a contravention of section 6 of the Criminal Law Consolidation (Scotland) Act 1995. The second warrant related to a contravention of section 102A of the Criminal Procedure (Scotland) Act 1995.
(2) Mr Shreenan had a history of alcohol misuse which had affected his health, in particular causing him to shake and affecting his mobility. He required the use of a stick to assist in walking. Additionally, he had been hospitalised in around April 2008 as a result of a punctured lung. He had previously injured his wrist in a fall and had a splint on it. His partner gave evidence to the effect that he continued to drink heavily up to the date of his death.
(3) Mr Shreenan had previous criminal convictions and had spent time previously in custody.
(4) His partner described his mood on 14th July 2008 as "quiet". He had been sick during the night and into the early hours of the morning. He had given no indication that he was contemplating suicide.
(5) Mr Shreenan was arrested and taken to Greenbank Police Office, Blackburn. He was transferred from there to Clydebank Police Office by Reliance Custodial Services. The journey was divided into two parts. The initial part of the journey was from Blackburn to Airdrie Sheriff Court. The latter part was from Airdrie Sheriff Court to Clydebank Police office. It was during this latter part of the journey that Mr Shreenan was given a plastic property bag to be sick into. He hid this bag somewhere on his person. He used this bag to commit suicide whilst in custody at Clydebank Police office.
The arrest and detention of Mr Robert Shreenan and events at Blackburn Police Office:-
(6) Mr Shreenan was arrested at his home at 11 Apple Close, Blackburn at 0630 hours on 14 July 2008 in respect of the said petition warrants granted at Dumbarton Sheriff Court. His arrest was effected by PC Mark Emmett and PC Jonathan Hutton of Lancashire Constabulary. PC Emmett gave evidence to the Inquiry that Mr Shreenan had a splint on his wrist and had to use a stick to aid his walking. Mr Shreenan was fully compliant with the officers. He was not considered by them to present any risk and accordingly he was not handcuffed. He was searched before being placed in the police vehicle. He was conveyed by the officers to Greenbank Police Office, Blackburn (hereinafter referred to as "Blackburn Police Office").
(7) The arrival time at Blackburn Police Office was 0645 hours and at that time Custody Sergeant Marshall Seddon authorised Mr Shreenan's detention. Mr Shreenan was lawfully arrested and detained.
(8) Mr Shreenan was searched again at Blackburn Police Office. No plastic bag or other item was found on his person. His property was noted as consisting of cigarettes, a lighter, trainers, walking stick and a medical tag. At the charge bar Mr Shreenan was asked a number of questions including his name, date of birth and place of birth. He was also asked if he had any medical conditions. Mr Shreenan volunteered that he had suffered a punctured lung, had problems with his legs and that he was feeling unwell although did not elaborate on this. He also advised the officers that he was taking prescribed medication. Sergeant Seddon described Mr Shreenan as being difficult but co-operative.
(9) The Inquiry viewed CCTV footage taken at the charge bar when Mr Shreenan was being processed by Sergeants Marshall Seddon and David Simpson. As a result of their attitude to Mr Shreenan they were both disciplined in respect of a breach of the Code of Conduct for Police Officers paragraph 3 relating to politeness and tolerance. Sergeant Simpson received a written warning and Sergeant Seddon was fined 7 days pay. Having viewed the CCTV footage I can well understand why such disciplinary proceedings were taken.
(10) However, despite this, Sergeant Seddon did show concern for Mr Shreenan's medical condition. He placed him on fifteen minute checks and called MEDACS for assistance from a health care professional. MEDACS is an external agency used by the police in relation to the provision of health care to detained persons. Contact was made with MEDACS at 0703hours.
(11) Mr Shreenan was seen at 0830 hours by Nurse Tracy Moorby. He vomited a little in her presence. She prescribed him Buccastam to alleviate his nausea which was taken immediately. Further she prescribed Diazepam (to alleviate the symptoms of alcohol withdrawal), Dihydrocodeine and Co-codamol (to alleviate his back pain), which, in addition to being taken immediately, was to be taken again at 1500 hours and 2100 hours. At 0905 hours Mr Shreenan was observed to be sleeping and had not vomited further. Nurse Moorby considered Mr Shreenan fit to travel.
(12) At 1145 hours Mr Shreenan was handed over to Reliance officers for transfer to Clydebank Police Office. This hand over was carried out by civilian detention officer Christine Balmer. Part A of a Personal Escort Record (PER) relative to Mr Shreenan was completed by Ms Balmer. Mr Shreenan's property was also handed over for transfer. The medication prescribed by Nurse Moorby was not handed over for transfer. Detention Officer Balmer told the Inquiry that this was standard practice and that the medication would be destroyed within the Police Office. Detention Officer Balmer did not consider that there was anything untoward in Mr Shreenan's demeanour and considered him fit to travel.
(13) It is regrettable that the custody sergeants at Blackburn Police Office were, at best, discourteous to Mr Shreenan, but they nevertheless ensured that he received appropriate medical attention. There was no evidence presented to the Inquiry to suggest that Mr Shreenan had concealed a plastic bag prior to entering Blackburn Police office nor that he had a plastic bag when he left Blackburn Police office. There was no evidence presented to the Inquiry to suggest that the arrest and detention of Mr Shreenan at Blackburn had any bearing on his death.
Personal Escort Record:-
(14) A Personal Escort Record (PER) is completed in respect of every prisoner being transferred from one secure unit to another. Such a record was competed in respect of Mr Shreenan and formed production number 13. Part A of the record was completed at Blackburn Police office by civil detention officer Balmer and was handed to Reliance officers together with a copy of the record relating to the custody of Mr Shreenan at Blackburn Police Office. This custody record was completed whilst he was in custody within Blackburn Police Office. The Inquiry heard evidence that this PER has since been updated and is now more detailed in the information it contains in relation to a prisoner.
(15) Part A of the form in use as at July 2008 provided details of the prisoner including his name and date of birth. It also provided details of the escort, in this case from Greenbank (Blackburn) to Clydebank. Thereafter there were a number of "Risk Categories" set out under three sub-headings, being "Medical", "Security" and "Other". The record as in use at July 2008 listed a number of headings under each category requiring those which were relevant to the prisoner to be ticked.
(16) In relation to Mr Shreenan, under the heading "Medical" the box next to the sub-heading "Medical Condition" was ticked. No other box was ticked under this heading and in particular nothing was ticked to indicate any medication issued was with the prisoner or with the escort.
(17) In relation to Mr Shreenan under the heading "Security" the boxes next to the sub-headings "violence" and "conceals weapons" were ticked.
(18) In relation to the heading "Other", no boxes were ticked in relation to Mr Shreenan. It is noted by the Inquiry that a sub-heading of "suicide/self-harm" was detailed under this heading but this box was not ticked in relation to Mr Shreenan.
(19) The PER relating to Mr Shreenan was signed at the foot of Part A by Reliance Custody Officer Gary Dewar indicating that the prisoner and his property had been received by the escort.
(20) Part B of the PER was for completion by Reliance officers to detail every event in relation to the prisoner from the point at which he comes into their care until he leaves their care. At least two witnesses described this PER as their "bible" and should, when completed, form a complete and accurate record of the prisoner's time in the care of Reliance Custodial Services. The PER is handed over to the receiving secure unit along with the prisoner's custody record and his property.
(21) Part B of the PER relating to Mr Shreenan was completed by Reliance Officers during his journey from Blackburn Police Office to Clydebank Police Office. The various entries on the form are dealt with in greater detail further in this note.
(22) The new form of PER was produced to the court as Production 38. It came into use on 1st September 2009. The Inquiry heard from Mr Grant Adams, Head of Operations with Reliance Custodial Services that as an agency Reliance are constantly appraising procedures and the new PER reflects this.
(23) The current PER is an eight page booklet. It requires a Risk Indicator Sheet to be completed in relation to a prisoner with details of current and relevant risk factors. In the Escort Handover part of the Form there is a section dedicated to Prescribed Medication. The History and Record of Detention and Escort Events part of the form is similar to Section B of the form in use in July 2008.
Journey from Blackburn to Airdrie Sheriff Court:
(24) Mr Shreenan was collected by Reliance Officers Maider and Dewar at Blackburn Police office at 1145 hours. Part B of the PER form (production 13) discloses that he was searched and wanded at 1145 hours when taken into Reliance custody. This procedure was carried out by Custody officer Dewar. He was placed in Cell Number 1 of van number 511. On leaving Blackburn Police Office the van had a full complement of prisoners, numbering 4 in total. Custody officer Maider remained in the rear of the van whilst Custody officer Dewar drove the vehicle.
(25) The PER form indicates that Mr Shreenan was checked by Custody officer Maider every thirty minutes from 1200 hours until 1500 hours. In evidence she stated that she had in fact checked on him more frequently but had only noted the half-hourly checks on the PER.
(26) At 1430 hours Mr Shreenan vomited twice. It was noted on the PER form that he was sick at 1430 hours. Custody Officer Maider gave him a newspaper to place on the floor which she passed to him under the door of his cell. She advised Custody Officer Dewar that Mr Shreenan had been sick and also advised her control room. They told her to keep an eye on him.
(27) Van number 511 developed a slow puncture and was re-directed by Reliance Control to Airdrie Sheriff Court (the nearest secure unit) for a change of vehicles to be effected.
(28) Van number 511 arrived at Airdrie Sheriff Court at approximately 1445 hours and the prisoners on this van were transferred to van number 546. The prisoners, including Mr Shreenan, were handed over into the custody of Officers Norma Scott and John McKenzie.
(29) Mr Shreenan was not provided with a plastic bag during the journey from Blackburn Police Office to Airdrie Sheriff Court. He did not have a plastic bag when he left the custody of Officers Maider and Dewar.
(30) There was no evidence presented to the Inquiry to suggest that any of the events of the journey from Blackburn Police office to Airdrie Sheriff Court had any bearing on the death of Mr Shreenan.
Handover at Airdrie Sheriff Court:-
(31) Mr Shreenan was transferred from van 511 to van 546 at 1500 hours at Airdrie Sheriff Court. He was placed in cell number 1. Custody Officer Maider advised Custody Officer Norma Scott that Mr Shreenan had been sick on the first leg of the journey. Custody Officer Maider stated in evidence to the Inquiry that she advised Officer Scott that she had not given Mr Shreenan a bag to be sick in due to the risk involved but Officer Scott had no recollection of being told that. Officer Scott advised the Inquiry that she did not like having to deal with vomit and accepted an offer from Officer McKenzie that she should drive the vehicle initially and he would remain in the rear with the prisoners.
(32) Whilst putting Mr Shreenan onto the van, Officer Scott gave him a clear plastic property bag to use if he was going to be sick again. It is unclear from the evidence that emerged at the Inquiry whether Mr Shreenan requested the bag or whether it was offered to him by Officer Scott. Officer McKenzie advised the Inquiry that he was aware that a bag had been given to Mr Shreenan but could not recall whether Officer Scott specifically told him this or he had simply overheard it. However the Inquiry can be satisfied that both Officers were aware that Mr Shreenan had been given a plastic bag.
(33) Officer Scott advised the Inquiry that she had given Mr Shreenan the plastic bag as an act of kindness so that he did not have to be sick on the floor again. She did not record on the PER form that she had given him this plastic bag. In her evidence to the Inquiry she stated that this may have been overlooked because "there was so much else going on."
Journey from Airdrie Sheriff Court to Clydebank Police Office:-
(34) Custody Officer Scott drove van 511 from Airdrie Sheriff Court to Stewart Street Police Office, Glasgow where one prisoner was dropped off. From there she drove the van to Kilmarnock Police Office where another custody was dropped off. The Officers then swapped over and Officer McKenzie drove the van on its final leg of the journey from Kilmarnock to Clydebank Police Office.
(35) The PER form indicates that Mr Shreenan was checked on three times by Officer McKenzie between 1535 hours and 1615 hours. Officer McKenzie told the Inquiry that Mr Shreenan seemed fine during this part of the journey. They had a conversation about the route being taken by the van and Mr Shreenan accepted that he would be the last prisoner to be dropped off. At no time was Mr Shreenan given a comfort break nor was he offered food. He did not request any water from Officer McKenzie.
(36) The PER form discloses that Officer Scott checked on Mr Shreenan at 1750 hours however this is an error and the correct time should be 1650 hours. She described him as being fine and alert. He was checked on again at 1715 hours and the PER records "All OK". The van arrived at Clydebank Police Office at 1745 hours. Officer McKenzie took Mr Shreenan, his property and associated paperwork (including the PER form) into Clydebank Police Office. Neither Officer Scott nor Officer McKenzie retrieved the plastic bag from Mr Shreenan.
(37) Officer McKenzie handed Mr Shreenan into the custody of Sergeant Graeme Spence at the charge bar at Clydebank Police officer. He did not advise Sergeant Spence or any other police officer that Mr Shreenan had been given a plastic bag and that it had not been retrieved from him.
(38) Officer Scott told the Inquiry that when Mr Shreenan left the van at Clydebank Police office she noticed that the bag she had given him was not there, however she assumed that Officer McKenzie had cleared it away when they had stopped at Kilmarnock to drop off another prisoner.
(39) Officer McKenzie told the Inquiry that he had looked in Mr Shreenan's cell whilst at Kilmarnock however it would not have been appropriate to enter his cell until he had reached his personal destination, ie Clydebank. It is only after the last prisoner is dropped off that the debris in the van is cleared away.
(40) Both officers seemed to be of the view that the other had disposed of the plastic bag.
Events at Clydebank Police Office:-
(41) Mr Shreenan arrived at Clydebank Police Office at 1745 hours. Sergeant Graeme Spence was the custody sergeant on duty there at the time. Also on duty were Constable Gavin Murray and civilian custody officer John McRae.
(42) Mr Shreenan's paperwork was handed to Sergeant Spence by Reliance officer McKenzie. A Police National Computer (PNC) check had been carried out earlier by police in anticipation of Mr Shreenan's arrival. No adverse information was given to Sergeant Spence by Officer McKenzie about Mr Shreenan. Officer McKenzie did not advise Sergeant Spence, or any other officer on duty at Clydebank Police office, that Mr Shreenan had been given a plastic bag and that it had not been retrieved from him.
(43) Nothing on the PNC check nor on the PER form which accompanied Mr Shreenan raised any concern that Mr Shreenan may present as a suicide risk.
(44) Sergeant Spence asked Mr Shreenan questions about his health and why he needed a stick to aid his walking. He answered that he was fine and that his walking was affected due to alcohol abuse. Sergeant Spence ordered PC Gavin Murray to search Mr Shreenan. This was a "normal" pat down search as opposed to a strip or intimate search neither of which were deemed necessary.
(45) Mr Shreenan was subject to a pat down search by PC Gavin Murray. No item was retrieved and specifically a plastic bag was not found in the course of this search. The search was carried out in the presence of Sergeant Spence.
(46) Mr Shreenan was placed in cell number 17 by PC Gavin Murray. His shoes and hooded jacket were left outside the cell. The only furniture within the cell was a mattress and toilet. There was nothing on the floor of the cell. PC Murray arranged for Mr Shreenan to be given water which was given to him by civilian officer McRae. PC Murray noted that Mr Shreenan was shaking and, although he had no immediate concerns about his health, had intended to have a police doctor look at Mr Shreenan if he were attending any other prisoner. Sergeant Spence had also considered this appropriate.
(47) Mr Shreenan was placed in cell number 17 at approximately 1815 hours.
(48) Mr Shreenan was not deemed by Sergeant Spence to be a risk to himself or others. He was, accordingly, to be subject to hourly checks as is the normal procedure.
(49) At approximately 1845 hours civilian officer McRae went to cell 17 to ask if Mr Shreenan wished a meal. He did not enter the cell at this point. He observed that Mr Shreean was lying with a plastic bag over his head and something around his neck. Mr McRae immediately sounded the alarm situated on the left hand side of the cell door. Within seconds he was joined Sergeant Spence and at that point they entered the cell.
(50) Sergeant Spence and Officer McRae removed the bag from Mr Shreenan's head and removed the ligature (his socks) from around his neck. They then commenced CPR which continued until after the arrival of rapid response paramedic Sheila Parr and ambulance crew.
(51) Rapid response paramedic Sheila Parr received the emergency call to attend at Clydebank Police Office at approximately 1845 hours and arrived there within seven minutes. Ambulance crew were dispatched at 1852 hours and arrived at Clydebank Police office within twelve minutes. Attempts at CPR continued within Clydebank Police Office and within the ambulance conveying Mr Shreenan to Western Infirmary Glasgow. The ambulance arrived there at 1932 hours. All attempts at CPR proved unsuccessful. Life was pronounced extinct at 1938 hours.
(52) Paramedic Sheila Parr and Ambulance Technician Stephen Taylor both praised the CPR efforts being made by officers at Clydebank Police office.
(53) The Inquiry had the benefit of viewing CCTV footage from different angles of the search of Mr Shreenan at Clydebank Police Office. It was clear from the footage viewed that Mr Shreenan was treated with courtesy and respect by the officers processing him at Clydebank Police Office on 14 July 2008.
Search Of Robert Shreenan at Clydebank Police Office:-
(54) The Inquiry heard considerable evidence about the search technique used by PC Murray on Mr Shreenan at Clydebank Police office on 14 July 2008. The Inquiry also had the benefit of CCTV footage taken from two angles depicting the search. This footage was viewed by witnesses Murray, Spence and Cowie.
(55) PC Gavin Murray was on duty at Clydebank Police office charge bar when Mr Shreenan was brought in by Reliance Officer McKenzie. He carried out a search of Mr Shreenan in the presence of Sergeant Spence and under his instruction. He described giving him a "pat down" search. He removed the splint from Mr Shreenan's wrist and examined it. It was found to be blunt and was therefore replaced on the instruction of Sergeant Spence. He had Mr Shreenan remove his shoes.
(56) CCTV footage revealed that PC Murray did not pat down the inside of each of Mr Shreenan's legs nor did he search the groin area or under his arms nor did he pat down his chest area.
(57) All three witnesses who viewed the CCTV footage described the search as reasonable. This footage also confirmed that Mr Shreenan was not asked if he was secreting any items about his person.
(58) Production 26 is a manual issued by Strathclyde Police and sets out the standard operating procedures in relation to Prisoners' Custody, Care and Welfare. Paragraph 8.6 thereof sets out guidelines in relation to the search process. In terms of these guidelines, among other things, the prisoner should be asked if he is secreting any article on his person. Paragraph 8.6 (j) provides that the search should be systematic and conducted with an Ample Probe. Collars and cuffs should be checked as should waistbands of trousers and skirts. The armpits should be checked. The area around the small of the back and the groin should be searched. Both legs and the soles of the feet should be searched.
(59) Officers Murray, Spence and Cowie all stated that it was reasonable not to use and Ampel Probe in searching Mr Shreenan. An Ampel probe is used to detect objects such as syringes. Sergeant Cowie in a custody sergeant based at Ayr and was not directly involved in any way in the search of Mr Shreenan but was invited to view the CCTV footage of the search. Sergeant Cowie was previously a trainer of police. He confirmed that, from viewing the CCTV footage that PC Murray had not patted the chest area, the underarms, the groin area nor the inside legs. He stated that the search was reasonable but conceded that it was not thorough. In fairness, PC Murray conceded this too.
(60) All three witnesses told the Inquiry that officers have to use some discretion in electing which type of search to carry out and the manner in which that search is conducted. Both PC Murray and Sergeant Spence had taken into account the fact that Mr Shreenan had been searched in Blackburn and by Reliance prior to coming into custody in Clydebank although Sergeant Cowie considered that it would have been sensible and prudent to have treated Mr Shreenan as a new custody when he entered the charge bar at Clydebank.
(61) Sergeant Spence did not consider that Mr Shreenan presented a risk to himself or to others. He did not consider that a strip or intimate search of Mr Shreenan was necessary or appropriate.
(62) Both PC Murray and Sergeant Spence advised the Inquiry that had they been told that Mr Shreenan had been given a plastic bag that had not been recovered from him then they would have (a) asked him about it and (b) searched him until it was located. If necessary this would have involved a strip or intimate search.
(63) Mr Shreenan was not asked if he was secreting any article on his person. There was no evidence presented to the Inquiry to suggest that, had he been asked this question, Mr Shreenan would have volunteered that he had a plastic bag.
(64) Sergeant Cowie was shown a plastic bag of identical size to that used by Mr Shreenan and was of the view that this could be folded down to a reasonably small size and could easily have been missed on a pat down search and it could be hard to find such an item if it is secreted in, for example, the groin area.
(65) There was no evidence before the Inquiry as to where on his person Mr Shreenan had secreted the bag. The Inquiry cannot speculate on this.
(66) In all the circumstances, given the information available to Sergeant Spence and PC Murray, the search of Mr Shreenan at Clydebank Police Office on 14 July 2008 was reasonable albeit not thorough.
(67) There was no evidence to suggest that a more thorough pat down search of Mr Shreenan would have resulted in the bag being detected.
Provision of Plastic Bags to Prisoners in transit:-
(68) As at 14 July 2008 the only bags in use in Reliance vans were large, clear, non-perforated plastic bags. The primary function of these bags was the storage of prisoner's property.
(69) From on or about 15 July 2008 small paper bags, similar to those in use of airlines, have been deployed for use on Reliance vans. Such paper bags were available within Reliance Custodial services as at 14 July 2008 but were not in use.
(70) Immediately after 14 July 2008 Reliance staff were verbally briefed on the use of paper sick bags and, in particular, briefed that plastic property bags are not to be given to prisoners for use as sick bags. This now forms part of the basic training of Reliance officers.
(71) The provision of a sick bag to a prisoner is to be noted on the PER form and the serial number of the bag noted. The bag is to be retrieved from the prisoner and this has also to be noted on the PER form.
(72) As at 14 July 2008 no protocol existed within Reliance in relation to the situation where a prisoner is sick in transit.
(73) A plastic property bag may still be given to a prisoner in certain circumstances. The example given to the Inquiry was to allow the prisoner to extinguish and dispose of a cigarette.
Comfort Breaks for Prisoners in transit:-
(74) The Inquiry heard evidence that prisoners in transit are to be given comfort breaks every four hours. Bottled water is available in the cell area of Reliance vans and is made available to prisoners on request. Prisoners are told that water is available on request.
(75) Mr Shreenan was taken into the custody of Reliance Custodial Services at 1145 hours on 14 July 2008. He would have been due a comfort break at 1545 hours. Mr Shreenan was not given a comfort break during his period in transit with Reliance on 14 July 2008.
(76) Reliance Officer McKenzie told the Inquiry that he did not check when Mr Shreenan was due a comfort break.
(77) Mr Shreenan was not offered any food whilst in transit with Reliance on 14 July 2008. There was no evidence to suggest that he was offered or asked for any water whilst in transit with Reliance on 14 July 2008.
(78) There was no evidence to suggest that the non-provision of a comfort break or food or water to Mr Shreenan whilst in transit on 14 July 2008 had any bearing on his death.
Transfer of Prescribed Medication with prisoners in transit:-
(79) Mr Shreenan was prescribed medication by Nurse Tracy Moorby whilst in custody at Blackburn Police Office. This was to be re-administered to him later in the day. The prescription of this medication was not noted on the PER and the medication did not accompany him in his transfer to Clydebank Police Office.
(80) The PER form in use in July 2008 had provision for any medication issued to a prisoner to be marked on it. Reliance Custody Officer Margaret Maider told the Inquiry that if medication had been issued to Mr Shreenan she would have expected it to be noted on Part A of the PER and the medication itself to be placed in his property bag.
(81) The Inquiry heard evidence that Reliance Officers can, and do, administer prescribed medication to prisoners. This is done at an appropriate secure location.
(82) Sergeant Seddon told the Inquiry that any medication prescribed to a detained person did not accompany them in transit, but remained within the custody suite. He could offer no explanation why this was the case.
(83) Civil Detention Officer Christine Balmer told the Inquiry that if a prisoner brought in his own medication, with his name on it, it would be "tagged and bagged" and would accompany him in transit. If medication was prescribed to a prisoner whilst in custody it did not accompany the prisoner but was disposed of in the custody suite. She also told the Inquiry that, as at July 2008, there was no requirement to put details of any prescribed medication on the PER, however the updated PER is more detained and this information is now put on the form.
(84) Nurse Tracy Moorby also told the Inquiry that, as at 14 July 2008, any medication she prescribed to Mr Shreenan would have remained within Blackburn Police Office. She could offer no explanation as to why this should be the case.
(85) Inspector David Croll gave evidence to the Inquiry that the new PER form, which came into force on 1st September 2009, was, in part, designed to provide greater clarity around the issue of prescribed medication transferring with a prisoner. If medication has been properly prescribed to a prisoner, it is documented on the PER and placed in the prisoner's property. He also told the Inquiry that, as at July 2008, if medication had been properly prescribed there was no reason why it should not have accompanied a prisoner.
(86) The situation regarding the transfer of prescribed medication with a prisoner as at July 2008 appears to have been confused. No witness was able to explain to the Inquiry why prescribed medication should not have accompanied a prisoner in transit. However, the situation has not been clarified. Prescribed medication is noted on the PER and accompanies the prisoner in transit.
(87) There was no evidence placed before the Inquiry to suggest that the fact that the medication prescribed to him by Nurse Moorby did not accompany Mr Shreenan had any bearing on his death.
Conclusion:
Section 6 (1) (a):-
The Inquiry can be satisfied that Mr Shreenan died sometime after being placed in cell 17 at Clydebank Police Office. There was clear evidence that he was placed in his cell at around 1815 hours by PC Murray. He was discovered in his cell by Custody Officer McRae at around 1845 hours. The hearing heard evidence from Professor Anthony Busitill that death would have occurred very quickly. None of the parties represented at the Inquiry sought to argue that the time of death was anything other than as determined by me. Death therefore occurred sometime between 1815 hours and 1845 hours on 14 July 2008. Life was pronounced extinct at 1938 hours.
Section 6 (1) (b):-
Mr Shreenan was discovered by Custody Officer McRae at 1845 hours. He had a plastic bag over his head and a ligature, made from his socks, around his neck. There was no one else in his cell. The post-mortem concluded that the cause of death was presumed plastic bag asphyxia. This conclusion was supported by Professor Anthony Busitill who was called to give evidence to the Inquiry by Mr Shreenan's mother. Having heard all of the evidence of the circumstances surrounding the death of Mr Shreenan, I am satisfied that the cause of death was plastic bag asphyxia. At some point in the course of 14 July 2008 Mr Shreenan determined to take his own life. He secreted the plastic bag given to him about his person with a view to avoiding detection. He did so deliberately with the intention of taking his own life.
Section 6 (1) (c):-
In terms of this section, the Inquiry has to consider any reasonable precautions, if any, whereby the death might have been avoided. I am satisfied that the word "might" should properly be interpreted as meaning "possibly" rather than "probably".
Carmichael on Sudden Deaths and Fatal Accident Inquiries at page 175 para 5.75 confirms that what is envisaged by this section is not a "probability" but a real or lively possibility.
There was clear evidence before the Inquiry that Mr Shreenan was given a plastic, non-perforated bag, by Reliance Officer Scott. I am satisfied that she did so as an act of kindness. Neither she nor her colleague retrieved this bag from Mr Shreenan before he left Reliance custody. The Inquiry can be satisfied that this was the bag used by Mr Shreenan to commit suicide. The Officers each thought the other had disposed of the bag. There was clear evidence that Officer McKenzie did not advise Custody Officers at Clydebank that Mr Shreenan had been given a bag and that this had not been retrieved from him and further that, had Custody Officers been aware of this they would have searched Mr Shreenan until the bag was recovered. This could have been a strip or intimate search.
The Crown submitted that I should determine that a reasonable precaution whereby death might have been avoided was if Officer Scott had not given Mr Shreenan the bag to use if was going to be sick again. I respectfully do not agree with that submission. There were no other bags in use at that time within Reliance vehicles. Other officers from Reliance gave evidence that in all probability they would have given Mr Shreenan a bag of this nature as nothing else was immediately available for them to use. It is not the provision of the bag itself which amounts to a reasonable precaution whereby death might have been avoided but rather not retrieving the bag from Mr Shreenan. That in my view amounts to a reasonable precaution in terms of the section.
Mr Batchelor on behalf of Reliance submitted that, in addition to the reasonable precautions upon which I have determined that a further reasonable precaution is if the area around Mr Shreenan's groin, torso and armpits had been searched at Clydebank Police Office. I do not agree with that submission. It was accepted by PC Murray that the search of Mr Shreenan was not as thorough as is set out in Standard Operating Procedures Manual. The Inquiry heard evidence that these procedures are "best practice" but that discretion should still rest with the custody sergeant as to the nature of the search. I have determined that this search was a reasonable pat down search in all the circumstances. There was no information available to the Officers at Clydebank to indicate that anything other than a pat down search was required. However had they known that a bag had been given to Mr Shreenan and not retrieved then they would have searched him until it was recovered. In any event the Inquiry heard evidence that a pat down search, even if it had included the groin and other areas, would not necessarily have discovered the bag. There was no clear evidence as to where Mr Shreenan hid this bag and the Inquiry cannot speculate on where it may have been hidden. It is clear however that Mr Shreenan did not want the bag to be discovered and deliberately took steps to conceal it.
In all the circumstances I am satisfied that the reasonable precautions whereby the death might have been avoided are:-
· If officers of Reliance had ensured that that the plastic bag given to Mr Shreenan was retrieved from him;
· If officers of Reliance had informed the custody officers at Clydebank Police Office that Mr Shreenan had been given a plastic bag and this had not been retrieved from him.
Section 6 (1) (d):-
The Crown submitted that I should make a finding under this section to the effect that Reliance did not use paper sick bags as at 14 July 2008 and did not emphasis to Officers the importance of retrieving potentially dangerous items, such as a plastic bag.
Mr Batchelor on behalf of Reliance submitted that this sub-section is primarily concerned with workplace accidents although accepted that it can be given a broader application
The Inquiry heard evidence from a number of Reliance Officers, all of whom spoke to the importance of retrieving an item from a prisoner. Officers Scott and McKenzie both told the Inquiry that they were aware of the importance of this. The only bags in use as at 14 July 2008 were plastic property bags. There was a system in place for retrieval and disposal of bags given to prisoners. This was not adhered to on this occasion but, in my view, that does not amount to defect in the system of work. There may have been a defect in the application of the system on this occasion but a system was in place. I am therefore making no findings under this sub-section.
Section 6 (1) (e):-
I agree with the submission made by Mr Batchelor that in contrast with sub-sections (c) and (d) there does not require to be a causal connection with the death in terms of this sub-section. However any findings I may make under this sub-section must be relevant to the circumstance of the death as those may affect the public interest.
The Crown submitted that a relevant factor under this sub-section is the fact that, in some circumstances Reliance would still consider it appropriate to provide a plastic bag to a prisoner in their care and that I should make appropriate recommendations accordingly. I do not agree that this is appropriate. The Inquiry heard evidence that paper sick bags are now deployed on Reliance vans. No recommendation in that regard is therefore needed. I agree with Mr Batchelor that a plastic bag is only dangerous if it is used in a dangerous way. There may still be some circumstances, albeit rare, in which it is deemed appropriate to provide a plastic bag to a prisoner.
I am not satisfied that there should be any determination under this section. There is no need for any recommendation in relation to comfort stops for prisoners nor in relation to the transfer of prescribed medication with prisoners in transit which procedure has now been clarified.
Accordingly I do not find it necessary to make any recommendations as a result of this Inquiry.
In conclusion it appears that, tragically, Mr Shreenan was determined to take his own life on 14 July 2008. Every effort was made to save his life at Clydebank Police Office and by emergency services but this proved unsuccessful. The Inquiry would wish to extend its condolences to Mr Shreenan's family.