Robert Evans
4 Mar 2025 · Coroner David Lewis · Liverpool and Wirral
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. swallowed drug package causing respiratory compromise
“The Deceased was observed by officers conducting what they suspected to be a drug deal. Within minutes, he was detained in the street for the purposes of a search under S.23 of the Misuse of Drugs Act 1971. At this time, he was seen/suspected by officers to have swallowed something, which they believed might be drugs. He denied it. Nothing was found on an external search other than Methadone, which had been prescribed to his partner. He could have been arrested for this, but was not.”
2. drug package in colon causing potential fatal obstruction
“Post mortem examination found a package containing drugs in the Deceased's colon, but it could not be established whether this had been swallowed (at the time of the detention or otherwise) or inserted per rectum at some time.”
3. lack of mandatory medical response for non-arrested detainees
“The court heard that College of Policing Guidance for Custody Officers and Detention Officers provides that "...If officers know or suspect that a detainee has swallowed or packed drugs...they must treat the person as being in need of urgent medical attention and transfer then straight to hospital"”
4. inadequate post-detention monitoring leading to missed deterioration
“Officers told the court that if somebody declines an offer of medical attention they simply monitor their condition, for signs of any change or deterioration. However, even if that is effective and adequate, any monitoring inevitably ends when the individual is released from detention. In this case that was little more than an hour after the suspected swallowing event.”
5. privacy concerns preventing family warning
“One officer said that nothing could be said to the family (about the need to keep him under close watch, because of the risk), because that would breach the individual's right to privacy.”
Linked reports
Closely relatedConfidence 0.85 · high
Earlier report
“The evidence before me showed that police officers were trained to deal | with suspects who had swallowed drugs. The evidence however | disclosed a complete lack of knowledge of the risks of choking when suspects were either arrested or in the process of being detained”
This report
“The court heard that College of Policing Guidance for Custody Officers and Detention Officers provides that "...If officers know or suspect that a detainee has swallowed or packed drugs...they must treat the person as being in need of urgent medical attention and transfer then straight to hospital"”