FAI DETERMINATION SUMMARIES

While the missed opportunities were not the cause of death or indeed materially contributed to it, it is the opinion of Sheriff Principal Derek Pyle that they might have prevented Mr Fenty from dying at Kittybrewster Police station in June 2014.

The Sheriff Principal has concluded that no one individual can be held responsible. Indeed, all those involved, whether medical practitioners or police officers, were doing their best in what proved to be quite exceptional circumstances. He makes no recommendations in this case as the current culture for the care of police custodies is fundamentally different from that of 10 years ago.

NHS Grampian Health Board and Police Scotland rightly accepted that changes in systems and processes were required as a result of Mr Fenty’s death, which they have now introduced.

Background

In the early hours of 28 June 2014, Mr Fenty was found lying unconscious, having taken an apparent overdose. He was taken by ambulance to Aberdeen Royal Infirmary. In the hospital high dependency unit, Mr Fenty received treatment for a methadone overdose by the infusion of the drug, Naloxone. The infusion was interrupted by the intravenous access being lost by the displacement of the cannula in Mr Fenty’s arm and his refusal to allow it to be reinstalled. The infusion ceased at 12.44 hours

Mr Fenty intimated his intention to discharge himself from the hospital. After a psychiatric assessment was carried out, the Accident and Emergency consultant, released him from hospital at 15.20.

While in hospital Mr Fenty was observed by police constables who had been instructed immediately to detain him upon his discharge. He was transported to Kittybrewster custody centre.

The custody officer was told that Mr Fenty had seemingly overdosed on methadone the previous night and had been treated in hospital. He was not told that Mr Fenty had been treated in the hospital high dependency unit and with Naloxone.

Mr Fenty was assessed as a high-risk custody due to recent self-harm marks on his wrists. He was taken to his cell, and was provided with anti-suicidal clothing. He was placed on a 30-minute observation regime.

At the request of a police officer, the forensic medical examiner examined Mr Fenty at 20.55 to assess whether he was fit enough to be interviewed in relation to suspected offences, because the police officer had witnessed Mr Fenty being sick. The police officer did not advise the doctor of the circumstances which had led to Mr Fenty’s detention. He deemed Mr Fenty to be fit for interview.

During the course of the night, Mr Fenty was subject to cell visits. Neither of the officers who carried out the visits was aware that he had had a methadone overdose, been in hospital, been sick earlier and had been seen by the doctor.

The relevant Police Scotland standard operating procedure required that at each visit the custody should be roused and spoken to and be required to give a distinct verbal response (“DVR”). A PC carried out seven visits to Mr Fenty’s cell between 22.43 and 04.52. Only his first two visits were DVR compliant. A PCSO carried out seven such visits between 00.40 and 06.40. Only the first visit was DVR compliant.

The last visit to Mr Fenty’s cell was by another PCSO at 07.07 on 29 June 2014. She found Mr Fenty to be unresponsive. She immediately called for assistance. An ambulance was called. Paramedics arrived at 07.19, at which point police officers were trying to resuscitate Mr Fenty. He was pronounced dead at 07.25.

The cause of Mr Fenty’s death was methadone intoxication.

Delays in the FAI

Sheriff Principal Derek Pyle acknowledged the investigation into Mr Fenty’s death has taken far too long. The actings of the Crown Office and Procurator Fiscal Service and the failure of the presiding sheriff to make the determination all contributed to that delay.

Everyone is affected by such unacceptable delays not least the family of Mr Fenty and especially his mother. The Sheriff Principal, met with Mrs Fenty when he took over the determination and it was obvious that the delay had added considerable burden to the grief caused by the loss of her son.

Findings

As a result of the Fatal Accident Inquiry, Sheriff Principal Derek Pyle made the following findings:

• Mr Fenty died on 29 June 2014 at 07.25 hours at Kittybrewster Police Station, Aberdeen. The cause of death was methadone intoxication.
  
  
• The Police Scotland standard operating procedure for care of custodies should have had a procedure for the obtaining by police officers from hospital clinicians information on the nature of the medical condition, the treatment and any further precautions which should be taken post discharge where a person has been admitted into hospital prior to arrest into police custody;
  
  
• The forensic medical examiner should have carried out a more thorough medical examination of Mr Fenty, which created a missed opportunity which if taken might have resulted in his re-admission into hospital and which would be likely to have avoided his death;
  
  
• The custody officers should have conducted cell checks of Mr Fenty in accordance with the then standard operating procedure, which created a missed opportunity which might have resulted in them seeking the advice of the forensic medical examiner, which might in turn have resulted in Mr Fenty’s re-admission into hospital, which might have avoided his death.
  
  
• Police Scotland should have had a system in place to ensure that the Kittybrewster custody centre opened with sufficient staff to cover all eventualities, including unexpected problems with new equipment, thereby allowing custody staff to perform their duties properly, including the passing on of information at shift changes and the recording of relevant information on the Cellfile computerised system.