The inquest into the death of Matthew Terrill found issues around training, documentation, and communication with South Yorkshire Police.
Sarah Finney of Watson Woodhouse Solicitors has been instructed to support the family of Matthew Terrill who died at Shepcote Custody Suite, Sheffield on 22 April 2020. Counsel, Ciara Bartlam of Garden Court North was instructed to represent the family at the inquest which commenced on 19 February 2024. The three weeklong inquest took place in South Yorkshire (West) Coroner’s Court before a jury.
On 22 April 2020, Matthew was approached by South Yorkshire Police Officers on suspicion of being in breach of Covid 19 lockdown restrictions. Matthew was agitated having been stopped by the Police and in a strange turn of events, was knocked to the ground by a civilian male. Police Officers had initially called an ambulance, however, they proceeded to cancel the ambulance whilst Matthew was lying unresponsive on the floor. Police Officers simply referred to Matthew as being asleep as they believed he was snoring. Matthew was roused and helped into the back of the Police van and taken to Shepcote Police Station.
It is believed that Matthew was suffering from an Acute Behavioural Disorder as he was displaying signs of severe agitation and distress resulting in him banging his head against a wall on several occasions. In response to Matthew’s behaviour, Officers restrained him by handcuffing him to the rear, applying double leg restraints and placing him on a mat on his cell floor. There is a dispute as to whether Matthew was left in the prone or semi-prone position. The two arresting Officers were instructed to carry out Level 4 (close proximity) Observations whilst Matthew was in his cell. Despite being on the highest level of observation, it appears that they did not make any attempts to rouse Matthew despite the Level 4 (close proximity) Observation Sheet instructing that this should be done. Matthew was left for a period of around 1 hour and 12 minutes before being found unresponsive. The Officers say that during this time, Matthew had been snoring and they believed him to be asleep. Matthew did not receive any medical intervention whilst he was in Shepcote Police custody until it was believed he had stopped breathing. Matthew was later pronounced dead by Paramedics who were called to the scene.
Conclusion
At the conclusion of the inquest, assistant coroner Alexandra Pountney found that Matthew Terrill’s death had been a result of a cardiorespiratory arrest, hypoxic brain injury and ingestion of drugs. The jury was highly critical of the circumstances surrounding Matthew’s death and found “fundamental failures” around training, documentation, and communication stating there had been a “missed opportunity” to medically assess Matthew on arrival because of “a lack of integration of health care professionals with police staff”.
The assistant coroner said a prevention of future deaths report will be sent to South Yorkshire Police and the College of Policing reflecting the concerns the jury highlighted.
Matthew’s family commented on the conclusion, “Matthew has left behind a much-loved daughter, his mum and dad, 3 siblings and his granddaughters who he will sadly never meet. Nearly 4 years after Matthew’s death, we have finally received the jury’s conclusion and as a family, we are exceptionally grateful to them. They have highlighted serious concerns that we as a family have been saying for years. We cannot understand why police officers called and then cancelled an ambulance, even though they can be seen on camera discussing whether parts of Matthew’s body were blue. We were horrified that Matthew was left lying in a cell on his front for 1 hour and 12 minutes without anyone trying to speak to him.
The jury have concluded that there were ‘fundamental failures in areas of training, documentation and communication’, ‘inadequate’ training to Police Constables and in particular inadequate training on the risks of leaving someone who is intoxicated lying on their front.
The jury also confirmed that the ‘key requirements’ of constant observations were not prioritised.
The level of communication between all custody staff and healthcare professionals in the custody suite were described by the jury as ‘poor, ineffective, and disorganised’. As a family we fundamentally agree with this finding.
We agree, with the jury’s finding of fact, that there was a missed opportunity to medically assess Matthew especially during Constant Observations at which detainees are at their highest risk.
The Police Officers and Police Force have tried with all of their strength to reduce the jury’s conclusion and today the jury have fought back. It has been a rollercoaster three weeks, however, we 100% agree with the fundamental failings that the jury have highlighted. It has restored our faith in the justice system and in particular the jury.
We feel very strongly, this could have all been avoided if the ambulance had not been cancelled and Matthew would have been taken to A&E. The outcome for Matthew could have been very different.
We welcome the Coroner’s decision to issue a prevention of future death’s report as we still have concerns particularly around the training of the officers and fear that this could so easily happen again. We, as a family, hope that this brings about meaningful change and that another family do not have to go through what we have.
We wish to say thank you to the Court staff and Sarah Finney and Watson Woodhouse Solicitors for their support.
In particular, I would like to thank Ciara Bartlam of Garden Court North Chambers for representing our family and giving Matthew a voice.”
Inquest updates
19.02.2024 – Day one
11 members of the jury were sworn in. The inquest was shown CCTV footage that showed Police Officers had initially called an ambulance however, they proceeded to cancel the ambulance despite him lying unresponsive on the floor and suspecting that he was under the influence of drugs.
The inquest then heard there was a period of around half an hour when Matthew’s brain had been deprived of sufficient oxygen prior to death and possibly during CPR.
20.02.2024 – Day Two
The inquest heard from pathologist Dr Robinson who identified possible and probably contributory factors to Matthew’s death. Dr Robinson concluded that there are several factors that could have caused Matthew’s death, including police restraint.
Statements made to the investigatory body, the Independent Office for Police Conduct (IOPC) by some of the officers involved were read into evidence.
21.02.2024 – Day Three
The inquest heard from three witnesses today, Inspector Hogg, PCSO Needham and PC Ward.
Inspector Hogg stated the policies and procedures at the time. This included explaining the role of custody sergeants and detention officers. Hogg shared that the custody sergeant is responsible for establishing whether the detained person needs any healthcare before they go to their cell. Once in the cell, if the detained person is under the influence they will be woken up and engaged with every 30 minutes.
PCSO Needham discussed her interactions with Matthew, stating that she thought that he had fallen asleep due to loud snoring after being ‘rugby tackled’ to the ground by a friend. She explained that she was involved in the discussion to cancel an ambulance, but it was not her who made the final decision.
PC Ward also spoke about his interaction with Matthew, particularly walking him to the police van, he commented that Matthew was sleepy but jovial at the time.
22.02.2024 – Day Four
On day four, the jury heard evidence from PC Sian Ahmed who had been with Matthew whilst he was on Verdon Street up to his death in Shepcote Police Custody. PC Ahmed told the jury that she did not know of Matthew before approaching him on 22 April 2020. In evidence, PC Ahmed radioed the control room to request an ambulance after a civilian male made comments that Matthew’s lips had turned blue. PC Birch informed PC Ahmed that Matthew’s lips weren’t blue however, the ambulance was not initially cancelled as PC Ahmed believed she would have been leaving Matthew in the community and wanted to have him checked out.
HMAC Alexandra Pountney asked PC Ahmed if at any point Matthew was aggressive towards her to which she responded ‘no’ and explained that Matthew wouldn’t engage with the police.
A decision was made, and PC Ahmed proceeded to cancel the ambulance whilst Matthew remained on the floor unresponsive however, PC Ahmed felt this was not anything “other than him being asleep”.
Following the ambulance being cancelled, there is a discussion among police officers present about whether Matthew’s hand/arm was blue. PC Ahmed was informed it could have been due to the way he had been lying on it whilst on the floor.
After being roused, Matthew appears to gain some level of consciousness however, PC Ahmed admitted that Matthew had difficulty walking and understood this to be as a result of his intoxication and due to a bad hip or ankle.
Matthew was transported to Shepcote Custody Suite where he appears visibly agitated but not aggressive and proceeds to hit his head against a wall. Matthew was placed in handcuffs and leg restraints were applied. A suggestion was made to PC Ahmed that Matthew was placed in the prone position however, it was her view that Matthew had been placed in the semi-prone position whilst restrained in his cell.
The jury was told that the Custody Sergeant PS Furniss stated that “there’s going to have to be two of you on him” to which PC Ahmed and PC Birch found themselves responsible for monitoring Matthew whilst in his cell. PC Ahmed informed the jury that she thought her job was to check that Matthew was not self-harming but stated that she only ‘skimmed’ a form which gave instructions on how to carry out close proximity observations. A requirement of close proximity observations was to rouse Matthew every 30 minutes however, PC Ahmed did not believe this was necessary as she could see Matthew’s chest moving and he was snoring loudly.
The jury asked PC Ahmed whether Matthew’s mouth and nose were obstructed. PC Ahmed explained that Matthew’s mouth and face were facing away from the cell door.
The Court timetable has overrun as PC Ahmed’s evidence took 1 day. The jury will hear from PC Birch on Monday.
That concludes the end of week 1 of this inquest.
26.02.2024 – Day Five
The inquest heard evidence from both PC Birch and PC Fysh. PC Birch first approached Matthew alongside PC Ahmed on Verdon Street, Sheffield. Whilst PC Birch was not the officer who called the ambulance, she was involved in the discussion to cancel an ambulance.
PC Birch was the arresting officer, however, she was unable to say with any accuracy at what point she placed Matthew under arrest whilst he was on Verdon Street. PC Birch told the jury that she suspected Matthew was under the influence of drugs and commented that Matthew had been waking up and falling back asleep. During questioning, PC Birch was asked how she would establish if someone was asleep or unconscious to which she drew the distinction that an unconscious person cannot be woken (cannot be roused).
On arrival at Shepcote Custody Suite, PC Birch accepted that she did not inform the Custody Sergeant, PS Furniss that an ambulance had been called due to concerns Matthew’s lips were blue or that the ambulance had been cancelled.
Later at the Police Station, PC Birch accepted the task (along with PC Ahmed) to carry out observations on Matthew. PC Birch referred to this task as ‘sitting duties’ however, the task is more accurately described as ‘level 4, close proximity observations’. Unlike PC Ahmed, PC Birch was not given a copy of the level 4, close proximity observations form which included detailed instructions on how to carry out such observations. Nevertheless, PC Birch stated that she did understand what the requirements were, save for the requirement to rouse the detainee as she did not think arousals were ‘necessary’. PC Birch was reminded of the evidence she gave earlier regarding how she would distinguish between someone asleep or unconscious. Whilst PC Birch answered that an unconscious person cannot be woken, she accepted that she did not attempt to rouse Matthew as she had not been specifically asked to do this. PC Birch believed that the intention of the level 4 close proximity observation was only to ensure Matthew was not self-harming in his cell.
PC Fysh believed Matthew was intoxicated as he hadn’t been steady on his feet and he was ‘a little bit sweaty’. This is particularly relevant in understanding whether Matthew was suffering from Acute Behavioural Disorder; a disorder that carries a known risk of sudden death as a result of positional asphyxia, especially where restraint is applied.
An expert in Accident and Emergency Medicine will be giving evidence to the jury on Friday 1st March 2024.
27.02.2024 – Day Six
Today, the jury heard evidence from PC Yeardley, Nurse Gough, and Nurse Wilson (Nee Leyland).
PC Yardley confirmed he had been called to attend the scene as the driver of a police van to assist in the transportation of Matthew from Verdon Street to Shepcote Custody Suite. HMA Coroner asked PC Yeardley when he would consider getting an intoxicated detainee urgent medical attention. PC Yeardley stated that he would seek urgent medical attention for a detainee intoxicated if they were incapable of speech or walking.
It was Nurse Gough’s evidence that when he found out Matthew had taken cocaine and heroin, he informed an unidentified Detention Officer that Matthew should be taken to hospital. He explained that when Matthew was in the cell, he was unable to assess him due to him being restrained but maintained that when he did go into the cell, he checked Matthew was breathing. Nurse Gough stated he would be worried about someone’s presentation if they were unable to hold a conversation and would want to find out the reason why. Nurse Gough was shown CCTV footage from Matthew’s cell and corridor in which the Court room could hear an individual saying “I can’t watch this it is going to be a catastrophe” though, Nurse Gough denied this was him. However, it is worth noting that in PC Ahmed’s statement, she confirmed that one of the nurses stated that they couldn’t watch.
Nurse Wilson (nee Leyland) was unable to recall Nurse Gough’s conversation with the Detention Officer about Matthew needing urgent care at a hospital due to taking heroin and cocaine however, she agreed that this didn’t mean he did not say this. Whilst Nurse Wilson stated that, in her opinion, Matthew didn’t need urgent medical attention, when questioned by the Coroner, she agreed she was unable to assess Matthew to determine this.
28.02.2024 – Day Seven:
On day seven, the inquest heard evidence from PS Furniss, a Custody Sergeant at Shepcote Custody Suite responsible for booking Matthew into custody on 22 April 2020.
PS Furniss informed the jury that he would expect Officers carrying out Level 4 (close proximity) observations to rouse a detainee every 30 minutes. According to the Code of Practice, PS Furniss stated that to rouse, good practice would involve attempting to wake a sleeping detainee, asking them their name and where they are. This process is intended to assist the Officer in carrying out Level 4 (close proximity) observations to assess the detainee and make an informed decision as to whether the detainee is okay.
It is understood that PS Furniss provided the Detention Officer with a Level 4 (close proximity) observation form and that the Detention Officer gave the form to PC Ahmed. We heard earlier in the inquest that PC Ahmed accepted instructions to carry out close proximity observations alongside PC Birch. In this case, PS Furniss accepted that he did not give any verbal instruction to either the Detention Officer or the Police Constables as to how the constant observations should be carried out. Similarly, PS Furniss accepted he did not give any instructions to the Detention Officer or the Police Constables to advise them when Matthew had calmed down that he could be medically assessed by the Healthcare Professionals.
When giving evidence, PS Furniss stated that he accepted he should have rung the Healthcare Professionals call centre earlier (this was the process for requesting medical assessments by the Healthcare Professionals whilst in Shepcote Custody Suite). He stated the reason this did not take place at an earlier stage was because he had not been informed by PC Ahmed, or PC Birch that Matthew had calmed down and that he had other professional duties to attend to.
HMA Coroner asked PS Furniss whether the guidance provided that a detainee could be at risk of positional asphyxia related only to an individual in the prone position who was restrained. PS Furniss replied that the guidance would apply to ‘anyone who’s been restrained’.
Overall, it was the evidence of PS Furniss that he expected the Police Constables to carry out Level 4 (close proximity) observations. Furthermore, it was the evidence of PS Furniss that he expected the Police Constables, having read the guidance, to rouse and move a detainee to prevent obstruction of an airway.
PS Furniss was asked to comment on the word ‘spaz’ written on the top of a form placed on the custody desk. He concluded that this was disrespectful.
01.03.2024 – Day Eight:
On day eight of the inquest, we heard evidence from Mr David Kirby, a consultant in Emergency Medicine with dual accreditation in Paediatric Emergency Medicine.
Mr Kirby was instructed by HM Assistant Coroner for South Yorkshire (West), Ms Alexandra Pountney, to prepare a report regarding the death of Matthew Terrill on the 22nd of April 2020. He was asked to comment upon survivability, and whether earlier medical intervention would on the balance of probabilities have improved Matthew’s chances of survival. Furthermore, Mr Kirby was asked whether Matthew would have survived had he been conveyed to hospital by ambulance before midday or at any point following his arrival at the custody suite before he stopped breathing. Specifically, he was asked whether an action or inaction has more than minimally, negligibly, or trivially contributed to a worse outcome for Matthew.
Mr Kirby gave clinical evidence and his expert opinion in which he concluded that had Matthew been brought to an Emergency Department, on the balance of probabilities his chances of survival would have been increased and it is likely that he would not have died.
In the media
BBC News: Sheffield custody death: Man had a heart attack after a cocktail of drugs, inquest told
https://www.bbc.co.uk/news/uk-england-south-yorkshire-68512022