Jury finds Metropolitan Police failure to provide care contributed to death

An inquest into the death of Frank Jackson whose family was represented by Peter Walker of Saunders Law and Tom Stoate of Doughty Street Chambers was recently held at Inner West London Coroner’s Court before HM Coroner Sabina Khan and a Jury from 9-12 January 2024

Frank Jackson was only 23 when he died. He was described as “a big, beautiful character” by his family, of which he was the centre. Caring and loyal, Frank had a laugh that instantly brought a smile to everyone’s face.

At 2.32pm on Thursday 21 November 2019 the Metropolitan Police Service (MPS) received a report of a disturbance at a flat on London Road in Tooting. At 2.42pm, four police officers attended. They spoke to two of the three occupants of the flat and established that no crimes had taken place.

During the police visit, Frank Jackson was found lying supine on the bed and snoring loudly. He had wet himself, was unrousable and made no purposeful movements throughout the police attendance. The officers concluded he was simply sleeping and did not conduct any assessment of Mr Jackson, or call an ambulance, before leaving.

At 7.42pm, the London Ambulance Service (LAS) requested police help with a patient – Frank Jackson – who was in cardiac arrest. The same four officers reattended the flat on London Road. At 7.53pm, LAS staff declared that Mr Jackson had died. The cause of his death was later found to be multidrug and ethanol toxicity.

The inquest heard independent expert evidence from Prof Alan Fletcher, a Consultant in Emergency Medicine and Acute General Medicine at Sheffield Teaching Hospitals NHS Foundation Trust. Prof Fletcher told the inquest that, had basic steps been taken to safeguard his airway and an ambulance been called to convey Frank Jackson to hospital , it is extremely unlikely he would have died.

The inquest also heard from Sue Warner, the MPS Senior Advisor for First Aid, Policy, Assurance and Training, that in October 2018 (more than a year prior to these events) the MPS had introduced training that officers should be aware that snoring can indicate a problem with a person’s airway, and that anyone identified as a casualty with noisy breathing should have their airway opened and cleared.

This was formally written into training guides by April 2019 which two of the attending officers would have received (although in their evidence neither could recall having done so). Ms Warner said that officers were expected to use their common sense and experience in assessing whether to treat someone as a casualty. If a person was unresponsive, officers should conduct an ‘AVPU’ assessment of that person’s basic level of consciousness (Alert, response to Voice, Response to Pressure, Unresponsive).

After legal argument at the conclusion of the inquest, the Coroner found that Article 2 of the European Convention on Human Rights remained engaged.

The jury found that Frank Jackson’s death was contributed to by:

  •  A failure by the police officers in their first attendance to London Road to take appropriate action; and
  • A failure by the police officers to conduct an ‘AVPU’ assessment of Mr Jackson in line with their training.
  • The jury commented: “This inadequate response denied Mr Jackson appropriate medical assistance”.

Ashley Firth, Frank Jackson’s step-mother, said: “I have never so much as walked past an injured bird without stopping and dropping all of my plans whilst I go to every effort to save it. I don’t think I will ever understand why four police officers – people who are in that position of power to ‘help’ us, found our boy that day – in a concerning state and didn’t between them deem him as important as I deem a bird – and get him the help he needed. If they had done this, we wouldn’t be facing a life without that smile, without that laugh, loyalty or love. I just don’t and can’t understand.

Peter Walker, the family’s solicitor, said: The sad fact is that Frank’s death could have been prevented had the police taken the basic but necessary steps to assist him in line with their training. It is at least some measure of justice for the family that the jury was able to recognise this fact and returned a verdict to reflect what should have been clear all along to the officers present – that Frank was in need of help that day.”

The issue of MPS training and officer awareness of snoring as a risk to life has been raised previously, most notably prior to Frank Jackson’s death in a Prevention of Future Death report (‘PFD report’) of 20 October 2016 arising from the death and subsequent inquest of Susan Sian Jones. The PFD report states:

  • “Snoring is not always a reassuring sign and may indicate a partial airway obstruction. A partial airway obstruction can be life threatening;
  • In considering whether snoring is sign for concern, the fact of intoxication by alcohol or drugs or both – even if the individual is capable – is highly relevant  [emphasis added]. In addition, officers should bear in mind that members of the public sometimes lie about alcohol or drug taking, even when there seems no obvious reason to lie.
  • The only way of determining whether snoring is benign is by rousing, most particularly by waking the individual and determining whether they are able to sit up and hold a conversation.
  •  Any relevant information gleaned by officers, for example that an individual is a methadone user, should be passed on to colleagues with responsibility (and preferably recorded in some way or other).
  • The only way of determining whether snoring is benign is by rousing, most particularly by waking the individual and determining whether they are able to sit up and hold a conversation.
  • The rousing itself may have a therapeutic purpose even over and above its value as a tool of assessment. And an unresponsive individual must be treated as a medical emergency.” 

In their PFD response dated 14 November 2016, the MPS confirmed that the head of MPS first aid training instructed that the Trainers Guide for Emergency Life Support Training (‘ELS’) be revised to explicitly add the word ‘snoring’ to the risk of potential breathing warning signs to be aware of, when monitoring a person (both responsive and unresponsive). She also further requested that:

“Trainers be advised that in future Emergency Life Support (ELS) sessions, they should explicitly mention that ‘snoring’ can be a partial airway issue, that officers noticing this should do further checks, and that they should not assume snoring is normal breathing. This instruction has been implemented with immediate effect. Within a year the revised training will have reached every serving officer at their annual ELS refresher training”.

The issue was raised again in a PFD report dated 26 February 2021 arising out of the death of Joseph Agnew. The PFD report states:

"My independent expert in A&E gave evidence that snoring indicates partial airway obstruction. He dismissed perceptions of officers that there was such a thing as good or bad snoring. He opined that in a person with reduced consciousness officers should assume that snoring needs medical attention. The person needs assessment to exclude when it is not a concern. Whilst he acknowledged the difficulty of assessing breathing, he stressed its importance as an indication of medical emergency, gave little weight to the value of chest movements which officers used, and highlighted the danger signs of very slow or very fast breathing. He also stressed that concern for medical attention should be triggered by unrousability."



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