Critical conclusion at inquest of Leroy Junior Medford

After two weeks of evidence, the inquest into the death of Junior Medford, who died whilst in the care of Thames Valley police officers at London Valley Police Station on 2 April 2017, concluded yesterday afternoon (27 June 2019) with the jury returning a highly critical narrative conclusion identifying individual and systemic failures.

The jury concluded that Junior's death was contributed to by "a clear lack of awareness" of and failure to implement, the Thames Valley Police Drugs Standard Operating Procedure on the part of all officers who dealt with Junior on the evening of his death. The failure by police officers to adequately carry out constant observations, providing an opportunity for Junior to ingest drugs suspected to be in his possession, was described as the main contributory factor leading to Junior's death. 

A misinformed decision on the part of the custody sergeant in discounting the possibility Junior had swallowed drugs, meant that appropriate medical care was not provided. The jury heard unchallenged, evidence from experts in emergency treatment and toxicology that timely medical treatment would have made it "very, very likely" that Junior would have survived.

In the light of the jury's conclusions and her own concerns H M Senior Coroner Heidi Connor confirmed she would be using her powers under Regulation 28 to issue a Prevention of Future Deaths Report by writing to the Chief Constable of Thames Valley Police, College of Policing and the National Police Chiefs' Council with respect to the systemic issues raised by the case, specifically with regard to how training is disseminated, nationally, across police forces. In her ruling she stated that, "the current system is not effective or safe" and "a national review and a debate on how training is given to police officers" was now required. Given the seriousness in scope of the matters she would be raising, HMSC Connor indicated she would allow a month's extension on the statutory 56 days for a response.

• On 1 April 2019 Junior Medford, a father of eight , was arrested and transported to London Valley Police Station (LVPS);
• At the time of his arrest (1:45pm), police officers were told by a member of the public that he had "plugged" drugs (in his back passage);
• On arrival at LVPS (2:30pm) Junior was subject to a strip search: the two PCs involved identified an item in his anal region which was suspected to contain controlled drugs;
• CT scans did not disclose an item hidden within his rectum and he was discharged back into police custody;
• Upon arrival back at LVPS, the custody sergeant, aware of the limitations of the CT scans, directed a further strip search at 7:20pm;
• Two further PCs conducted this search and both confirmed that an item was still present, variously stating, "there's definitely something there"... "it's very large";
• Junior was placed in a dry cell (no toilet/running water) at 7:34pm by the two PCs, who were tasked to keep him under constant observation;
• At 7:36pm neither officers were watching Junior as he retrieved the package from his bottom area and swallowed the item;
• Some 10 minutes later Junior claimed to officers and a Health Care Professional (HCP) that "the package in his anus had fallen out" and he requested a further strip search;
• At 7:58pm the custody sergeant was captured outside Junior's cell, mimicking to police officers, the removal of an item from the bottom area and placing it in the mouth (Whilst the family accept that it is unlikely that the sergeant saw Junior do this, they consider it was the strongest conceivable evidence of the failure of the officers to recognise at the very least the possibility that Junior had done this);
• The final strip search at 8:02pm confirmed (inevitably) the package had disappeared. On CCTV the PCs expressed their extreme surprise to the custody sergeant, describing what had happened as "one hell of a f***ing magic trick";
• Erroneously concluding that the only conceivable explanation for the disappearance of the package (having searched the cell) was that Junior had somehow "sucked up" the item into his back passage, the custody sergeant directed that constant watch should continue until Junior used the drugs toilet;
• Junior used the drugs toilet at 8:10pm passing "a large stool": no package was identified;
• At 8:41pm CCTV shows a Chief Inspector unable to rouse Junior;
• At 8:59pm CCTV also shows one of the PCs unable to rouse Junior;
• At 9:07pm CCTV shows the HCP struggling to rouse Junior before doing so to move him to a normal cell as, by then, the custody sergeant had mistakenly taken Junior off the Drugs SOP;
• At 10:02pm Junior attended his solicitor for a police interview;
• His solicitor gave evidence that Junior simply could not keep his eyes open or his head up from the interview table; he was unable even to hold let alone drink a cup of coffee provided to him such was his level of drowsiness;
• Notwithstanding this presentation, at around 10:15pm the HCP took the view that Junior was "alert and orientated" and decided that he could be safely placed on an 8 hour rest period, with 30 minute observations, without a need for him to be roused;
• Junior was observed over the next 5 hours to be sleeping in virtually the same position with the majority of the observations conducted through the spy hole rather than the cell hatch;
• CPR was commenced; ambulance paramedics attended at 4:10am, finding Junior in a collapsed state with a compromised airway and in cardiac arrest;
• Resuscitation efforts continued and he was transferred back to Royal Berkshire Hospital where he was pronounced dead at 5:13am;
• During the course of their evidence police officers sought to downplay the significance of the item they had seen, relying on claims that the item may have been merely a small piece of tissue paper. However, as is captured by CCTV and audio, these officers expressed with clarity to the custody sergeant that they believed an item, suspected by all to contain drugs, was indeed present.  

The custody sergeant purported to implement the Thames Valley Police Standard Operation Procedure ('Drugs SOP') relating to detention and care of detainees suspected of swallowing or concealing drugs until around 9pm.

This Drug SOP had been brought to the attention of all police officers in July 2016, with specific training apparently notified to sergeants, alerting all to the increasing frequency and significant dangers presented by individuals hiding drugs whilst in custody.

A key aspect of this training is that the individual in question is to be placed on a cell watch involving constant observation by two police officers. In light of the two strip searches this is what the custody sergeant directed should happen. However the sergeant, together with all of the relevant police witnesses who gave evidence to the inquest, were ignorant of the absolutely critical provision that at least one of the officers were required to be sat within the cell at all times to ensure that the detainee did not have an opportunity to access and then swallow the item suspected to be in their possession.

Within 2 minutes of Junior being placed in the dry cell there was a catastrophic failure on the part of the officers to maintain the required constant observations with one officer familiarising himself with the drugs toilet set up in a separate cell whilst the second officer, rather than being sat in the cell and in close proximity of Junior, was seen on CCTV in the corridor and at various points using his police radio and fiddling with a document whilst in the corridor clearly not watching Junior.  

The custody sergeant, the two police officers, and the HCP (who had been aware of the 'positive' strip searches followed by the 'negative' one) all failed to consider what the family believe to have been the blindingly obvious and only reasonable explanation for the suspected drugs package to have disappeared: that Junior had swallowed it.

Had this possibility been given any consideration then the CCTV footage available to the officers for review would have confirmed this was precisely what had happened. The family consider this a calamitous failure to apply basic common sense to the facts of the situation. This was all the more surprising given that the custody sergeant was captured outside Junior's cell mimicking the removal of an item from the bottom area and placing it in the mouth in the minutes after Junior had done precisely that.

Had it been suspected that Junior had swallowed a package of drugs, as APP Guidance dictates, he should have been immediately treated as a medical emergency. The unchallenged expert evidence of Professor Forrest, expert in toxicology, and Dr Fletcher, a leading specialist in Accident and Emergency, was that had Junior been taken to hospital at any point until he was no longer seen to be moving then he would have been observed and successfully treated.

The significance of the jury's clear and unambiguous findings are that this was a tragic and avoidable death. Whilst the family recognises that Junior himself swallowed the package containing heroin, he was on any view a vulnerable man with a known history of drug abuse and as such Thames Valley Police had a clear responsibility to care for and protect him from himself whilst he was in their custody.

The family, devastated by the loss of a much loved brother and father, consider that the jury's conclusion reflects a truly distressing picture of individual and systemic failings combining to contribute to an unnecessary and avoidable death.

Marilyn Medford-Hawkins, sister of Junior Medford said:

"Our brother has gone forever and as his family we all have to try to come to terms with that. With the jury's clear conclusions identifying the way in which the flawed system in place at the time and the failure of officers to do their job contributed to Junior's death, together with the robust comments of the coroner regarding the need for change at a national level in how officers are trained, we can only hope and pray that lessons really will be learned. We will be watching like hawks to see what responses the police service makes to the coroner's concerns but until we see those responses and the necessary changes, we will remain, sadly, sceptical. After all, having apparently accepted that it was failures by police officers which gave Junior an opportunity to swallow the drugs, the Chief Constable, through his barrister, refused to accept that this caused or contributed to our brother's death. With such an attitude expressed in the face of clear scientific evidence, we will have to remain vigilant.  We would like to thank our legal team: Sean Horstead and Rachel Harger, who have provided us amazing support, advice and representation for the last two years." 

Rachel Harger, of Bindmans LLP said:

 It has taken the inquest process and over two years before there has been any proper recognition of the individual and systemic failures which caused Junior's death. The scale of the systemic failures and evidential inconsistencies between witness accounts and CCTV footage would have been identified at a much earlier stage by the IOPC had they taken the same approach as the family in scrutinising the CCTV and evidence available to them. 

Sean Horstead is a member of the Garden Court Chambers Inquests Team.