Inquest jury finds Metropolitan Police failure to provide care contributed to death

A four-day inquest into the death of 23-year-old Frank Jackson has now concluded at Inner West London Coroner’s Court, with a jury finding of contributory failure to provide care by the Metropolitan Police. 

Frank 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. 

The facts of the case were as follows: 

At 2.32pm on Thursday 21 November 2019 the Metropolitan Police Service received a report of a disturbance at a flat 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, London Ambulance Service 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 a Consultant in Emergency Medicine and Acute General Medicine that, had basic steps been taken to safeguard Frank Jackson’s airway and an ambulance been called to convey him to hospital, it is extremely unlikely he would have died. 

The inquest also heard from 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”. 

Tom Stoate of Doughty Street Chambers Inquests and Public Inquiries Team, instructed by Peter Walker of Saunders Law, represented the family of Frank Jackson.  

Further information about the issues raised can be found on the INQUEST website.