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Train officers or risk more choking deaths, says coroner

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Several officers have faced IOPC investigations after suspects swallowed drugs and died.

Train officers or risk more choking deaths, says coroner


Date - 5th November 2018
By - JJ Hutber- Police Oracle
3 Comments3 Comments}


More people will choke to death during or after police incidents if the service does not “urgently” clarify what officers are expected to do when a suspect swallows drugs, a coroner has said.

In May 2016, 48-year-old Karl Brunner died in Bedford town centre after swallowing a package of Class A drugs which became lodged in his throat.

The four officers involved did not realise he was choking and were initially subject to an Independent Police Complaints Commission investigation.

But an inquest jury ruled in January Mr Brunner’s death was accidental and found no one, not the paramedics called to the scene or clinicians at Bedford Hospital, saw the package lodged in his throat.

During the inquest, counsel for Mr Brunner’s family, Tom Stokes, presented College of Policing endorsed advice emphasising that attempts to prevent an individual swallowing an object by “any means” will increase the choking hazard.

But none of the senior police officers or instructors who gave evidence had ever seen the document before.

Assistant Coroner for Bedfordshire and Luton Martin Oldham wrote in a Regulation 28 Report to Prevent Future Deaths he had been shocked when the officers who tried to arrest Mr Brunner said in their evidence mouth shields are universally considered “useless”.

The officers gave Mr Brunner chest compressions but did not give breaths as they didn’t believe the equipment would protect them. Mr Brunner had also vomited, was a known drug user and was known to have recently been discharged from hospital.

“Police officers are provided with mouth and face guards which are so defective and inappropriate when dealing with high risk suspects who may have significant health issues that they are neither carried nor used in appropriate cases,” Mr Oldham wrote in his report.

“This should be urgently addressed”.

He added although officers are trained to deal with suspects who swallow drugs “the evidence disclosed a complete lack of knowledge of the risks of choking when suspects were either arrested or in the process of being detained".

“This should be urgently addressed in the officers’ training and the appropriate medical procedures should be adopted.”

Last week the Independent Office for Police Conduct found police use of force against Edir Frederico Da Costa, who died one week after trying to swallow bags of heroin and crack cocaine while being restrained, was proportionate.

Senior Coroner Mary Hassell told the Metropolitan Police to improve their choking awareness training in a Regulation 28 Report released this summer into the death of 22-year-old Rashan Charles, who was restrained after swallowing a package found to contain caffeine and paracetamol.

Chairman of Befordshire Police Federation Jim Mallen said: ”The matter of providing mouth guards to officers that would operationally need them is a debate about cost vs benefit.

“Is it feasible to provide more expensive mouth guards against how often officers are using them?

“In an ideal world police officers should have all the kit they need to keep the public and themselves safe and to administer CPR or first aid where required.

“I am still in talks with our Chief Constable around this issue and this Regulation 28 report from our coroner will refocus that debate.”

Mr Oldham’s Regulation 28 report is addressed to Bedfordshire Police Chief Constable Jon Boutcher and "Association of Chief Police Officers" who must respond by December 20.

Bedfordshire Police Assistant Chief Constable Jackie Sebire said: “The force is dedicated to improving our procedures to ensure the safety of those in our custody and is currently reviewing the recommendations in relation to the death of Karl Brunner.

“Our training is regularly revised and additional guidance on dealing with the swallowing of objects by those detained by police is now included in the first aid training delivered to officers and staff. This includes using tactical communications to persuade the person to remove the object themselves. 

“We continue to evolve our policies in line with national guidance. We are aware that there are several reviews on the subject and we will align our procedures to the recommendations when they are published if required.”

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Zulu 22

They seem to disregard the fact that when a suspect decides he will swallow evidence then, that is his/her decision. Any person trying to swallow a foreign object is liable to choke. Of course there are people who would always want to blame someone and the easiest to blame the Police, or Paramedic.  There is only one person responsible and to blame, the suspect.

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This is when it takes a senior officer to tell it how it is. For example:

  •  that if a driver crashes a car when refusing to stop for police
  •  that if someone swallows drugs (which are illegal in themselves)

Then there is only one person to blame. And it isn't the police.



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You can't force police officers or first aiders to perform mouth to mouth on complete strangers with unknown history or high risk of transmissible diseases. The option to do so lies with the person administering first aid and always should. It's absurd to suggest otherwise.

I have never seen ambulance staff or hospital nurses perform mouth to mouth. They always use a bag and mask in my experience. Asking officers to keep carrying multitudes of kit is not always practical either.

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Probably the same Coronor who stated that all Military personnel conducting live firing should be hand searched before they leave a range. 


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CPR is a very useful tool to have, but haven't these officers ever been trained in the Heimlich maneuver? In some of the cited cases it would be far more useful than CPR.

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CPR is a very useful tool to have, but haven't these officers ever been trained in the Heimlich maneuver? In some of the cited cases it would be far more useful than CPR.
I suspect the issue is not realising the person is choking until they stop breathing; at which point CPR is the only option.

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I find this all a bit strange and a bit muddled. 

Of course the training does reccomend rescue breaths however there is no way to reasonably expect people to be giving them to someone who has vomited, had blood all over or may have infectious diseases, it just won’t happen. If anything I would question why someone was doing this.

Compression only CPR is still a valid option in the circumstances and is still useful particularly when you should have an ambulance resource there within a short space of time. The other thing to consider here is if the blockage is large and completely blocking the airway then the rescue breaths wouldn’t do anything anyway.

The important thing we need to emphasise here is Police officers are absolutely not experts in giving CPR and rescue breaths. Yes, we get an input in first aid training with a doll but so do a lot of members of the public. We sometimes are over confident as cops or people think that we are some sort of experts on the subject. In 7 years I have never had to give CPR ‘for real’ thankfully. 

As a cop, like a member of the public we do what we can to help the person until the real experts arrive.

More importantly, if someone puts something in their mouth, especially in the commission of a crime then frankly this is the only cause of their death. And sadly they are the only ones to blame. As usual instead of pandering we should be robustly saying this to try and prevent any future cases.

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