The jury at an inquest at Westminster Coroner’s Court into the death in police custody of a 32-year-old man with known psychiatric illness has criticised the response to his medical emergency as “chaotic, disorganised and lacking urgency”, which possibly contributed to his death.
Joseph Phuong, who worked as a web designer, was diagnosed as suffering from paranoid schizophrenia 10 years ago. He subsequently received monthly injections of an anti-psychotic drug, which allowed him to live with periods of happiness and calm.
According to his mother Tu Tran, Joseph began behaving erratically in June 2015 and, despite her phone calls for help from both his psychiatrist and the crisis line at the Maddison NHS Centre in Teddington and A&E at West Middlesex Hospital, Joseph was arrested on 4 June for breaking into a neighbour’s house and detained under the Mental Health Act.
He was transported by police van to Springfield psychiatric hospital in Tooting but there were no beds available. A request to University College Hospital (UCH) in Euston, which did have a bed, was refused because Mr Phuong lived out of borough.
Police officers decided to transfer Mr Phuong to St George’s Hospital, Tooting but while they waited for an ambulance, he became increasingly agitated, repeatedly banging his head on the ground and was restrained by up to five officers for around three hours in the middle of the night. Mr Phuong was observed to be spitting blood. While waiting at St George’s, Mr Phuong was arrested on suspicion of assaulting a police officer and taken to Kingston Police Station.
Here he was restrained for a fourth time by five officers and left naked in a cell for four hours. After nine hours, doctors finally arrived to assess him under the Mental Health Act.
Joseph was then detained for a further eight-and-a-half hours before being taken back to Springfield Hospital, where a bed had become available. Officers noted that he was coughing up bloody phlegm and was breathing strangely, but did not call a doctor or report any concerns to the nurse transporting him to hospital.
Joseph arrived at Springfield Hospital at in the early hours of 5 June 2015. His pulse rate was high but no other concerns were noted. After kicking tables and chairs in his room, Joseph was restrained for a sixth time, taken to the seclusion room and tranquilized. He was placed on constant observation at 2.05am that morning but was discovered dead less than two hours later, apparently due to a heart attack.
A CID murder investigation focused on the actions of NHS staff only and concluded in April 2016 that no referral would be made because the cause of death was unascertained.
“During the inquest, witnesses were asked about the adequacy of the help offered by multiple agencies, including the hospital and the police, leading up to Joseph’s death.
“Joseph was very unwell and desperately needed urgent medical attention. A catastrophic lack of resources meant that he didn’t receive the right care and treatment and instead endured prolonged police restraint and spent a long time in police custody before being restrained and tranquilised in mental health detention, where he died.
“Tragically, Joseph’s case highlights the extraordinary and unacceptable difficulties faced by those in mental health crisis with securing the support they need when they are at their most vulnerable.”
Joseph’s sister, Louise Rowlands, 29, said the family had been left heartbroken by Joseph’s death and “frustrated with the services who are supposed to keep us safe”.
“All Joseph needed was help. Instead, he was met with ambivalence and
disrespect. No one took responsibility for his welfare and instead left it to someone else to take care of, which no-one did.
“Joseph’s death could easily have been prevented, had he received the appropriate
attention… instead, there was a catalogue of errors and every 50/50 call went against him.”
Deborah Coles, director of INQUEST, said: “Sadly, Joseph’s death is not an isolated case. It is yet another case which demonstrates the vital need for partnership working between police and mental health services to protect people in crisis.”
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