In Section 7 of the protocol, entitled of Police Officers attending the scene of “Role death”, the following passage appears:- Tasks of the attending officer: “7.2 ... • ... • assess the circumstances - sight body if possible - and make the following • decisions and direct where appropriate:- * ... * attendance of pathologist * ...”. As it stands, Detective Huppatz complied with that direction. 7.8 In retrospect, I think that the protocol should give a more positive suggestion to the investigating officer to call the pathologist. In my view, when investigating a death in custody, the pathologist should be called to the scene except where it is obviously impracticable to do so. The attendance of the pathologist will have many advantages, but the relevant one for present purposes is the ability to take accurate temperature measurements in order to attempt an estimate of the time of death. The investigating officer will not know in advance whether or not this will be an important factor. As to circumstances where it is not practicable to call a pathologist (for example in country areas), the investigating officer should make telephone contact with a pathologist and discuss the situation with him or her. Decisions can then be made whereby, for example, the local Police Medical Officer could be called to the scene for the purpose of taking the relevant measurements. Alternatively, a registered nurse or another medical practitioner might be able to do so. 8. Cell design 8.1 In their Departmental Review into this incident, Messrs Smedley and Leggat noted that the design of the double-bunk beds provides a hanging point in the cell. They also noted that:- management cannot recall a previous incident which involved a prisoner hanging “ARC (Exhibit C.19a, p6). from the rail of a bunk bed”. 8.2 Messrs. Smedley and Leggat also noted that Mr. Nobels was not considered at risk of self-harm. If he had been considered at risk, I accept that further steps would have been taken, including placement in different accommodation.
In Section 7 of the protocol, entitled “Role of Police Officers attending the scene of death”, the following passage appears:- “7.2 Tasks of the attending officer: • ... • ... • assess the circumstances - sight body if possible - and make the following decisions and direct where appropriate:- * ... * attendance of pathologist * ...”. As it stands, Detective Huppatz complied with that direction. 7.8 In retrospect, I think that the protocol should give a more positive suggestion to the investigating officer to call the pathologist. In my view, when investigating a death in custody, the pathologist should be called to the scene except where it is obviously impracticable to do so. The attendance of the pathologist will have many advantages, but the relevant one for present purposes is the ability to take accurate temperature measurements in order to attempt an estimate of the time of death. The investigating officer will not know in advance whether or not this will be an important factor. As to circumstances where it is not practicable to call a pathologist (for example in country areas), the investigating officer should make telephone contact with a pathologist and discuss the situation with him or her. Decisions can then be made whereby, for example, the local Police Medical Officer could be called to the scene for the purpose of taking the relevant measurements. Alternatively, a registered nurse or another medical practitioner might be able to do so. 8. Cell design 8.1 In their Departmental Review into this incident, Messrs Smedley and Leggat noted that the design of the double-bunk beds provides a hanging point in the cell. They also noted that:- “ARC management cannot recall a previous incident which involved a prisoner hanging from the rail of a bunk bed”. (Exhibit C.19a, p6). 8.2 Messrs. Smedley and Leggat also noted that Mr. Nobels was not considered at risk of self-harm. If he had been considered at risk, I accept that further steps would have been taken, including placement in different accommodation.
NOBELS%20Laurens%20Adrian%20Keith.docx