Robert Evans
PFD Report
All Responded
Ref: 2025-0120
All 2 responses received
· Deadline: 29 Apr 2025
Response Status
Responses
2 of 2
56-Day Deadline
29 Apr 2025
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner’s Concerns
The Deceased was observed by officers conducting what they suspected to be a drug deal. Within minutes, he was detained in the street for the purposes of a search under S.23 of the Misuse of Drugs Act 1971. At this time, he was seen/suspected by officers to have swallowed something, which they believed might be drugs. He denied it. Nothing was found on an external search other than Methadone, which had been prescribed to his partner. He could have been arrested for this, but was not. The Deceased sustained a significant injury to his leg at the scene (which was found on the post-mortem examination to be a fractured fibula), due to a blow from a police baton. He was asked if he wanted medical attention, but said not. He was taken to a nearby police station for a strip search. Again, nothing was found. Officers then took the Deceased back to his home address and left him there, with members of his family in attendance. Little more than an hour elapsed between the officers’ first and last contact with the Deceased that day. Post mortem examination found a package containing drugs in the Deceased’s colon, but it could not be established whether this had been swallowed (at the time of the detention or otherwise) or inserted per rectum at some time. The court heard that College of Policing Guidance for Custody Officers and Detention Officers provides that “…If officers know or suspect that a detainee has swallowed or packed drugs…they must treat the person as being in need of urgent medical attention and transfer then straight to hospital”. However: (a) a person detained for a search under the Misuse of Drugs Act does not come to the attention of a Custody or Detention Officer, unless arrested; (b) there is no guidance (known to the court) to assist officers involved in such a search as to what they should do; (c) there is seemingly no power for officers to convey to hospital somebody detained under these provisions (but not arrested), if that is against their wishes. The upshot seems to be that, whilst the risk arising from swallowing a package containing drugs is the same in each case, there is a material difference between how different types of detainee are managed, depending upon whether an arrest has taken place. Officers told the court that if somebody declines an offer of medical attention they simply monitor their condition, for signs of any change or deterioration. However, even if that is effective and adequate, any monitoring inevitably ends when the individual is released from detention. In this case that was little more than an hour after the suspected swallowing event. When he was returned home, officers gave no advice to the Deceased or his family about the need for continued monitoring. There appears to be no guidance directed towards them as to what advice should be given. One officer said that nothing could be said to the family (about the need to keep him under close watch, because of the risk), because that would breach the individual’s right to privacy. It occurs to me that a person suspected of involvement in a drugs deal (even if nothing is found on a search) might well be keen to avoid further attention from the police and/or medical services as quickly as possible, for fear of something being found that might incriminate them. I am concerned that a person detained for the purposes of a search under the Misuse of Drugs Act, who is then suspected of having swallowed drugs, might be exposed to a risk of death (or other significant harm) if they do not receive the sort of medical attention which the guidance to Custody and Detention Officers considers an ‘urgent’ requirement, and/or if they are not given appropriate guidance on their release from detention. I am further
Official concerned that officers are not given guidance or training in how to address this risk, by means of communication or otherwise.
Official concerned that officers are not given guidance or training in how to address this risk, by means of communication or otherwise.
Responses
The NPCC disputes the suggestion that officers cannot share information with next of kin in vital interest situations, stating existing national training covers this. For other concerns, the Stop & Search portfolio will work to provide necessary training and guidance to officers regarding drug ingestion during stop & search, and commit to strengthening aftercare/safeguarding.
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Dear Mr Lewis,
I write on behalf of the National Police Chiefs Council (NPCC) in relation to paragraph 7, Schedule 5 of the Coroners and Justice Act 2009, and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, in relation to the prevention of future deaths report sent via email to the NPCC dated 1st May 2025.
The notice sets out concerns that arose from the information received during the inquest into the death of Robert John Evans. I am very sorry to read of the circumstances of Mr Evans death. My sympathies are with his family and friends.
As noted within the Authorised Professional Practice, there is clear guidance for what Custody Officers should do, when presented with a detainee who is suspected of having packed or swallowed drugs. I agree with your observations that there is a material difference between the action taken for those arrested, and those who are not. Further to this there is currently no power for officers to convey to hospital somebody detained under these provisions against their wishes. Whilst custody is heavily regulated with law, policies, procedures and best practice, fundamentally, an officers primary role is to preserve life and the risks in such cases should be recognised and further mitigated.
The NPCC Stop & Search portfolio has reviewed the Regulation 28 document and will work to ensure officers are equipped to resolve incidents such as these in the most appropriate manner. The portfolio will work with other national policing portfolios and stakeholders, to provide the necessary training and guidance to ensure officers have a refreshed knowledge of all policing powers available to them.
The suggestion that an officer cannot share information with a next of kin, or other family, to manage risk and prevent serious injury or death, is misguided. The police can disclose private information about a data subject if it is necessary to protect the vital interests of the data subject or another person. This typically applies in life-or-death situations, such as suspected drug ingestion (UK
GDPR Article 6(1)(d)). There are also similarly worded exemptions within the Data Protection Act
2018. There is already in place, national training modules that cover this subject in detail, and include scenarios where disclosure is proportionate and necessary, whilst emphasising the importance of disclosing the minimum amount of information necessary, to achieve the objective sought.
Safeguarding is a key area of focus for the NPCC and we are committed to working across relevant NPCC portfolios to ensure there is appropriate aftercare / safeguarding following a stop & search and will work to ensure a consistent approach that keeps people safe.
I hope the information provided will go some way to address your concerns. Please do not hesitate to contact me if you require further action or information in relation to my response.
I write on behalf of the National Police Chiefs Council (NPCC) in relation to paragraph 7, Schedule 5 of the Coroners and Justice Act 2009, and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, in relation to the prevention of future deaths report sent via email to the NPCC dated 1st May 2025.
The notice sets out concerns that arose from the information received during the inquest into the death of Robert John Evans. I am very sorry to read of the circumstances of Mr Evans death. My sympathies are with his family and friends.
As noted within the Authorised Professional Practice, there is clear guidance for what Custody Officers should do, when presented with a detainee who is suspected of having packed or swallowed drugs. I agree with your observations that there is a material difference between the action taken for those arrested, and those who are not. Further to this there is currently no power for officers to convey to hospital somebody detained under these provisions against their wishes. Whilst custody is heavily regulated with law, policies, procedures and best practice, fundamentally, an officers primary role is to preserve life and the risks in such cases should be recognised and further mitigated.
The NPCC Stop & Search portfolio has reviewed the Regulation 28 document and will work to ensure officers are equipped to resolve incidents such as these in the most appropriate manner. The portfolio will work with other national policing portfolios and stakeholders, to provide the necessary training and guidance to ensure officers have a refreshed knowledge of all policing powers available to them.
The suggestion that an officer cannot share information with a next of kin, or other family, to manage risk and prevent serious injury or death, is misguided. The police can disclose private information about a data subject if it is necessary to protect the vital interests of the data subject or another person. This typically applies in life-or-death situations, such as suspected drug ingestion (UK
GDPR Article 6(1)(d)). There are also similarly worded exemptions within the Data Protection Act
2018. There is already in place, national training modules that cover this subject in detail, and include scenarios where disclosure is proportionate and necessary, whilst emphasising the importance of disclosing the minimum amount of information necessary, to achieve the objective sought.
Safeguarding is a key area of focus for the NPCC and we are committed to working across relevant NPCC portfolios to ensure there is appropriate aftercare / safeguarding following a stop & search and will work to ensure a consistent approach that keeps people safe.
I hope the information provided will go some way to address your concerns. Please do not hesitate to contact me if you require further action or information in relation to my response.
The College of Policing states its existing Authorised Professional Practice (APP) on Detention and Custody already provides clear and robust guidance requiring immediate medical response, guidance at the point of arrest, joint risk assessment, and information sharing for individuals suspected of having swallowed drugs.
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Dear David, I write in response to your Prevention of Future Deaths (PFD) report dated 7 March 2025 concerning the tragic death of Mr Robert Evans, following his detention and subsequent medical complications.
Firstly, I wish to express our sincere condolences to Mr Evans’ family and acknowledge the seriousness of the concerns raised in your report. The College of Policing takes these matters with the utmost gravity and is committed to ensuring that national guidance supports the safety and wellbeing of all individuals in police custody.
In relation to the specific concern that individuals suspected of having swallowed drugs may not receive urgent medical attention or appropriate guidance upon release, I can confirm that the College’s Authorised Professional Practice (APP) on Detention and Custody provides clear and robust guidance. This includes:
- Immediate medical response: The APP explicitly states that any case involving suspected swallowed drugs must be treated as a medical emergency, with detainees taken to hospital without delay.
- Guidance at point of arrest: The APP outlines procedures for arresting and escorting officers, not just custody staff. It includes criteria for when to call an ambulance and how to manage the detainee’s care en route to hospital.
- Joint risk assessment: The guidance supports collaborative decision-making between police and ambulance services to ensure safe and timely medical intervention.
- Information sharing: Officers are instructed to provide relevant information to ambulance control, including mental health or behavioural concerns, to support appropriate clinical
decisions.
This guidance is publicly available and regularly reviewed to ensure alignment with operational realities and emerging risks. The relevant section can be accessed here:
We are confident that the current APP addresses the concerns raised in your report. However, we remain open to further review and engagement with stakeholders to ensure continuous improvement in custody practices.
Thank you for bringing this matter to our attention. Should you require any further information or wish to discuss this response in more detail, please do not hesitate to contact me or the lead for Crime and Criminal Justice, Chief Superintendent ( ) if you need any further information or assistance.
Firstly, I wish to express our sincere condolences to Mr Evans’ family and acknowledge the seriousness of the concerns raised in your report. The College of Policing takes these matters with the utmost gravity and is committed to ensuring that national guidance supports the safety and wellbeing of all individuals in police custody.
In relation to the specific concern that individuals suspected of having swallowed drugs may not receive urgent medical attention or appropriate guidance upon release, I can confirm that the College’s Authorised Professional Practice (APP) on Detention and Custody provides clear and robust guidance. This includes:
- Immediate medical response: The APP explicitly states that any case involving suspected swallowed drugs must be treated as a medical emergency, with detainees taken to hospital without delay.
- Guidance at point of arrest: The APP outlines procedures for arresting and escorting officers, not just custody staff. It includes criteria for when to call an ambulance and how to manage the detainee’s care en route to hospital.
- Joint risk assessment: The guidance supports collaborative decision-making between police and ambulance services to ensure safe and timely medical intervention.
- Information sharing: Officers are instructed to provide relevant information to ambulance control, including mental health or behavioural concerns, to support appropriate clinical
decisions.
This guidance is publicly available and regularly reviewed to ensure alignment with operational realities and emerging risks. The relevant section can be accessed here:
We are confident that the current APP addresses the concerns raised in your report. However, we remain open to further review and engagement with stakeholders to ensure continuous improvement in custody practices.
Thank you for bringing this matter to our attention. Should you require any further information or wish to discuss this response in more detail, please do not hesitate to contact me or the lead for Crime and Criminal Justice, Chief Superintendent ( ) if you need any further information or assistance.
Report Sections
Investigation and Inquest
On 20 July 2022 I commenced an investigation into the death of Robert John EVANS aged
59. The investigation concluded at the end of the inquest on 04 February 2025. The conclusion of the inquest was that: The Deceased died from a combination of drug use and underlying pneumonia. Fractures to his ribs, fibula and larynx contributed more that minimally to his death. It is more likely that these fractures resulted from force used by police officers when he was detained for the purpose of a drug search five days earlier. The force used was not reasonable and proportionate in the circumstances. The Deceased declined offers of medical assistance, from officers and from his family.
59. The investigation concluded at the end of the inquest on 04 February 2025. The conclusion of the inquest was that: The Deceased died from a combination of drug use and underlying pneumonia. Fractures to his ribs, fibula and larynx contributed more that minimally to his death. It is more likely that these fractures resulted from force used by police officers when he was detained for the purpose of a drug search five days earlier. The force used was not reasonable and proportionate in the circumstances. The Deceased declined offers of medical assistance, from officers and from his family.
Circumstances of the Death
The Deceased was found dead at his home address at , Liverpool on 3rd July 2022. His death was due to a combination of drug use (Heroin, Diazepam and Cocaine) and underlying established pneumonia. He had sustained fractures to his fibula, five ribs on the right side of his chest and his larynx. These fractures contributed more than minimally to his death, by reducing his mobility and adding to his difficulty in breathing normally, thus likely exacerbating his underlying pneumonia. On 28th June 2022 the Deceased had been in contact with officers from Merseyside Police, when he was detained for the purposes of a search under the Misuse of Drugs Act 1971. Some of the officers used force in the course of his detention, which probably caused the fractures to the fibula, ribs and larynx. The force used was not reasonable and proportionate. The officers offered the Deceased the opportunity for medical assessment but he declined it. The Deceased was returned to his home address later the same day and remained there until his death. In the intervening period he complained to his family of being in pain, for which he self-medicated, but he declined suggestions that he should seek medical advice. Officers suspected that the Deceased had swallowed something previously concealed in his mouth at the time of detention but didn't pick up or fully convey to other officers on the urgency of a potentially life threatening condition. At post mortem a package containing drugs was found inside the Deceased's colon. It is unlikely that this package was the reason for the drugs found in the sample of blood analysed as part of the post mortem toxicology. There was reasonable suspicion that the Deceased ingested drugs, however this information was not relayed to all officers in attendance despite there being life-threatening
Official consequences. Furthermore, upon handover to the Deceased's family, the potential drug ingestion was not communicated to them, which did not allow the family to facilitate appropriate medical care.
Official consequences. Furthermore, upon handover to the Deceased's family, the potential drug ingestion was not communicated to them, which did not allow the family to facilitate appropriate medical care.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.