Dear Mr Longstaff Re: Regulation 28 response: Inquest touching the death of Nicholas Oliver James Gedge I write in response to your Regulation 28 report dated 11 March 2025 concerning the death of Mr Nicholas Oliver James Gedge. In advance of responding to the specific concerns raised in your report, may I begin on behalf of Leeds Community Healthcare NHS Trust ("the Trust") by conveying my deepest condolences to the family of Mr Gedge for their loss. Your report that was issued to The Chief Constable, West Yorkshire Police and to Leeds Community Healthcare NHS Trust, raised the following concerns: "From the point when the Detention Officer first entered Nicholas’ cell to when CPR was commenced, 8 minutes and 12 seconds elapsed without CPR being given. Within that timeframe, two Detention Officers and a nurse were present in the cell after 75 seconds had passed. On the evidence, there did not appear to be any shared understanding between the three people in the cell with Nicholas of the urgency of starting CPR on an unresponsive person. There did not appear to be a co-ordinated approach to assisting Nicholas, with the Detention Officers and the nurse not appearing to have defined roles which they understood and undertook. It was not clear whether there were any protocols in place to define the respective roles of detention staff and medical staff attending a medical emergency in a cell. The passage of time before CPR was commenced gives rise to a concern either that the importance of early CPR was not

appreciated, or that the communication between detention and medical staff did not facilitate its prompt commencement." These matters of concern have been given careful consideration by the Trust and I set out below the actions that have been agreed in response.  At the time of the event, Health Care Professionals (HCP) employed by LCH received Life Support training on an annual basis. This included basic life support (affiliated to the Resus Council UK standards) and training on the automated external defibrillators and emergency bag contents including bag valve mask, nasal and Guedel airways, oxygen and emergency drugs.  Since January 2024, (after this incident) the training session for LCH staff has been expanded to include the use of a further airway adjunct (i-gel) and reflective discussions around any clinical issues or themes (e.g. recently staff have experienced an increase in opiate overdoses in custody). This is in addition to introducing medical emergency / CPR scenarios to introduce elements of teamwork. I would like to reassure you and Mr Gedge's family that the concerns raised in your Regulation 28 report have been listened to and reflected upon and in order to improve the timeliness and co- ordination of basic life support, the Trust will implement the following actions: Concern Response Timescale Lack of shared understanding and co- ordination between detention officers and healthcare professionals for starting CPR  In addition to the organisational mandatory bespoke life support training, LCH will expand the scenario aspect of training to include simulation exercises in the custody suite environment with the aim of improving the co-ordination between LCH staff and detention officers in the event of emergency scenarios.  The service has added a photographic description of the contents of the emergency bag to aid the quick identification of items in an emergency. Discussion to take with police by May 28th, 2025, with the aim of introducing joint scenarios in training by August 31st,
2025.  A working group consisting of LCH HCP’s, led by a clinical team manager, has commenced to review the Death in Custody (DIC) procedure.  The service will ensure that they include ‘coordination of response’ in the investigation process of incidents where there has been a life-threatening response or a DIC. The task group will conclude by August 31st,
2025.

 The procedure will be agreed with the police to ensure the coordination of response in life threatening situations is robust.  LCH has conducted a reflective conversation with the staff involved in the incident and has incorporated their recommendations and suggestions for improvements into the CPR training.  The DIC review will also enhance the joint reflection process with all colleagues involved in the incident. Unclear if protocols in place to define roles and responsibilities in emergency  All current LCH protocols are organisation specific and are agreed with the police. As a matter of clarification, Leeds Community Healthcare NHS Trust would also like to note that within the Regulation 28 report (page 1, section 4) it states: “Nicholas was moved from the cell bench to the floor, and the nurse inserted an intraosseous needle at 1548 hours and an oxygen mask shortly thereafter.” This was in fact not an intraosseous needle and it was the administration of Naloxone (medicine that rapidly reverses opioid overdose) as an intramuscular injection. We hope the above actions taken by Leeds Community Healthcare has addressed the Coroner’s concerns, but should the Coroner have any further queries, please do not hesitate to contact Leeds Community Healthcare Trust.

IN THE WAKEFIELD CORONERS’ COURT IN THE MATTER OF AN INQUEST INTO THE DEATH OF

NICHOLAS GEDGE

POLICE RESPONSE TO REPORT TO PREVENT FUTURE DEATHS

1. This response is prepared on behalf of the Chief Constable of West Yorkshire Police to the Coroner’s Report to Prevent Future Deaths in the case of Nicholas Gedge.

2. It is hoped that the following will allay some of the Coroner’s concerns:

(a) The evidence of the Detention Officer who found Mr Gedge unresponsive was that when she called for the nurse she believed that Mr Gedge was breathing. The Healthcare Professional who attended recorded in her notes that she found slight breath and a faint pulse on examination.

(b) Police Detention Officers have basic life support training only. They are not trained to start CPR on “unresponsive” individuals who are breathing. Starting CPR on people who are unresponsive but breathing can cause harm. For this reason only a Healthcare Professional, who has Intermediate Life Support training would be qualified to start CPR on a person who was believed to be breathing.

(c) In a medical emergency, Detention Officers do have a defined role which is made clear to them in regular training:

(i) Until the custody Healthcare Professional attends, they are to follow their training and provide Basic Life Support, including giving CPR to people who are not breathing.

(ii) Once the Healthcare Professional arrives, Detention Officers are to take direction from the Healthcare Professional. The Detention Officers in this case understood this and did so when requested, such as when a Detention Officer assisted in moving Mr Gedge from the bench to the floor. It would be inappropriate and dangerous for a Detention Officer with lesser training to be doing anything other than following directions in an emergency response when an individual with greater training is present and leading the response.

(d) The Chief Constable makes no comment on the actions of the Healthcare Professional, which is a matter for the Trust.

3. Nevertheless, the Chief Constable intends to review the contracts, policies and procedures that are in place between Leeds Community Healthcare and the Force, in partnership with Leeds Community Healthcare, to ensure that the respective roles of the Detention Officers and Healthcare Professionals in custody in an emergency situation are sufficiently clear.