On the 14 February 2017 commenced an investigation into the death of Eugeniusz Niedziolko and an Inquest was_opened bY Assistant Coroner Dr__Claire Balysz on the 11 April 2017 . The Wiltshire & Swindon Coroner'$ Office; 26 Endless Street; Salisbury, Wiltshire, SPI IDP Tel 01722 438900 Fax 01722 332223

Inquest; which was held with Jury; was concluded on the 28 June 2017 and the Jury determined that the medical cause f death was Acute Alcohol Toxicity and Hypothermia In box 3 in the Record of Inquest the Jury in relation to the mechanism of the death recorded as regards the how, when and where Eugeniusz came by his death:- At 7.45 am on 14 February 2017, Eugeniusz Niedziolko was found unresponsive in a lavatory block at Lush House Car Park, Salisbury, after left by the police at 3.17 am to sleep off the effects of alcohol consumption in the early hours of that morning: Eugeniusz was pronounced dead at 8.17 am on 14 February 2017 and died as a result of acute alcohol intoxication and hypothermia: The short form conclusion and narrative conclusion recorded by the in box 4 of the Record of Inquest was recorded as follows:- "Accident contributed by neglect" "Narrative Conclusion Failure by the Police and Ambulance Services to and clarify information from the control room to front line staff: In addition, failure to follow protocol and document findings by the Police and Ambulance Services was compounded by inappropriate training delivery processes: With insufficient knowledge of the options available this culminated in poor decision making and a lack of professional judgment by the Police who subsequently left Eugeniusz in the toilet block at Lush House car park at 0317 on the 14th February 2017 rather than being taken to an appropriate place of safety to be monitored and receive appropriate care if necessary.

At around 0130 on the morning of the 14 February 2017 the Police were called to attend believed drunken person that had gained access into a communal hallway area inside a private block of flats at Mill Road Mews in Salisbury: Eugeniusz had been asked to leave a train a few hours earlier in Salisbury partly because it was suspected that he had no ticket but also due to degree of his intoxication: Police Officers were tasked to attend the flats at 0200 hours and arrived at the flats at 0227, the call having been given priority" status: Eugeniusz was found by both Officers lying on his left-hand side on the top landing intoxicated and in a pool of his own urine_ Right from the outset it was clear that the attending police officers were having communication issues with Eugeniusz whose English was not good at all. Initially they assisted him to his feet and escorted him out of the block of flats whereupon one of the officers called the ambulance service with the intention of them checking Eugeniusz over_ The call to the ambulance service was made at 0244. The Paramedics were dispatched at 0248 and arrived at the scene some minutes later at 0252 Contrary to the relevant Paramedic protocol (the Appropriate Care Pathway Policy dated 2014) no observations were carried out on Eugeniusz and as a consequence nothing was recorded" The lead Paramedic opted to carry out a visual examination at the roadside using scene lighting and not inside the ambulance. Neither the lead paramedic nor the trainee paramedic that formed the ambulance crew noted that Eugeniusz had been incontinent of urine_ It was clear however that Eugeniusz was drunk ad that there was a degree of unsteadiness noted although he was able to walk with a rucksack on his back, slightly staggering but unaided. The lead Paramedic assesses a Glasgow coma scale of 15 and has no reason to believe as do the Police that Eugeniusz did not have mental capacity. Eugeniusz at one point tried to get into the ambulance cab and is stopped by the lead Paramedic. Eugeniusz said that he was a "good alcoholic and that he wanted to go to hospital. When asked why he said "detox" The lead Paramedic went on to indicate that there were no detox facilities at Salisbury at that time of night: In evidence, no one in attendance considered that actually Eugeniusz might have been asking for help as a result of having drunk too much: The lead Paramedic forms the view that the matter is a social issue in nature as opposed to a medical one and decides that hospital was not the appropriate place for Eugeniusz to be taken: The Paramedic at the time had 10 months experience in front line operations. At the time the Paramedics were leaving the scene, one of the options that was considered was for Eugeniusz to be_taken to a nearby_hotel: After the Paramedics had left it was ascertained that Wiltshire & Swindon Coroner Office; 26 Endless Street; Salisbury; Wiltshire; SPI IDP Tel 01722 438900 Fax 01722 332223 Ia) being Jury relay key the being

Eugeniusz does not have sufficient money for a hotel. Around the same time at 0312 the 2 police officers received an update following a PNC check however only 1 of 3 markers appears to have been effectively communicated to the 2 officers on the ground, both officers in their evidence were clear that they were only aware of the ailment being an alcoholic marker_ Their view was supported by the transcript of the recording of the communications that the control room operator had with the officer at the scene. The Control room operative in evidence believed that she would have passed on all 3 markers and would not have picked out or 2 in priority to the complete set: Within 5 minutes of receiving this communication, Eugeniusz had been taken round and deposited in the male lavatory at the Lush House Car Park public lavatory located in Crane Bridge Road, Salis] Wiltshire. The police officers had considered taking him to an area frequented by other homeless people near Sainsbury's but decided against that due to concerns that he may be picked upon: Eugeniusz had in his possession a rucksack and a TV box, although both officers were unclear as to whether it contained a television or not and at no stage did they confirm the position: Eugeniusz was able to walk into the lavatory block unaided carrying his rucksack and television. A remaining bottle of Gin was confiscated by one of the Officers and the contents disposed of later_ Eugeniusz is left with a 7Ocl bottle of rum containing about SOml of rum; which when his body was found was empty. That having been said the Consultant A & E Expert_ Isaid in evidence that it probably would not have made a difference in respect of the outcome No arrangements were made to check further on Eugeniusz and he was left alone in the lavatory block which unbeknown to the Officers had no heating in circumstances where the outside temperature dropped as low as Celsius that night. His unresponsive body was found 4%2 hours later by a cleaner and his death was confirmed at 0817 by a attending Paramedic On post mortem examination, including toxicology, blood alcohol levels were recorded at 434mgs per 1OOml of litres of blood and 493mgs per 10Oml of urine. None of the usual signs in relation to hypothermia were found at post mortem hence in her reportl the Forensic Pathologist; records single cause of death as Acute alcohol toxicity: This as you will see from above was varied by the Jury to include hypothermia whichl in her evidence thought was highly likely at the time of death,_despite the absence of the usual indicators, that there was a degree of hypothermia. was also of the opinion that more likely than not the level of blood alcohol in Eugeniusz s System was still rising to point of equilibrium with urine alcohol levels. Both and were both of the view that it was likely that Eugeniusz had a further period of incontinence prior to death as he was found in a pool of urine and at post mortem his bladder was still relatively full:

In my opinion action should be taken to prevent future deaths and believe you have the power to take such action.

- "Accident contributed by neglect" "Narrative Conclusion Failure by the Police and Ambulance Services to and clarify information from the control room to front line staff: In addition, failure to follow protocol and document findings by the Police and Ambulance Services was compounded by inappropriate training delivery processes: With insufficient knowledge of the options available this culminated in poor decision making and a lack of professional judgment by the Police who subsequently left Eugeniusz in the toilet block at Lush House car park at 0317 on the 14th February 2017 rather than being taken to an appropriate place of safety to be monitored and receive appropriate care if necessary.