Timothy Clayton
PFD Report
1 of 1 responses identified
Ref: 2013-0361-wp26757
All 1 listed response identified
· Deadline: 6 Jan 2014
Coroner's Concerns (AI summary)
Police improperly pressured the grieving family regarding organ donation, and an officer subverted the coroner's judicial decision, leading to the loss of six organs.
View full coroner's concerns
1. Kent Police approached Mr Clayton’s family to consider a decision that is, by law, conferred upon HM Coroner. This action placed Mr Clayton’s family in desperately difficult and desperately painful position. Having already given their consent to donation, they were asked to go back on this and to make a further decision based upon the likely success of prosecution of Mr Clayton’s killer, rather than this separate decision resting with a trained, experienced, dispassionate judge – the coroner.
This must have added horribly to their distress, and it was a wholly improper burden to place upon them.
2. As the coroner with responsibility for this matter, I did not make the decision not to object to organ donation on a whim. I did so after a great deal of discussion and thought.
Though I am a senior coroner with particular experience of organ donation, a subject on which I have lectured to doctors, nurses and police officers on several occasions, I nevertheless sought out a senior coroner colleague on a Sunday afternoon, to try to ensure that I had not missed anything.
I was transparent in my thinking, I listened carefully to all advice, including that of the senior investigating officer, and I gave detailed reasons for my decision. Nevertheless, that police officer sought to subvert my judicial decision.
He did not ask a more senior police officer to contact me to discuss the matter further. He did not seek to challenge in a higher court. Instead, he effectively reversed the decision made by a judge because he preferred his own view of the matter, and he did this by bringing pressure to bear on a grieving family.
In short, a police officer has subverted the rule of law.
You may be surprised that I write to you about this matter by way of a prevention of future death (PFD) report. I do so because in this instance, six organs were lost to their potential recipients - two lungs, two kidneys, a small bowel and a pancreas. Six organs represents six lives.
This must have added horribly to their distress, and it was a wholly improper burden to place upon them.
2. As the coroner with responsibility for this matter, I did not make the decision not to object to organ donation on a whim. I did so after a great deal of discussion and thought.
Though I am a senior coroner with particular experience of organ donation, a subject on which I have lectured to doctors, nurses and police officers on several occasions, I nevertheless sought out a senior coroner colleague on a Sunday afternoon, to try to ensure that I had not missed anything.
I was transparent in my thinking, I listened carefully to all advice, including that of the senior investigating officer, and I gave detailed reasons for my decision. Nevertheless, that police officer sought to subvert my judicial decision.
He did not ask a more senior police officer to contact me to discuss the matter further. He did not seek to challenge in a higher court. Instead, he effectively reversed the decision made by a judge because he preferred his own view of the matter, and he did this by bringing pressure to bear on a grieving family.
In short, a police officer has subverted the rule of law.
You may be surprised that I write to you about this matter by way of a prevention of future death (PFD) report. I do so because in this instance, six organs were lost to their potential recipients - two lungs, two kidneys, a small bowel and a pancreas. Six organs represents six lives.
Responses
Action Taken
• A formal review was commissioned and completed into the circumstances that led to the report being issued. (AI summary)
• A formal review was commissioned and completed into the circumstances that led to the report being issued. (AI summary)
View full response
Dear Madam,
I refer to your Regulation 28 Prevention of Future Deaths Report dated the 11 November 2013 concerning Timothy Patrick Clayton deceased and this letter serves as my response in accordance with Regulation 29.
The Coroners and Justice Act 2009 replaced Rule 43 Reports with Reports on Action to Prevent Future Deaths (PFD) under paragraph 7 Schedule 5 of that Act and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. It is accepted that Coroners have a duty not only to determine how an individual came by their death but also where appropriate to report about that death with a view to preventing future deaths.
I am aware that normally a PFD report will be made after the conclusion of an Inquest. However, a report can be made before an Inquest is heard so long as there has been compliance with Regulation 28(3) and that will only be when the Coroner has considered all of the documents, evidence and information that in the opinion in the Coroner is relevant to the investigation. It is with this condition in mind that I suggest that that criteria perhaps has not been met in this particular referral.
The report from the Coroner states the concerns that there is a risk that future deaths will occur unless action is taken by Kent Police and that it is the Coroner's statutory duty to report to me. The reference to the use of a PFD report is due to the perceived belief that 6 transplant organs were lost to potential recipients and that 6 organs represents 6 lives. This PFD report concerns the issue therefore of organ donation from Timothy Clayton, a 45 year old homeless male who was a homicide victim. The circumstances concerning his death thereby being a live criminal investigation. Following receipt of the PFD report, however, a formal review has been commissioned and completed into the circumstances that led to the report being issued. The review has thoroughly considered the circumstances and the Coroner's concerns and is therefore appended hereto.
Kent Police : Form No. 3058b rev 9/05 v1.21 In accordance with the requirements of Regulation 29, I now write to confirm that all Senior Investigating Officers in Kent Police and Essex Police have been reminded of the guidance contained within the Journal of Homicide and Major Incident Investigation published by the National Policing Improvement Agency. All Senior Investigating Officers are to be advised that any challenge to a decision by HM Coroner is through the Courts processes.
An urgent review is to be conducted to consider the number and availability of family liaison officers to ensure suitably trained staff are available for deployment when required in homicide investigations. This will ensure that families are in possession of full and appropriate information at all times.
The circumstances that arose in this particular case will also be included into future Senior Detective training and has been drawn to the attention of senior personnel in the Association of Chief Police Officers Homicide Working Group for national consideration. What is also of note, however, is that no one has been provided with either the original or a copy of Mr Clayton's organ donation card, despite this appearing to have been the catalyst for the consent being sought from the family. The family had not requested the consideration of organ donation.
Despite the Coroner's assertion that 6 deaths were preventable if the organ donation had been completed, in fact only the kidneys were potentially viable but as Mr Clayton was a known homeless alcoholic, the viability of these organs for successful transplantation is therefore unknown. The use of a report in accordance with Regulation 28 by the Coroner is therefore questionable.
There is still considerable distress being experienced by the family of Mr Clayton as his body has not been transferred to Kent which has caused an additional burden on them. In accordance with the provisions of Regulation 29(8)(b) of The Coroners (Investigations) Regulations 2013 I would request that the review document appended to this letter is not disclosed for publication as it contains third party information which does not have the consent for publication and is provided to the Coroner and the Chief Coroner in response to the Regulation 28 PFD report.
I refer to your Regulation 28 Prevention of Future Deaths Report dated the 11 November 2013 concerning Timothy Patrick Clayton deceased and this letter serves as my response in accordance with Regulation 29.
The Coroners and Justice Act 2009 replaced Rule 43 Reports with Reports on Action to Prevent Future Deaths (PFD) under paragraph 7 Schedule 5 of that Act and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. It is accepted that Coroners have a duty not only to determine how an individual came by their death but also where appropriate to report about that death with a view to preventing future deaths.
I am aware that normally a PFD report will be made after the conclusion of an Inquest. However, a report can be made before an Inquest is heard so long as there has been compliance with Regulation 28(3) and that will only be when the Coroner has considered all of the documents, evidence and information that in the opinion in the Coroner is relevant to the investigation. It is with this condition in mind that I suggest that that criteria perhaps has not been met in this particular referral.
The report from the Coroner states the concerns that there is a risk that future deaths will occur unless action is taken by Kent Police and that it is the Coroner's statutory duty to report to me. The reference to the use of a PFD report is due to the perceived belief that 6 transplant organs were lost to potential recipients and that 6 organs represents 6 lives. This PFD report concerns the issue therefore of organ donation from Timothy Clayton, a 45 year old homeless male who was a homicide victim. The circumstances concerning his death thereby being a live criminal investigation. Following receipt of the PFD report, however, a formal review has been commissioned and completed into the circumstances that led to the report being issued. The review has thoroughly considered the circumstances and the Coroner's concerns and is therefore appended hereto.
Kent Police : Form No. 3058b rev 9/05 v1.21 In accordance with the requirements of Regulation 29, I now write to confirm that all Senior Investigating Officers in Kent Police and Essex Police have been reminded of the guidance contained within the Journal of Homicide and Major Incident Investigation published by the National Policing Improvement Agency. All Senior Investigating Officers are to be advised that any challenge to a decision by HM Coroner is through the Courts processes.
An urgent review is to be conducted to consider the number and availability of family liaison officers to ensure suitably trained staff are available for deployment when required in homicide investigations. This will ensure that families are in possession of full and appropriate information at all times.
The circumstances that arose in this particular case will also be included into future Senior Detective training and has been drawn to the attention of senior personnel in the Association of Chief Police Officers Homicide Working Group for national consideration. What is also of note, however, is that no one has been provided with either the original or a copy of Mr Clayton's organ donation card, despite this appearing to have been the catalyst for the consent being sought from the family. The family had not requested the consideration of organ donation.
Despite the Coroner's assertion that 6 deaths were preventable if the organ donation had been completed, in fact only the kidneys were potentially viable but as Mr Clayton was a known homeless alcoholic, the viability of these organs for successful transplantation is therefore unknown. The use of a report in accordance with Regulation 28 by the Coroner is therefore questionable.
There is still considerable distress being experienced by the family of Mr Clayton as his body has not been transferred to Kent which has caused an additional burden on them. In accordance with the provisions of Regulation 29(8)(b) of The Coroners (Investigations) Regulations 2013 I would request that the review document appended to this letter is not disclosed for publication as it contains third party information which does not have the consent for publication and is provided to the Coroner and the Chief Coroner in response to the Regulation 28 PFD report.
Part of a Series
2 separate reports were issued from this inquest, each sent to different organisations.
-
2024-0206
Sent to: NHS EnglandSt George’s Epsom and St Helier GroupAll responses identified
This report (2013-0361-wp26757) is shown above.
Sent To
- Kent Police
Responses Identified
Responses identified
1 of 1
56-Day Deadline
6 Jan 2014
All listed responses identified
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
Yesterday, the death of Timothy Patrick Clayton was reported to me. I am still at the pre investigation stage of my inquiries, but I anticipate that I shall open an inquest touching Mr Clayton’s death.
Circumstances of the Death
Just before 1pm yesterday (Sunday, 10 November 2013), one of my coroner’s officers alerted me to the death of Timothy Clayton. He told me that Mr Clayton had been brought to the Royal London Hospital by helicopter from Kent with a severe head injury, and that brain stem death tests had been conducted a little over half an hour before, although Mr Clayton was still being supported medically. Police enquiries had revealed CCTV of Mr Clayton being kicked to the head and body in a sustained attack. My officer, , said that Mr Clayton’s family had given permission for organ donation and so I was being contacted in this respect.
When a death is reportable to HM Coroner, the coroner has lawful control of the body, and so his or her permission is sought before any organ donation. The coroner does not give consent to the donation, only the individual himself by way of advance directive, or his family consulted at the time of death, can do that. However, after consent is given, the coroner may then raise an objection to donation. If the coroner objects to donation, the donation cannot take place.
Mindful of the ongoing police investigation, I asked that the Kent Police senior investigating officer (SIO) telephone me to discuss the proposed donation. A short while later, the detective chief inspector in charge of the investigation, Paul Fotheringham, telephoned me. He gave me an account of the investigation so far, and told me that Kent Police objected to organ donation going ahead, on the basis that this would compromise the criminal investigation.
We talked through the matter at some length. He was concerned that the organs it was proposed to donate (lungs, kidneys, small bowel and pancreas) might be diseased and the suggestion be made that this had contributed to death. I put it to him that if they were diseased then they would not be suitable for transplant. He was further concerned that these organs might have been injured by the attack. Removal of them would therefore deny us the ability to determine the medical cause of death. I explained that the understanding that I had gained, was that Mr Clayton had died from a traumatic head injury, and therefore the organs in question would not take us any further forward in determining medical cause of death.
I told that I saw no reason to object to the donation. I suggested that we work together, to facilitate donation without compromise to the homicide investigation. I offered my assistance, for example, I authorised the taking of photographs before donation. The detective chief inspector remained very firmly opposed to donation.
I suggested that he contact the forensic pathologist who was to perform the post mortem examination and then, having spoken to him or her, ask that pathologist to telephone me. I asked to ascertain from Mr Clayton’s treating clinicians the nature and extent of the head injury.
A little while later, I was telephoned by , consultant forensic pathologist on call this weekend. and I discussed the proposed donation. s view was that going ahead with the donation carried with it the potential to lose some evidence, and he advised against it. gave me a thoughtful analysis, suggesting that if the organs were donated, we might not discover whether any of these organs had sustained contusions in the kicking that was apparently discernible on CCTV. I asked him how much further forward the discovery of a contusion (that presumably did not significantly affect function or the organs would not be suitable for donation) would really take us, given the nature of the CCTV (showing one person kicking Mr Clayton repeatedly) and most especially given that cause of death appeared to be a traumatic head injury.
He felt that this was really a legal question, and also explained that he did not have any detailed information on the clinicians’ view of medical cause of death or the extent of Mr Clayton’s head injury.
Having gone through the matter together carefully, remained of the view that there was a risk of losing some evidence by allowing donation but, in response to my direct question as to whether he viewed allowing donation to go ahead as foolhardy, he replied that he did not. He told me that he recognised that this was a balancing act, and that the decision was mine.
The decision before me seemed a difficult one. I was inclined towards donation, but I thought it would be helpful to articulate my thoughts by running through the scenario with another senior coroner, and so I telephoned a colleague in a different part of the country. I wanted to be sure that I had considered all angles before coming to my conclusion. Again, we spoke at some length.
I then spoke again to He re-emphasised that his duty was to ensure an effective investigation/prosecution, and he once again voiced his objection to donation. I requested that he ask Mr Clayton’s treating consultant to telephone me.
I was then called by is a consultant in critical care and renal medicine, and he explained that he was responsible for Mr Clayton’s care. He told me that there was absolutely no doubt in his mind about the cause of Mr Clayton’s death. This was an unsurvivable traumatic head injury. He said that the head injury was massive, and that he was not sure when he had seen a head injury of this magnitude, in spite of his role at the trauma centre of the Royal London Hospital.
I thought very carefully about all the evidence that had been presented to me and I made my decision. I telephoned once more and told him that I would not raise any objection to donation.
Once again I went through my responsibilities with him, re-iterating that I wanted to guard against the failure of a proper conviction or a proper acquittal because of any compromise by organ donation. I told him that, although I completely took point that some evidential detail might be lost by organ donation, I did not believe that this would impact upon the proper exploration/prosecution of any person potentially responsible for Mr Clayton’s death.
I asked that the following steps be taken:
1. an immediate whole body scan;
2. photographs before organ retrieval;
3. the forensic pathologist to be offered the opportunity to be present at organ retrieval;
4. the transplant surgeon(s) to document all findings at retrieval.
I telephoned my coroner’s officer and explained my decision. My involvement in the matter that day concluded at around 4pm. However, I received a telephone call at 5.30pm from .
introduced herself as the specialist nurse for organ donation with responsibility for this matter. She had spent much of the day working with Mr Clayton’s family on the potential donation.
She told me that, quite literally as Mr Clayton’s family were leaving the hospital, the Kent Police family liaison officer (FLO) stopped them and told them that, if they allowed the organ donation for which they had already given their written consent to go ahead, the person who had killed Mr Clayton might not be convicted (I paraphrase). Apparently the FLO had been instructed to have this conversation by .
Mr Clayton’s family had hoped that some good could come from Mr Clayton’s very untimely death. They had firmly indicated that they wanted organ donation to go ahead, and were apparently devastated at the news that donation would compromise the homicide investigation. They felt they had no choice but to withdraw their consent to organ donation.
The organ donation did not, therefore, go ahead.
When a death is reportable to HM Coroner, the coroner has lawful control of the body, and so his or her permission is sought before any organ donation. The coroner does not give consent to the donation, only the individual himself by way of advance directive, or his family consulted at the time of death, can do that. However, after consent is given, the coroner may then raise an objection to donation. If the coroner objects to donation, the donation cannot take place.
Mindful of the ongoing police investigation, I asked that the Kent Police senior investigating officer (SIO) telephone me to discuss the proposed donation. A short while later, the detective chief inspector in charge of the investigation, Paul Fotheringham, telephoned me. He gave me an account of the investigation so far, and told me that Kent Police objected to organ donation going ahead, on the basis that this would compromise the criminal investigation.
We talked through the matter at some length. He was concerned that the organs it was proposed to donate (lungs, kidneys, small bowel and pancreas) might be diseased and the suggestion be made that this had contributed to death. I put it to him that if they were diseased then they would not be suitable for transplant. He was further concerned that these organs might have been injured by the attack. Removal of them would therefore deny us the ability to determine the medical cause of death. I explained that the understanding that I had gained, was that Mr Clayton had died from a traumatic head injury, and therefore the organs in question would not take us any further forward in determining medical cause of death.
I told that I saw no reason to object to the donation. I suggested that we work together, to facilitate donation without compromise to the homicide investigation. I offered my assistance, for example, I authorised the taking of photographs before donation. The detective chief inspector remained very firmly opposed to donation.
I suggested that he contact the forensic pathologist who was to perform the post mortem examination and then, having spoken to him or her, ask that pathologist to telephone me. I asked to ascertain from Mr Clayton’s treating clinicians the nature and extent of the head injury.
A little while later, I was telephoned by , consultant forensic pathologist on call this weekend. and I discussed the proposed donation. s view was that going ahead with the donation carried with it the potential to lose some evidence, and he advised against it. gave me a thoughtful analysis, suggesting that if the organs were donated, we might not discover whether any of these organs had sustained contusions in the kicking that was apparently discernible on CCTV. I asked him how much further forward the discovery of a contusion (that presumably did not significantly affect function or the organs would not be suitable for donation) would really take us, given the nature of the CCTV (showing one person kicking Mr Clayton repeatedly) and most especially given that cause of death appeared to be a traumatic head injury.
He felt that this was really a legal question, and also explained that he did not have any detailed information on the clinicians’ view of medical cause of death or the extent of Mr Clayton’s head injury.
Having gone through the matter together carefully, remained of the view that there was a risk of losing some evidence by allowing donation but, in response to my direct question as to whether he viewed allowing donation to go ahead as foolhardy, he replied that he did not. He told me that he recognised that this was a balancing act, and that the decision was mine.
The decision before me seemed a difficult one. I was inclined towards donation, but I thought it would be helpful to articulate my thoughts by running through the scenario with another senior coroner, and so I telephoned a colleague in a different part of the country. I wanted to be sure that I had considered all angles before coming to my conclusion. Again, we spoke at some length.
I then spoke again to He re-emphasised that his duty was to ensure an effective investigation/prosecution, and he once again voiced his objection to donation. I requested that he ask Mr Clayton’s treating consultant to telephone me.
I was then called by is a consultant in critical care and renal medicine, and he explained that he was responsible for Mr Clayton’s care. He told me that there was absolutely no doubt in his mind about the cause of Mr Clayton’s death. This was an unsurvivable traumatic head injury. He said that the head injury was massive, and that he was not sure when he had seen a head injury of this magnitude, in spite of his role at the trauma centre of the Royal London Hospital.
I thought very carefully about all the evidence that had been presented to me and I made my decision. I telephoned once more and told him that I would not raise any objection to donation.
Once again I went through my responsibilities with him, re-iterating that I wanted to guard against the failure of a proper conviction or a proper acquittal because of any compromise by organ donation. I told him that, although I completely took point that some evidential detail might be lost by organ donation, I did not believe that this would impact upon the proper exploration/prosecution of any person potentially responsible for Mr Clayton’s death.
I asked that the following steps be taken:
1. an immediate whole body scan;
2. photographs before organ retrieval;
3. the forensic pathologist to be offered the opportunity to be present at organ retrieval;
4. the transplant surgeon(s) to document all findings at retrieval.
I telephoned my coroner’s officer and explained my decision. My involvement in the matter that day concluded at around 4pm. However, I received a telephone call at 5.30pm from .
introduced herself as the specialist nurse for organ donation with responsibility for this matter. She had spent much of the day working with Mr Clayton’s family on the potential donation.
She told me that, quite literally as Mr Clayton’s family were leaving the hospital, the Kent Police family liaison officer (FLO) stopped them and told them that, if they allowed the organ donation for which they had already given their written consent to go ahead, the person who had killed Mr Clayton might not be convicted (I paraphrase). Apparently the FLO had been instructed to have this conversation by .
Mr Clayton’s family had hoped that some good could come from Mr Clayton’s very untimely death. They had firmly indicated that they wanted organ donation to go ahead, and were apparently devastated at the news that donation would compromise the homicide investigation. They felt they had no choice but to withdraw their consent to organ donation.
The organ donation did not, therefore, go ahead.
Copies Sent To
, Chair of the IPCC (Independent Police Complaints Commission)
, Kent Police and Crime Commissioner
Detective Chief Inspector , Kent Police
, consultant forensic pathologist
, regional lead for organ donation
, specialist nurse for organ donation
, consultant in critical care & renal medicine, Royal London Hospital
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.