Inquest jury concludes that failures by the police, SERCO and Forensic Medical Examiner contributed to the death of Sivaraj Tharmalingam 

7th March 2016 

Mr Sivaraj Tharmalingam died on 18 April 2015 at Thames Magistrates Court, having been found collapsed unconscious on the floor of his cell. He had been transferred into SERCO’s care at court after being held overnight in Metropolitan Police custody at Forest Gate Police Station. He was 50 years old at the time of his death. The two week inquest into his death concluded on Friday at St Pancras Coroner’s Court. 

Mr Tharmalingam was a well-known member of the East Ham Tamil community and had helped locals with community engagement and dialogue. Sadly Mr Tharmalingham had a history of alcohol misuse following family bereavements in 2005, which led to the breakdown of his marriage. He had experienced seizures, one of which had resulted in a head injury that left permanent brain damage. Mr Tharmalingam was living in sheltered housing at the time of his death. Mr Tharmalingam was taking medication to prevent epileptic seizures as well as supplements for his alcohol misuse, and had previously suffered alcohol related seizures, including in police custody. 

The jury concluded that Mr Tharmalingam suffered a fatal alcohol related seizure in conjunction with an underlying heart condition. The jury identified a number of failures by those responsible for Mr Tharmalingam’s care that contributed to his death, including: 

• Mr Tharmalingam was seen by a Forensic Medical Examiner (FME) while in police custody. The consultation lasted less than a minute and the FME failed to make a meaningful connection with Mr Tharmalingam.The jury heard evidence that a police detention officer remained present in the examination room throughout.   The FME accepted that the examination was “cursory”. The FME was aware that Mr Tharmalingam was an alcoholic with epilepsy and yet did not look at Mr Tharmalingam’s medication or consider his previous custody records. The FME did not recommend a further medical review and relied on the fact that he had been interviewed by the police in concluding that Mr Tharmalingam was fit to be detained.
• Mr Tharmalingam told a police detention officer that he had vomited once in the morning before he was transferred to court. The inquest heard that despite being a possible symptom of alcohol withdrawal, the fact that Mr Tharmalingam had vomited was not passed on to the custody sergeant or to SERCO. It was accepted by a number of officers that this was a failure.
• Mr Tharmalingam’s Person Escort Record (PER) form had been inadequately completed, and it was unclear whether his medical form was included when he was transferred to court. The jury heard that the hard copy of the medical form has never been located and that significant parts of the form were left blank. Two police officers, including the custody sergeant responsible for signing off the PER, told the inquest that the blank sections were SERCO’s responsibility and that the police often left sections blank. SERCO witnesses stated that the blank sections were the responsibility of the police. It was confirmed in evidence from the National Offender Management Service, who provide the PER form, that the police were wrongly leaving sections of the form blank.
• The PER form included warning markers for alcoholism, epilepsy and suicidal thoughts. Despite this, the gaolers did not know of these warning markers even though they all attended a staff briefing that morning and despite the fact that two officers were sent to inform the gaolers of the warning markers. Mr Tharmalingam was therefore put on 10 minute checks, rather than five minute checks. The jury heard evidence that from 10am onwards Mr Tharmalingam was checked only once, at around 10.55am. Approximately 10-15 minutes later he was found collapsed in his cell.
• The jury concluded that SERCO’s cell checks were random and none were documented. The inquest heard evidence that at Thames Magistrates Court a SERCO computer operator marked that cell checks were completed on time despite having no knowledge of whether the checks had been done at all, or by whom. The operator told the inquest that she randomly guessed which gaoler might have done the checks and inputted the checks without ever having contact with the gaolers responsible for doing the checks. She informed the jury that this was how she had been trained. SERCO’s Head of Service Improvement accepted that the computer recording of the cell checks was a “work of fiction”.
• The gaoler who found Mr Tharmalingam collapsed in his cell failed to enter or begin CPR immediately. The inquest heard that the gaoler left the cell to inform his manager, causing a delay in the administration of medical help to Mr Tharmalingam.
• The jury concluded that there was a continuous lack of communication between organisations involved in the events leading up to Mr Tharmalingam’s death which contributed to Mr Tharmalingam’s death.

In addition to the jury’s findings, the inquest also heard evidence of a number of further failures and inadequacies in the care provided to Mr Tharmalingam by both the Metropolitan Police and SERCO: 

• Despite being arrested at sheltered accommodation known by the arresting officer for housing vulnerable individuals with ongoing care needs, no one at the police station was informed of this.
• Mr Tharmalingam’s anti-epilepsy medication was not listed on the custody record and the FME who examined Mr Tharmalingam was not made aware of it.
• Despite warning markers for alcoholism and epilepsy, a FME was not called straight away.
• Mr Tharmalingam was a vulnerable adult who was intoxicated on his arrival at the police station, he was recorded as rambling incoherently and he was marked as incapable of signing his own risk assessment. Despite this, Mr Tharmalingam was interviewed within an hour of his arrival, before the FME had examined him, and was interviewed without an appropriate adult.
• Mr Tharmalingham told the interviewing officer that he took medication as he had previously collapsed. This information was not passed to the FME and was not transferred to SERCO the next day.
• After Mr Tharmalingam had been interviewed, the FME arrived. No discussion took place between the FME and the custody sergeant either before or after the medical examination. As a result the FME was never made aware that Mr Tharmalingam had entered custody with anti-epilepsy medication in his possession.
• No consideration was given by police officers to ensuring a further medical review for Mr Tharmalingam in order to consider the known risks of seizure from alcohol withdrawal and epilepsy, and to allow Mr Tharmalingam to be given his medication.
• During the handover procedure at the police station Mr Tharmalingam asked for his medication. This information was not passed on to SERCO and no arrangement was made for Mr Tharmalingam to see a healthcare professional at court.

 
The Coroner indicated at the conclusion of the inquest that she will be writing a Report to Prevent Future Deaths. 

Mr Tharmalingham’s wife was very concerned to hear of the failings by SERCO and the police and the lack of care that her husband received.  She hopes that by shedding light on this matter it will prevent the same thing happening in the future. 

  

Selen Cavcav, caseworker from INQUEST said: 
“Failures identified by this inquest re-enforces the concerns raised by the inspectorate who described court custody as an “accident waiting to happen” and recommended urgent improvement to the conditions of court cells.  Mr. Tharmalingham deserved proper medical care and attention as a vulnerable adult.  Instead he received substandard treatment from all the agencies concerned.  This case has also exposed serious gaps concerning the transparency and  accountability when it comes to private contractors such as Serco.   There is at present no independent investigation mechanism in relation to deaths which take place in court cells as opposed to deaths in police or prison cells.   We call on the government to correct this dangerous gap in the investigation systems as it is essential that independent oversight is in place for all deaths in custody, to ensure accountability and enable the lessons to be learned and disseminated nationally to prevent future deaths” 

  

A recent report by the HM Inspectorate of Prisons found that poor conditions within court cell and recommended urgent improvement: https://www.justiceinspectorates.gov.uk/hmiprisons/inspections/court-custody-urgent-improvement-required/.   

INQUEST has been working with the family of  Tharmalingham Sivaraj since July 2015.  The family is represented by INQUEST Lawyers Group members Jo Eggleton and Christina Juman from Deighton Pierce Glynn solicitors and barrister Jesse Nicholls of Doughty Street Chambers. 

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