A fatal accident inquiry (FAI) has ruled that there is nothing police could have done to save the life of a Moray burns victim who took a deadly amount of cocaine around the time he was being arrested.
A probe into the death of Kyle Stewart, of Beech Walk in Elgin, was launched after he died while in police custody on November 25, 2019.
Mr Stewart, 28,was severely burned in a fire at a caravan park in July 2010 and required several operations, skin grafts and plastic surgery to reconstruct his head and upper body after a faulty gas canister exploded and set his clothes alight.
As a result of his burns and a road traffic collision in 2016, he suffered a disability where his spine was twisted and his neck was partially immobile, causing his head to hang permanently to the right.
While in a cell at Elgin Police Station, Mr Stewart fell unwell and first aid had been administered.
He was then taken by ambulance to Dr Gray’s Hospital where medical staff continued with resuscitation attempts but were unable to save him.
The preliminary hearings were held via video link on January 15 and January 29, and February 26.
The inquiry proceeded on March 23 and March 24.
‘Small, plastic bag removed from his mouth’
On Monday, November 25, 2019, at around 9.30am, constables Lawrence Ramsey and Carl Jellis attended Mr Stewart’s home address where he was cautioned and arrested in connection with the theft of a motor vehicle and driving while disqualified.
Police found him in his bathroom and thought he may have been concealing an item behind his back, but found that Mr Stewart had nothing in his hands.
According to the FAI report, Mr Stewart battled with anxiety and depression, and as a result “took street drugs including valium, speed, cannabis and he smoked heavily”.
He was also prescribed venlafaxine, pregabalin, omeprazole, quetiapine, co-codamol and folic acid.
While at Elgin Police Station, Sergeant Phillip Stuart had authorised a full strip search.
This was done because Mr Stewart had a drugs marker on the police national computer (PNC) and had responded to questions during the vulnerability assessment process saying that he had taken drugs in the last 24 hours.
Nothing untoward was found.
However, during the search, Sgt Stuart did not check inside Mr Stewart’s mouth.
After that, Mr Stewart was provided with magazines and coffee. He was also moved from one cell to another to a more comfortable bed to lie down in.
Video footage recorded soon after shows Mr Stewart’s body seemed to “jolt, as if having a seizure”.
Ten minutes after the first seizure, constable Kevin Anderson entered the cell where he was unable to rouse Mr Stewart and proceeded to call an ambulance.
Constable Fiona MacKinnon also attempted to wake Mr Stewart after repeated attempts and was unsuccessful.
Mr Stewart was placed in the recovery position on the floor and his airways were monitored and maintained clear.
After being unable to detect a pulse or breathing, constable Ramsay rolled Mr Stewart on his back and began to perform CPR.
Paramedic Claire Alldritt arrived shortly after and when she checked Mr Stewart’s airway, she noticed an item inside his right cheek.
She then removed a “small, black plastic bag” from his mouth. It was thought that he had “regurgitated” the bag, or that it had been dislodged during the attempts to save his life.
On arrival to Dr Gray’s A&E’s department, Dr Pamela Hardy and the resuscitation team continued to ventilate Mr Stewart, but he had a pulse but was not breathing, with no effort on his own.
Mr Stewart was pronounced dead at 12.43pm.
‘Catastrophic’ levels of cocaine
Pathologists Dr Leighanne Deboys and Dr Tamara McNamee carried out
a post mortem examination of Mr Stewart on November 28, 2019.
Dr Deboys confirmed the cause of death from the toxicological analysis of post mortem blood and urine showed a “very high concentration of cocaine and its metabolites”.
According to the report, Dr Deboys said it was “one of the highest levels she had ever encountered in her professional career”.
It added: “The level of cocaine was so catastrophic that it was beyond compatible with life and no realistic medical intervention and resuscitation could have retrieved Kyle Stewart.”
Timeline
10.50am – Kyle Stewart enters cell M2 and is helped to the bed. He is provided with a drink and reading material.
10.53am – Police constable Kevin Anderson leaves the cell.
10.56am – Mr Stewart’s body seen to jolt, as if having a seizure.
Between officers leaving the cell and the first seizure he makes no movement towards his mouth with his hands.
10.57am – Mr Stewart can be heard breathing loud/snoring his left arm is constantly shaking.
11.00am – He is seen to have seizure followed by another one minute later.
11.04am – He has another seizure and afterwards loud snoring is heard.
11.06am – Constable Anderson enters the cell and is unable to rouse Kyle Stewart. He leaves the cell and is heard calling an ambulance via his
radio, asking to attend for a male having a seizure within the custody area.
11.07am – Police constable Fiona MacKinnon enters cell unable to rouse Kyle Stewart after repeated attempts.
11.08am – Police Constable Lawrence Ramsay enters the cell and along with Constable Anderson and MacKinnon, they place Mr Stewart on the floor into a recovery position. He is seen to continue having a seizure. Officers monitor his airways and protect his head from the wall and bed.
11.15am – Mr Stewart is still in the recovery position, but there is no longer any loud breathing.
11.20am – Constable Ramsay and Anderson detect Mr Stewart is not breathing and cannot detect a pulse. They roll him onto his back.
Constable Ramsay commences CPR as paramedic Claire Alldritt enters the cell. Also joined by police constable Carl Jellis.
11.27am – A package is removed from Kyle Stewart’s mouth by paramedic Claire Alldritt.
11.30am – Additional medical staff enter cell.
11.53am – Mr Stewart is removed from the cell by ambulance staff.
The report went on to say that unfortunately, as soon as Mr Stewart had ingested this exceptionally high toxic dose, “there was no realistic possibility of survival even with immediate medical treatment”.
Police training called into question
Mr Stewart’s family raised concerns that police officers should be trained to deal with overdoses in police custody.
However, Sheriff Olga Pasportnikov ruled that “no amount of effort or medical intervention would have been successful”.
The report concluded that all officers who dealt with Mr Stewart said had he let them know that he was concealing drugs, or had they had any suspicion that this was the case, he would have been “immediately taken to the accident and emergency department at the local hospital”.
It added: “There was some discussion surrounding the procedures which might have been expected in that event, including taking an x-ray.
“Even so, it is not certain that Kyle’s life might have been saved even then.”
Sheriff Pasportnikov said she considered the adequacy of the level of training of the police officers, and even with additional training, it would be difficult “to see how one could expect custody staff to make a medical diagnosis”.