Coroner's fears over CPR delay for man in custody

A coroner has raised concerns after a man who died following a cardiac arrest while in police custody was not given potentially life-saving CPR for more than eight minutes when he was found unresponsive.

An inquest heard that Nicholas Gedge, 35, died in hospital after earlier being held at Elland Road Police Station in late 2022.

In a prevention of future deaths report, West Yorkshire's coroner said after his cardiac arrest there "did not appear to be any shared understanding between the three people in the cell with Nicholas of the urgency of starting CPR".

In a statement, West Yorkshire Police said the force would "review and consider" the coroner's report "with a view to responding".

"Our thoughts remain with Mr Gedge's family and friends at this time," the statement added.

The inquest into the death of Mr Gedge, from Leeds, heard he had been arrested and remanded in custody at Elland Road Police Station in November 2022 ahead of a court appearance the next day.

A detention officer found him unresponsive in his cell at about 15:45 GMT, with a nurse and another detention officer then making their way into the cell.

However, CPR was not administered until eight minutes and 12 seconds after the first detention officer found Mr Gedge, who died in hospital later that day.

The jury at Mr Gedge's inquest, which took place in April 2024, concluded: "We understand that initial assessments needed to take place, however we feel CPR should have been prioritised by all in attendance."

In his prevention of future deaths report, published earlier this month, Mr Longstaff said there "did not appear to be a coordinated approach to assisting Nicholas, with the detention officers and the nurse not appearing to have defined roles which they understood and undertook".

He added that it was "not clear" whether there were protocols in place to determine roles in the event of a medical emergency.

Mr Longstaff also said the time it took for Mr Gedge to receive CPR "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".

Mr Longstaff has written to West Yorkshire Police and the Leeds Community Healthcare NHS Trust to find out what action they have taken, or planned to take, to prevent future deaths in similar circumstances.

In a statement to the BBC, Leeds Community Healthcare NHS Trust said: "The safety and wellbeing of the people in our care remains our focus.

"We are always open to learning and improving practice and as such we are working together to take action in response to the coroner's feedback."

A spokesperson for the Independent Office for Police Conduct, which investigates the most serious conduct matters involving the police, said the actions of the officers and police staff who had contact with Mr Gedge "were in line with the relevant policies and procedures".

"We found no indication that anyone serving with the police had behaved in a way that would justify disciplinary proceedings," they added.

Listen to highlights from West Yorkshire on BBC Sounds, catch up with the latest episode of Look North.