The ACTUAL jury findings in the Jordan Begley Inquest

The mainstream media have this week been full of claims that the jury in the Jordan Begley case in Manchester found that he had been “killed by Taser”.  Most of them didn’t quite put it in so many words, but it was the distinct impression given by the way they reported the case.

Having read a few different reports of the case, it became apparent that the different media outlets were picking and choosing short quotes from the whole verdict (which came in the form of “Narrative Conclusions” – answers by the jury to a series of questions posed by the Coroner).  It didn’t take long for me to realise that some of the quotes in some of the pieces suggested that some of the claims made in others were unlikely to be accurate.

In view of the media interest in the case the Coroner supplied a copy of the “Narrative Conclusions” to the main media outlets in order to ensure their reporting was accurate.  The document is therefore in the public domain (it is also viewable by the public if they visit the Coroner’s Court in any case).

I have obtained a copy of the document and, lo and behold, some of the media reporting WAS misleading.  In order to allow people to make up their own minds, here are the actual findings of the jury.  I have transcribed it as accurately as possible.  The parts in italics are in handwriting on the original document.  The underlining is as on the original document.  I have used [square brackets] to show where information has been redacted.  The items marked [sic] have been transcribed exactly as they are in the original document even though they appear to be misspelt, etc.

Here are the full findings of the jury:

Record of Inquest:

Following an investigation commenced on the 25th day of July 2013
And Inquest opened on the 26th day of July 2013;
And an inquest hearing at Manchester Civil Justice Centre on the 1st day of June 2015 heard before Mr Nigel Sharman Meadows, Senior Coroner in the coroner’s area for Manchester (City) Area, and the undermentioned jurors [details of the jurors were redacted], the following findings and determinations were made

1: Name of Deceased:   Jordan Lee BEGLEY

2: Medical cause of death:

Ia – Cardiac arrest
Ib – Cardiac dysrmythmia / arythmia [sic]
Ic – Combined stressful events, multiple increase in catecholamines
II – Personal history / health and lifestyle

3: How, when and where, and for investigations where section 5(2) of the Coroners and Justice Act 2009 applies, in what circumstances the deceased came by his or her death:   See attached

4: Conclusions of the Jury as to the death:  See attached

5: Further particulars required by the Births and Death Registration Act 1953 to be registered concerning the death:  [Personal details of Jordan Begley]

Signature of HM Senior Coroner:  Nigel Meadows
Signature of Jurors:  [Redacted]

Attached document:

Inquest into the death of Jordan Lee Begley
Continuation of the Record of Inquest

3: How, when and where and for investigations where section 5(2) of the Coroners and Justice Act 2009 applies, in what circumstances the deceased came by his or her death:

Jordan Lee Begley died of a cardiac arrest on the 10th July 2013 at Manchester Royal Infirmary.
The circumstances of how the deceased came to his death was due to prolonged stress which produced a catecholamine induced cardiac dysrthythmia
[sic] and arrhythmias.  These factors caused the cardiac arrest.

4: Narrative Conclusion of the Jury as to Death:

QUESTIONNAIRE:

1. What were the circumstances which led to the police attendance at [redacted address] Road, including Jordan Begley’s behaviour and underlying condition?

ANSWER: The police attended [redacted address] Road after a 999 call from Mrs Begley (Jordan’s mother), claiming Jordan Begley, her son who suffered from acute alcoholism and was intoxicated on the day in question, was aggressive and threatening due to the fact he had been accused of stealing a handbag, which he denied.

He was threatening to go outside and attack the people who were supposed to be coming round.

She claimed he had a knife, she also stated he had been drinking, he had a violent nature and she was worried about his safety and the safety of others.  Mrs Begley requested a quick response to de-escalate and sort out the situation.

2. What were the circumstances which led to the deployment and discharge of the Taser in the back room?

ANSWER:  Jordan Begley was initially approached by PC Andrew Moore and Special Constable Jordan Thomas and engaged in a conversation outside [redacted address] Road.  At this point, Jordan was in a highly agitated state.  At or around 20:23:52, Jordan Begley entered the property, followed by PC Andrew Moore, and both individuals walked to the room known as the ‘spare room’.  Andrew Moore made a radio transmission that Jordan was agitated but was now calming down.  At this point only Jordan Begley and PC Andrew Moore were in the spare room.  Jordan and PC Andrew Moore engaged in a conversation for a period of time, which largely related to an accusation of theft made against Jordan.  The latter indicated a sum of cash, which at different times was in his hand and on the table in the spare room.

PC Ashley Owen Evans then entered the property and came to a location near the doorway of the spare room.  She communicated to Jordan that in fact his mother was the person who had called the police.  It was at this point that Jordan’s attitude changed, becoming much more agitated.  He requested that all officers leave, apart from PC Andrew Moore, with whom he had clearly developed a positive rapport.

Shortly after, Ashley Owen Evans left, exiting the house and PC Donnelly positioned himself in a similar location near the doorway.  This further increased Jordan’s agitation, prompting him to question aggressively why PC Donnelly was present.  PC Moore told Jordan to ignore PC Donnelly and concentrate on him.

However, at this stage, PC Donnelly took control of managing the situation.  He requested Jordan Begley to come towards him for the purposes of a search, to be carried out by PC Andrew Moore as the police had had a report of someone with a knife.  Jordan complied with this request.  At some point, he requested Jordan Begley to stand still as he approached him, moving slowly down the side of the table towards the front of the property.

At or around this point, PC Donnelly drew his Taser from its holster and aimed it at Jordan Begley.  Jordan moved towards the doorway.  Due to the fact the Taser was aimed, PC Andrew Moore was able to see the ‘red dot’ on Jordan Begley’s chest as he moved around the table.

Jordan’s movement caused PC Donnelly to take at least one step back in the direct of the front of [redacted address] Rd. This movement meant PC Donnelly was no longer visible to PC Andrew Moore when the Taser was fired.  Jordan Begley also passed out of PC Andrew Moore’s sight before the Taser was fired.

3: What was PC Donnelly’s honestly held belief at the point at which the Taser was fired?

ANSWER:  PC Donnelly’s belief was that Jordan Begley may have a knife on his person somewhere and that he may use this to injure himself or others, even though he knew from talking to Jordan’s mother that he last sighting of the knife was on the kitchen table.  His belief was that he needed to fire the Taser to stop Jordan coming towards him or pass [sic] him.

4: Was the use of the Taser by PC Donnelly reasonable in the circumstances as he honestly believed them to be?

ANSWER: PC Donnelly would have known that a reasonable circumstances to use the Taser would have been when there is a severe threat of violence or the potential of one.  He would also be aware that the Taser should not be used in a confined space and that there should be sufficient distance between the Taser and the subject for it to work effectively.  He would have also been aware that the red dot needs to be positioned lower than the heart and above the groin area.  He knew that the Taser can be used in various stages as a means of compliance even before it is discharged.

PC Andrew Moore did not believe that there was a severe threat of violence as he was comfortable to be in the room with Jordan as he was making progress and building a rapport with Jordan through communication, and was seeing Jordan calm down.

This was in contrast to PC Donnelly who drew his Taser even though Jordan had complied with his request to come towards him and therefore saw it as a threat, albeit that there was still no violence.

Once the Taser was drawn, the situation escalated, which made PC Donnelly be on a higher state of alert.  As he believed the threat warranted a response the Taser was deployed.  PC Moore agreed the most appropriate physical response was the Taser compared to the baton or CS spray.  However PC Donnelly inappropriately used the Taser by holding the trigger down [illegible] that it was deployed for over 8 seconds which is not reasonable use.

For the whole question (9:2) for NO.

5: Was the nature and manner of the restraint reasonable?

He was forced to the floor by the fire arms [sic] officers which we believed caused the lump on his head.

Once on the floor the fire arms [sic] officers did not try to establish whether he was conscious.  They all ignored the fact he did not cry out or make any verbals at all during the restraint.

Jordan offered minimal resistance as medical evidence says that there was minimal bruising.  There was no need to punch twice without even checking his first response to the first punch.

No firearms officer took control of the the [sic] head. On the balance of probability Jordan was left too long face down once handcuffed.  They were more concerned about their own welfare than that of Jordan.

6: Did any officers fail to follow their training and, if so, in what respect?

ANSWER:  Yes there were several failures.

Overall communication has been poor, this has been covered in 4.8

PC Donnelly:
  – Communication failures (see 4.8)
  – Taser use must be proportionate, but was used for 8-9 seconds +
    then a 3rd round was offered.
  – The mechanics of Taser use are not known, specifically:
– What effect holding on to the trigger has
– Distance needed between the barbs
– Distance needed between subject + officer
– Length of cycling times when holding down the trigger
– Need to aim below heart
– Draw / aim / red dot shown should be 3 separate actions

 Evans:
–  Communication failures (see 4.8)

Fire Arms [sic] officers:
– Communication failures (see 4.8)
– Inadequate warnings to accompany distraction strikes
– Search didn’t happen quickly enough
– Jordan was left face down for too long to be safe
– No verbal reassurance was offered after the restraint
– No officer looking after Jordan’s head during restraint even though
there were enough officers in the room
– No team leader giving clear and effective orders to coordinate
restraint, search of and verbal communication to Jordan
– No after care or communication for Mrs Begley (see 4.8)
– Delay to statements

Sergeant Burnett:
– Not adequately overseeing operation
– Didn’t check what was happening in the spare room, assumed it was
just first aid
– Allowed crime scene to be contaminated by family dog being left in
house overnight

– No after care for Mrs Begley while on scene

7A:  Did the whole package of stressors (which includes chronic alcoholism, acute alcohol intoxication, the initial altercation with members of the public, the arming himself with a knife, the calling of the police, the news that the mother had called the police, the confrontation with the police and the use of the Taser and restraint) materially contribute to the death of Jordan Begley?

ANSWER:  Yes.  We conclude that the whole package of stressors did more than minimally and materially contribute to the death of Jordan Begley.  We have reached this conclusion based on the medical evidence of Drs. Todd, Saltissi and Carter.

7B:  Did the stress of the discharge of the Taser and the restraint materially contribute to the death?

ANSWER: Yes.  Although we accept that Jordan Begley had underlying physical vulnerability, we conclude that the stress of the discharge and the restraint more than minimally and materially contributed to the death of Jordan Begley.

8: Was there a failure in communication between the officers and, if so, what?  Did any such failure possibly contribute to the death?

ANSWER:  We conclude that a number of major and minor failures in communication occurred, several of which possibly and probably more than minimally contributed to the death of Jordan Begley.  These relate to:

1) The information contained within the transmissions to and between call handler(s), police officers and duty response commanders.  We note that Sergeant Burnett and Inspector Rainford were monitoring radio transmissions.  The ability of different officers to listen effectively to different channels to the exclusion of others, with critical information, was an important factor.  For example, we note that all the firearms officers (bar PC Troy Tyldesley, who played no critical role) did not hear the communications for patrols to slow down, PC Andrew Moore’s message that Jordan Begley was calming down, or PC Donnelly’s message confirming he was a Taser trained officer at 20:19(44).  If they had been aware, it is possible they would either not have attended or secondly modified their behaviour with regard to the restraint.

2) Special Constable Jordan Thomas and PC Ashley Owen Evans did not pass on the information from Dorothy Begley to the effect that the last time she saw the knife it was on the kitchen table.

3) PC Andrew Moore did not inform PC Donnelly that he had asked Jordan Begley to show hi his hands and that he was successfully managing the situation.

4) PC Donnelly made several failures of communication.  He did not follow the 5-step communication model (p.125 of evidence bundle), omitting steps 3 and 4.  Given PC Andrew Moore’s previous success in calming Jordan it is possible PC Donnelly would not have had to Taser him had he adequately followed the model.  In relation to this, PC Donnelly did not speak to Ashley Owen Evans when they were briefly in the doorway as to what had occurred while she was observing the situation.  Subsequently, PC Donnelly did not communicate to Andrew Moore the information he had gleaned from Dorothy Begley or ask if he had searched him already.

5) Failures in communication by firearms officers
No officer explained adequately to Dorothy Begley what was occurring, particularly with regard to the life threatening events once it became evident Jordan was experiencing breathing and heart complications.  While restraint was occurring, adequate and appropriate reassurance was not being given to Jordan Begley.  Had this happened they may have been alerted to the serious state of his health.  Furthermore, PC Mills did not communicate an adequate warning to Jordan between the distraction strikes.

Overall, PC Andrew Wright did not adequately manage the communication.  No firearms officer indicated that Jordan spoke at any point during restraint, but until the vital signs were checked no reassurance was given.  In evidence, Andrew Wright acknowledged he did take a lead role.  While communication with ambulance staff appears to have been adequate, communication with Dorothy Begley was not.

 

 

Advertisements

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google+ photo

You are commenting using your Google+ account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

w

Connecting to %s