“Now, in this particular case we have a position of somebody who has held wraps in his mouth. The evidence that the jury need to look at, is there evidence that could go before the jury to show that the absence of the procuring of basic medical attention meant a contribution towards his death? There has to be a clear and direct causal connection established between the conduct so described and the cause of death. I remind myself that there is incontrovertible evidence that an ambulance was called at 1508. I know that the first call from Sergeant Cassells, uncontroversial, referred to the fact 'under arrest, not urgent'. But is there evidence that can go before the jury to show a clear and direct causal connection that meant that the failure to call the ambulance before 1508 and when there were signs of distress indicated in those circumstances - would the failure of that have caused the death? I remind myself and both counsel have helpfully reminded me of what the second ambulance lady said. There is some evidence that should go before the jury about the question of whether there was CPR, whether there was mouth to mouth resuscitation, these are matters that are clearly matters for the jury. But even on those bases, I do not think that there is evidence before the jury that can say that that failure and the failure to call an ambulance, if that is a failure, before 1508 had a direct and causal connection to the death. It is my view that there isn't evidence to go before the jury to suggest that. ”
“The conclusion I have come to is that, so far as the evidence called before the jury is concerned, a coroner should adopt the Galbraith approach in deciding whether to leave a verdict. The strength of the evidence is not the only consideration and, in relation to wider issues, the coroner has a broader discretion. If it appears there are circumstances which, in a particular situation, mean in the judgment of the coroner, acting reasonably and fairly, it is not in the interest of justice that a particular verdict should be left to the jury, he need not leave that verdict. He, for example, need not leave all possible verdicts just because there is technically evidence to support them. It is sufficient if he leaves those verdicts which realistically reflect the thrust of the evidence as a whole. To leave all possible verdicts could in some situations merely confuse and overburden the jury and if that is the coroner's conclusion he cannot be criticised if he does not leave a particular verdict.”
“(9) Neglect in this context means a gross failure to provide adequate nourishment or liquid, or provide or procure basic medical attention or shelter or warmth for someone in a dependent position (because of youth, age, illness or incarceration) who cannot provide it for himself. Failure to provide medical attention for a dependent person whose position is such as to show that he obviously needs it may amount to neglect …. (12) Neither neglect nor self-neglect should ever form any part of any verdict unless a clear and direct causal connection is established between the conduct so described and the cause of death.”
“The key to the proper approach here is, in my judgment, an appreciation that the expression 'clear and direct causal connection' was not used by the Master of the Rolls in the Jamieson case in the same sense in which such words might be used when considering whether a breach of contract or a tort has caused recoverable damage or, perhaps most pertinently, when considering whether the cause of a loss is to be found within a list of insured or excluded perils in a policy of insurance …. I make the point … to emphasize that the causal connection which is relevant in the context of consideration by an inquest jury of the addition of a neglect rider is, in my judgment, not the same as the causal connection for which one may look in the context of other, perhaps more familiar, enquiries. The touchstone in the present context is, I believe, the opportunity of rendering care, in the narrow sense of that word, which would have prevented the death …. That does not mean that a conscientious person would necessarily have done that which would have successfully prevented death. The question is whether he had the opportunity of doing something effective.”
“… I am unable to accept [counsel for the coroner's] submission that the intervening steps … represent sufficient breaks in the chain so as to prevent there being a 'clear and direct causal connection' between a failure to arrange to have a check made upon the patient and the patient's death. There is no complex chain of events here. One is dealing with the consequences of failing to make a simple check. There is, in truth, no real dispute between Dr Barry and Professor Redmond as to what would have happened if Mr Nicholls' respiratory rate had been checked. They differ as to whether any doctor acting reasonably would have checked ….”
“… The negligence must have caused the death in the sense that it more than minimally, negligibly or trivially contributed to the death. On the one hand, none of the experts can be sure that even if he had received the best possible immediate care in the custody suite he would have survived …. On the other hand some experts, notably perhaps Professor Crane and to a lesser extent possibly Dr Carey, approached this problem - and problem it surely is - from a different direction …. … It was [Professor Crane's] opinion that whatever the reasons for loss of consciousness, the position in which [the deceased] was placed hastened death significantly, and both these factors were more than minimal or negligible. I suggest you ask yourselves this question, members of the jury, as you wrestle with this difficult concept of causation: If the experts cannot be sure that his condition was survivable, come what may when he arrived at the custody suite, can you in turn be sure, as a jury, that any hastening of the death you may find by omitting to place him in the recovery position and check his airway etcetera caused his death more than minimally, trivially or negligibly? His death may have been hastened by his position but can you say that caused his death more than minimally …. Can you be sure that a slight hastening … can properly be classed as a contribution to his death that is more than minimal? That is for you to decide.”
"if you have got somebody who you suspect of having drugs in their possession, you suspect they've put those drugs in their mouth then, one, get it out of their mouth and, two, get help very rapidly because they can go off very quickly"