The jury in the inquest looking into the death of Habib “Paps” Ullah returned a verdict of misadventure with a narrative.

Below are the answers to the questions put to the jury when reaching a narrative verdict.

1. For what reason did the police officers first have any engagement with Mr Ullah on the evening of July 3, 2008?

The police stopped Mr Ullah and others because, based on intelligence, they suspected that the occupants of the car may have been in possession of Class A drugs.

2. Whilst the search was taking place:-
a) How did Mr Ullah appear to be as viewed by any of the police officers?

Mr Ullah appeared to the police to be unwell, unsteady on his feet and possibly under the influence of drugs.

b) Was he compliant?

During the search Mr Ullah was fully compliant.

3. a) Was there a package containing crack cocaine in Mr Ullah’s mouth?

There was a package containing crack cocaine in his mouth.

b) Did the police officers believe Mr Ullah had put something in his mouth which was potentially fatal or seriously injurious to his health if swallowed?

The police officers believed that Mr Ullah had put something in his mouth that was potentially fatal or seriously injurious to his health.

4. a) For what reason did police officers use force upon Mr Ullah?

The police officers used force upon Mr Ullah initially in order to remove the package from his mouth to prevent him from swallowing it and to gain control over him.

b) Was a request or command made to him before the first back slap and if so, what was it?

A request was made to Mr Ullah before the first back slap to open his mouth and show the officers what was inside his mouth.

c) i) Was there any time interval between any such request and the back slap?
ii) Was there a time interval between that back slap and the officers taking hold of Mr Ullah?

[i) and ii)] The request was followed almost immediately by the first back slap and an officer taking hold of his right arm.

d) Could the officers have considered an alternative way to deal with Mr Ullah and the suspicion of a package in his mouth? Can you identify such an alternative from the evidence?

The jury believe that the officers could have considered alternative ways of dealing with Mr Ullah without using force. For example: engage in verbal communication using specific, clear and repeated commands as outlined in the police training for non-physical compliance; allow Mr Ullah sufficient time and opportunity to respond to the commands, that is to stand back and monitor, and consider handcuffing him at this time; once it had been decided to apply physical force the officers could have used their rear take down technique.

e) Once force was being used on Mr Ullah (but before he went limp):- 
i) Can you say what was said to Mr Ullah by police officers?

Officers repeatedly asked Mr Ullah to spit it out. Officers were also head to say: open your mouth, we’re doing this for your own good; if you swallow it you could overdose and die; and, don’t swallow it, it will kill you, spit it out.

ii) What they said to each other?

The only communication amongst the police officers were the words “break his arm”.

iii) Describe briefly what force was being used on Mr Ullah?

Physical force was applied to Mr Ullah in the form of distraction blows and pain compliance techniques. Additionally Mr Ullah was subjected to an accidental finger in the eye socket, gripping of the throat and a nose pinch. Neither of the latter two are formally trained and may carry additional risks.

f) i) What techniques were employed by police officers upon Mr Ullah?

The following techniques were applied: backslaps; knee strikes; mandibular angle pressure point; ground pin including pressure to the right shoulder; arm entanglement and labid sulcus.

ii) What were these techniques employed to achieve?

These techniques were used to gain control in order to prevent the package being swallowed and to try to eject the package from his mouth.

iii) List those techniques which were formally trained and those which were not.

All of these techniques were formally trained except the labial sulcus. The jury questions whether the level of force used was appropriate given the level of resistance initially shown by Mr Ullah. We believe that the officers’ primary objective was to prevent Mr Ullah from swallowing the package and that the officers felt it necessary to do everything they could to prevent the risk of a fatal overdose. The jury is particularly concerned that the techniques were applied by several officers simultaneously while Mr Ullah was restrained in the prone position. Given that Mr Ullah was known to be vulnerable due to his state of intoxication the jury feels that greater communication should have been given to the risk factors, including stress, associated with positional asphyxia and that more care should have been taken to monitor Mr Ullah for any warning signs displayed.

5. a) At what time, date and place was Mr Ullah seen to gi limp and remain motionless on the ground?

Mr Ullah was reported to police control as limp and motionless at 7.32pm on July 3, 2008 at Lea Court, Sharrow Vale, High Wycombe.

b) In the period between when Mr Ullah went limp and shortly before the arrival of the paramedic
i) Was an ambulance called?
ii) Was any CPR applied?
iii) Was he placed in the recovery position?
iv) What monitoring took place?

An ambulance was called, no CPR was applied before the ambulance arrive. He was not placed in a classic recovery position as trained in First Aid but the paramedic identified that an attempt was made at the recovery position. The police officers observed chest movement and noted some respirator sounds. The jury notes that officers first aid training highlights the need to maintain an adequate airway and monitor for signs of abnormal breathing. Several officers recognised some signs associated with abnormal breathing but no practical assistance was offered. Valuable time was lost due to the fact that the officers believed him to be feigning unconsciousness. Once Mr Ullah was unconscious rigorous monitoring should have been undertaken. The jury believes that the level of monitoring was inadequate. Furthermore the jury considered that the incident was poorly managed. In particular the lack of communication and clear commands by a leading officer resulted in an uncoordinated and ineffective restraint.