Ref:     2017NICORONER6
Neutral Citation No:  [2017] NICoroner 6
 
Judgment: approved by the Court for handing down
(subject to editorial corrections)* 

Delivered: 02/10/2017

IN THE CORONERS COURT FOR NORTHERN IRELAND
__________
IN THE MATTER OF
AN INQUEST INTO THE DEATH OF 
MAIREAD MCCALLION
________
Before: Coroner Patrick McGurgan

1.	The Deceased, Mairead McCallion, born on the 9th March 1977, of Flat 2, 26 Dublin Road, Omagh, died on the 24th February 2014.
2.	On the morning of the 23rd February 2014, the Deceased, who had a history of severe mental health problems and chronic alcohol dependency, was at 6 Castleview Court, Omagh. A brother of the Deceased’s then partner, Noel Knox, resided at this address.    
3.	Mr Patrick Slevin gave evidence to the Inquest. He described himself as being a life long friend of both Mr Brian Knox, the tenant of 6 Castleview Court and Mr Noel Knox. According to his evidence, on the morning of 23rd February 2014, he had been passing number 6 Castleview Court having come from his sister’s house. He knew that this was the address of Mr Brian Knox and so he decided to pay him a visit. On knocking the front door, he states that same was opened by the Deceased and he learnt that Mr Brian Knox was not at home. Mr Slevin told the Inquest that he knew the Deceased to see from over the years but did not know her well. Mr Slevin stated that the Deceased invited him into the house and on entering the property he could smell alcohol of the Deceased and noticed a two litre bottle of cider sitting on the living room floor. The Deceased appeared intoxicated to Mr Slevin. Mr Slevin stated that he then requested the Deceased to phone her partner in order to invite him to the property. Mr Slevin explained that this was because he wanted to have a chat with Mr Noel Knox. It appears that the Deceased did then contact her partner by phone. Mr Slevin stated that he heard the Deceased state to her partner “Noel, Paddy’s here and he wants to know if you are coming down?”.   Mr Slevin was unsure if he himself spoke to the Deceased’s partner on the phone either before he called at the property or during the phone call between the Deceased and her partner. He advised that Mr Knox may have spoken to him on the phone at this time but that he did not recall him being abusive or threatening. Mr Slevin confirmed that his nickname is “clown”. Mr Slevin and the Deceased proceeded to wait on Mr Knox attending the property. At this stage Mr Slevin stated that the Deceased appeared normal and made no complaints to him albeit that he could not recall in evidence what conversation, if any, occurred between them at this stage.
4.	Mr Slevin stated that Mr Knox arrived at the property at 6 Castleview Court within approximately 5 minutes of the phone call between the Deceased and Mr Knox ending.  He described Mr Knox as not being aggressive, nor did he have a raised voice. He stated that Mr Knox was cool and calm. On entering the living room of the property, Mr Slevin stated that Mr Knox told the Deceased that it was time for her to leave the property and that he gently ushered her out through the living room door and out the front door. Mr Slevin then indicated that he decided to leave notwithstanding the fact that he was apparently at the property to have a chat with Mr Knox. He stated that he was behind both the Deceased and Mr Knox whenever the Deceased was being ushered out of the property and that he did not witness the Deceased’s hair being pulled, her head being banged against a wall nor her falling into the garden. 
5.	Once both the Deceased and Mr Slevin were outside the property Mr Knox closed the front door. Mr Slevin noticed that the Deceased had no shoes on nor had she a coat and he described the weather as lashing and then drizzling. He stated that he proceeded to knock on the front door and shout through the letterbox to try and get to Mr Knox give out a coat and shoes for the Deceased.  This lasted for some 20 minutes approximately, although Mr Slevin did not believe it was that long.  At no time did Mr Knox open the door. Mr Slevin accepted that this was an unusual action for a person whom he described as being cool and calm and non-aggressive. Police then attended the scene after having been contacted by Mr Knox due to the continuous knocking on the door. I will return to this at a later stage.
6.	In his evidence to the inquest, Mr Marcus McCallion, half-brother of the Deceased, stated that for a number of months prior to the Deceased's death, the Deceased had been trying to persuade him to patch things up with her partner, Mr Knox, following an earlier fallout. On Saturday 23rd of February 2014, Mr McCallion was contacted by way of telephone by Mr Knox advising him that he had a Celtic top for Mr McCallion and inviting him to his brother’s home in order to enjoy some alcohol together. Mr McCallion met up with Mr Knox and they went to watch the rugby on television in Mr Knox’s brother’s house (Mr Cahal Knox). The Deceased remained at number 6 Castleview Court. Over the next few hours Mr McCallion and Mr Noel Knox consumed quite a lot of alcohol. Mr McCallion stayed the night in Mr Cahal Knox’s home and awoke shortly before 9 am on the Sunday morning as he was hungry. He and Mr Noel Knox went to a local shop in order to get some food. On returning to Mr Cahal Knox’s home more alcohol was consumed by both of them.
7.	Mr McCallion advised the Inquest that as he was still tired he found himself dozing on and off whilst on the sofa in the living room. He then recalled being woken by the sound of shouting from Mr Noel Knox. He stated that Mr Noel Knox was arguing with his brother Mr Cahal Knox and he witnessed Mr Cahal Knox pushing his brother that is, Mr Noel Knox, back in an attempt to stop him from leaving the room. Mr McCallion further stated that Mr Noel Knox was on a mobile phone and that he was pacing up and down the living room shouting; “put that clown on the phone”.  Mr McCallion described Mr Noel Knox as being extremely aggressive, roaring at the top of his voice and walking around waving his fist. He stated that he heard Mr Noel Knox threaten the other person on the phone who he referred to as “clown.”  Mr McCallion confirmed that he understood Mr Slevin’s nickname to be “clown”.
8.	Mr McCallion stated that the shouting on the phone between Mr Noel Knox and the other person lasted for around 1 minute before Mr Noel Knox stormed out of the house slamming the door behind him. Mr McCallion advised the Inquest that he questioned Mr Cahal Knox as to what was happening and was informed that the Deceased had phoned Mr Noel Knox and informed him that Paddy Slevin was at 6 Castleview court.
9.	In his statement to the police, which was introduced to the inquest under Rule 17, Mr Cahal Knox, now deceased, stated that there were no raised voices or shouting by his brother. 
10.	In her evidence to the Inquest, Ms Teresa Corcoran, advised that at the time she was the girlfriend of Mr Cahal Knox. She knew the Deceased through a course that she and the Deceased had been attending three days per week. She informed the Inquest that following the death of her partner, Mr Cahal Knox, the Deceased’s partner, Mr Noel Knox, had become very supportive, that they were now very close friends and that they would stay over at each other’s houses on occasions. She described how on the morning of Sunday 23rd February 2014, she was at her partner’s Mr Cahal Knox’s property and was up the stairs in a bedroom. She described hearing Mr Noel Knox on a phone downstairs but did not hear the exact conversation. Ms Corcoran advised that the Deceased had earlier phoned her then partner Mr Cahal Knox enquiring as to the whereabouts of her partner. Sometime later, she heard her partner Mr Cahal Knox arriving to the property as he apparently had spent the Saturday evening in his mother's home. She described the Deceased’s partner Mr Noel Knox as being “a bit annoyed” as he left the property. Ms Corcoran stated that she had never witnessed any violence between the Deceased and Mr Noel Knox.
11.	In his evidence to the Inquest, Mr Noel Knox stated that he had been in a relationship with the Deceased for approximately 6-7 years. Although she had a flat of her own she effectively resided at 6 Castleview Court with him and his brother, Mr Brian Knox. On the morning of the 23rd February 2014, he received a phone call from the Deceased advising him that Mr Slevin was at the property at 6 Castleview Court. According to Mr Knox, he informed the Deceased that he would be attending the property immediately as he did not want anyone to be in the property. He stated that he walked to the property and promptly asked both the Deceased and Mr Slevin to leave. He stated that he placed two hands on the Deceased’s upper arms and walked her to the front door. He demonstrated to the court how he lifted her.  He did accept that he may have used some force when lifting the Deceased to her feet. He further stated that the Deceased was unsteady on her feet and that she fell into the front garden. He then informed Mr Slevin that he had to leave the property and once Mr Slevin left, he closed the front door and remained in the property. Due to continuous knocking on the front door and window he telephoned the PSNI. 
12.	Whilst Mr Knox conceded in evidence that it was a “bad” thing to have done, that is put the Deceased out into the cold with neither shoes nor a coat, he denied pulling her hair or banging her head against a wall. He further denied ever being violent towards the Deceased.
13.	Mr Knox told the Inquest that the Deceased did not have a key to 6 Castleview Court as she had never asked for one and that if he and his brother were ever away he would make arrangements for her to gain access to the property. 
14.	Whilst Mr Knox could not recall if his brother Cahal had tried to stop him from going to number 6 Castleview Court, he did accept that he was annoyed by Mr Slevin being in the property in the absence of Mr Brian Knox. He further advised that on entering number 6 he left the front door open which would not be what he usually did. On putting the Deceased out of the property, he described how she fell onto the grass but that he did not go to her aid. He told the court that he didn’t have any concerns that she might have hurt herself as a result of the fall.  He also stated that he may have spoken to Mr Slevin on the phone threatening him prior to attending number 6 but that he could not be sure of this.
THE POLICE
15.	Constable McCrystal gave evidence to the Inquest. He stated that at approximately 11:45am on Sunday, 23rd February 2014, he was tasked to attend 6 Castleview Court, Omagh. He was aware that a male person had phoned and reported that there were intoxicated persons on his premises and that he wanted them removed. Constable McCrystal and three other police officers arrived at the property approximately 15 minutes later. On arrival, he could see two people: a male and a female knocking on the door of number 6 Castleview Court. Constable McCrystal recognised the male as Mr Patrick Slevin. Mr Slevin made his way towards the Constable along the garden path and spoke to the officer. Mr Slevin appeared intoxicated and he informed the officer that he had just been passing by and saw the woman at the house. From a distance Constable McCrystal described this female as looking quite intoxicated. At one stage Constable McCrystal heard the Deceased’s then partner, Mr Noel Knox, say something along the lines of “go away” to Patrick Slevin.  Constable McCrystal described Mr Noel Knox as shouting and irate. He further described the Deceased’s partner as appearing to be becoming wound up and he also looked to be intoxicated and was slurring his words.
16.	On being questioned by police at the scene as to what happened in the house, Mr Slevin stated that he didn't know anything. Mr Slevin left the scene.  Mr Noel Knox was subsequently arrested for common assault of the Deceased and he was taken by Constable McCrystal and another officer initially to Omagh police station and then to Enniskillen police station. At Omagh police station he was breathalysed and had a reading of 122mgs per 100mls.
17.	Constable McCrystal eventually returned to Omagh police station and on entering the public area of the enquiry office in order to assist his colleague Constable Kilkey with the Deceased, he observed the Deceased sitting at the rear of the public area of the enquiry office slumped to her left. He and Constable Kilkey assisted the Deceased to her feet and walked with her outside to the police car, where she then got into the rear of the car and sat behind the front passenger seat. Constable McCrystal was driving the vehicle and Constable Kilkey set next to the Deceased in the rear. Constable McCrystal described the Deceased has been barely coherent, she was slumped over to her right for more or less the whole journey to her friend’s house which was some 5 minutes away by car from the Police Station. Upon arrival at her friend’s house, the Deceased became more unwell and started to vomit. She was not unconscious but was sluggish without much movement. She continued to cough and retch and didn't speak. On request of police, the Deceased’s friend brought a juice drink to the Deceased and paramedics were tasked to the scene.
18.	Constable McCrystal advised the Inquest that essentially he had relied on the fact that the Deceased had been seen by a Forensic Medical Officer at the police station and that no urgent medical issues had been raised. He stated that he was concerned at the public perception of placing someone in the Deceased’s condition into a police car and that but for the fact that she had been examined by a Forensic Medical Officer, given the condition of the Deceased, as he observed, in the enquiry office, he would have tasked an ambulance.
19.	In her evidence to the Inquest, Constable Kilkey stated that she attended at number 6 Castleview Court accompanied by Constable McCrystal with two other officers arriving at the same time. On arrival Constable Kilkey approached the front door of number 6 and asked the male and female who were outside to move aside. She knocked on the door and same was answered by Mr Noel Knox. Constable Kilkey entered the property and she stated that there were no obvious signs of a disturbance in the hallway. According to Constable Kilkey, Mr Noel Knox informed her that the male and female who were outside were using the property as a drinking den and that he wanted them out. He then proceeded to hand Constable Kilkey one of the Deceased’s shoes, her mobile phone and handbag. Mr Noel Knox denied being either the boyfriend or partner of the Deceased. Constable Kilkey also retrieved a coat belonging to the Deceased and gave it to her outside. The Deceased informed Constable Kilkey that she wished to make a complaint of assault against her partner Mr Noel Knox. The Deceased told Constable Kilkey that her partner came into number 6, grabbed her by the hair, hit her head against a wall and threw her out into the garden.
20.	On speaking to the Deceased, Constable Kilkey noted that some of the Deceased’s hair on her left hand side of her head appeared to be hanging lower as if it had been pulled. At this stage Mr Noel Knox exited the house and indicated to Constable Kilkey that he had to leave and on this he was arrested by Constable Kilkey for the offence of common assault.
21.	The Deceased was escorted to one of the police cars and whilst she was in the rear of the police car, Constable Kilkey again spoke to her about her allegation. According to Constable Kilkey, the Deceased stated that her head was a bit sore. Constable Kilkey had noticed a small scratch to the inside of the Deceased’s left eye. On questioning, the Deceased indicated that she did this herself due to having long fingernails. 
22.	Constable Kilkey had been made aware from her colleague at the scene, Constable Cunningham, that the Forensic Medical Officer, Dr Paul Alleyway was present in the police station.  At this time there was an informal policy of bringing some injured parties of violence/assault to the police station to be medically examined by the Forensic Medical Officer (“FMO”). This approach was adopted in order both to gather evidence for any potential prosecution and for a medical examination to take place. It was particularly useful for victims of alleged domestic violence.  Constable Kilkey contacted the Custody Sergeant, Sergeant Sproule and it was agreed that the Deceased would be taken to the police station in order to see the FMO.
23.	Constable Kilkey together with Constable McCrystal proceeded to take Mr Noel Knox to Enniskillen police station. Whilst at Enniskillen police station, Constable Kilkey was contacted by acting Sergeant Boyle advising her that Mr Noel Knox would need to be rearrested for the offence of assault occasioning actual bodily harm. This was due to the number of bruises the Deceased had presented with on examination by the FMO.
24.	Due to the Deceased not being available the following day, it was agreed between Constable Kilkey and acting Sergeant Boyle that she, Constable Kilkey, would return to the police station in Omagh in order to photograph the bruises. On arrival at Omagh police station, Constable Kilkey went to the enquiry office. The Deceased was in the bathroom. A short time later the Deceased exited the bathroom and took hold of Constable Kilkey’s arm in order to help her walk. It appears that the Deceased made a comment regarding the high heel shoes she was wearing. Constable Kilkey noticed that the Deceased was alert and responsive although she did ask Constable Kilkey to slow down on the way to the medical room. In the medical room, Constable Kilkey proceeded to take the photographs of the Deceased’s bruises. The Deceased took off her coat and Constable Kilkey observed an unusual amount of her hair on the neck of her jumper, left to middle area. During the course of the photographs being taken the Deceased indicated she wanted to go home and by this stage she appeared drowsy. Constable Kilkey described the Deceased as being tired and generally fed up. On walking from the medical room to the enquiry office, which was described as a short walk, Constable Kilkey described the Deceased as being a little slower and not very chatty. Once in the enquiry office, the Deceased was quite unsteady before sitting down. 
25.	Constable Kilkey felt that the Deceased’s deterioration may have been due to the fact that the Deceased had not had her medication that day. Once the Deceased was placed in the rear of the police car Constable Kilkey sat in the rear with her which appears to have been borne out of a concern for her well-being.
26.	Upon arrival at the Deceased’s friend’s house, Constable Kilkey went into the house to discuss if the Deceased could stay there. On being informed by Constable McCrystal that the Deceased was vomiting in the police car Constable Kilkey made telephone contact with the FMO who was at his home and he advised that the Deceased should be supplied with a sugary drink. Constable Kilkey contacted an ambulance and wrote a note for the ambulance staff which was sent with the Deceased to the hospital. It detailed that she had made an allegation of a head injury, amongst other details which I find suggests that Constable Kilkey had realised the potential significance of the head injury at that point.
27.	In his evidence to the inquest, Constable Waddell, advised that he attended 6 Castleview Court accompanied by Constable Cunningham. He described the two individuals outside the property namely, Mr Slevin and the Deceased, as looking intoxicated and unsteady on their feet. He described them as not being loud. He overheard the Deceased stating to Constable Kilkey that she, the Deceased, wanted to report an assault on her by her partner stating that she had been pulled by the hair and that she had had her head banged of a wall and thrown into the garden. Constable Waddell advised that he then spoke to Mr Slevin and enquired from him if he had witnessed any assault inside the property. According to Constable Waddell, Mr Slevin replied, “leave me out of this”. The Deceased’s partner then came to the doorway of 6 Castleview Court and shouted towards Mr Slevin. On seeing Mr Knox, Constable Waddell described how the Deceased appeared to hide behind Constable Cunningham. Constable Waddell stated that Mr Knox appeared angry with Mr Slevin.
28.	In the police car, Constable Waddell stated that the Deceased, on the journey to Omagh police station, attempted to pass him some hair and that he advised her to keep it in order to show the FMO.
29.	On arrival at the police station, Constable Waddell went to the Custody suite in order to await the FMO becoming free to examine the Deceased. Constable Waddell did not inform the FMO or anyone else of the details of the Deceased’s complaint. Constable Waddell accepted that with hindsight he should have.   The Deceased remained in the police car with Constable Cunningham for around 10 minutes whilst Constable Waddell checked if the FMO was free.
30.	Constable Cunningham informed the Inquest that he drove himself and Constable Waddell to number 6 Castleview Court. He followed Constable Kilkey into the property and noticed from the tone of voice being used by Mr Knox, that he was angry and annoyed.  He stated that he overheard Mr Knox inform Constable Kilkey that he had found his girlfriend, the Deceased drinking in the living room with Mr Slevin and that Mr Slevin was trying to arrange a party in the property. According to Constable Cunningham Mr Knox indicated that he wanted both the Deceased and Mr Slevin out of the property at that time. He further described how on seeing her partner at the doorway, the Deceased stood behind him and his impression was that the Deceased was in fear of her partner.
31.	Once at the police station Constable Cunningham waited in the car with the Deceased until he was informed by Constable Waddell that the FMO was available to see the Deceased. Constable Cunningham explained that upon entering the station he handed the Deceased over to a Custody Detention Officer, Ms Linda Carson and that he did not advise anyone of the specifics of the Deceased’s allegations.
32.	I find that there should have been a proper handover of the Deceased to the FMO to include reference to the allegation of assault to the head and that the lack of details provided to the FMO represented a loss of opportunity in respect of the care and treatment of the Deceased.
33.	In his evidence to the Inquest, Acting Sergeant Boyle stated that on the day in question he received a telephone call from Custody Sergeant Sproule advising him that the Deceased had been seen by the FMO and was ready to go home. Acting Sergeant Boyle then went to the Enquiry Office and spoke with the Deceased. He could smell what he believed to be alcohol on the Deceased’s breath. He did not have any concerns regarding the Deceased’s conversational ability. The Deceased made no mention of having sustained a head injury or of having her hair pulled to him.
34.	I find that following Acting Sergeant Boyle’s meeting with the Deceased she then began to deteriorate. 
35.	Chief Superintendent Karen Baxter gave evidence to the Inquest. She indicated that since May 2017 the policy of police officers bringing injured parties to police stations to be seen by the FMO had changed. Injured parties are now referred either to their GP or to hospital. Whilst Chief Superintendent Baxter suggested that it is working guidance and that there is some flexibility in the guidance she has issued, I find that the guidance is clear and does not provide for flexibility. 
36.	The evidence suggests that each case may benefit from individual assessment and that there may remain some advantages for bringing an injured person firstly to the FMO in the police station. 
37.	Chief Superintendent Baxter also outlined how police officers are guided by the Authorised Professional Practice (“APP”) Detention & Custody and are continually carrying out risk assessments of the situations they face. Notwithstanding this, I find that neither Constable McCrystal nor Constable Kilkey carried out a fresh risk assessment in relation to the Deceased’s condition whenever they arranged to take her to her friend’s house. As a result neither sought to contact an ambulance nor Dr Alleyway and I find that this represented a loss of opportunity in respect of the care and treatment of the Deceased.       
38.	Miss Linda Carson told the Inquest that she guided the Deceased into the medical room as she was slightly unsteady on her feet. Miss Carson was present throughout the examination by the FMO and remained with the Deceased whenever the FMO left the medical room. Miss Carson described the Deceased as being very articulate and chatty. She appeared somewhat scared when asked by the FMO as to what had happened. Miss Carson described her as appearing reluctant to answer to this line of questioning and that she chose her words carefully.  She did not recall the FMO enquiring from the Deceased about any bruising to her head, neck or face. During the examination it appears that the Deceased was twirling her hair with her finger on both sides and loose strands of hair were coming out which she placed on the table. Miss Carson believed that the hair loss may have been due to the numerous medical conditions that the Deceased suffered from. She further described the Deceased at the end of the medical examination as being a bit unsteady on her feet but the Deceased informed her that this was due to the shoes she had on being slightly big. During the period of examination, Miss Carson advised the Inquest that she did not notice any major change or deterioration in the Deceased’s demeanour.

FMO
39.	In the medical room the Deceased was examined by the FMO, Dr Paul Alleyway. He confirmed that he had received no handover or history from the investigating officer, but was simply told by the Custody Sergeant that a domestic incident had resulted in injuries to the Deceased. Dr Alleyway indicated that the Deceased informed him that she had been manhandled and grabbed by both arms. Initial examination demonstrated multiple bruises of varying ages. He described bruising on the left and right arms as being of a nature consistent with the history given to him by the Deceased of being grabbed by the arms. As result of the amount of bruises Dr Alleyway spoke to the Custody Sergeant as he felt that it indicated a possible pattern of repeated assaults. The Custody Sergeant informed the Duty Inspector and it became apparent that the Deceased was known to the Domestic Violence Officer. Dr Alleyway was satisfied that his concerns had been passed on appropriately. Dr Alleyway stated that he noted that the Deceased had a lump/bruise to her face and that he specifically questioned the Deceased about this. He was informed by the Deceased that this was a cyst which was due to be removed the following day. Dr Alleyway described how he did not see any change in the Deceased’s demeanour whilst he was dealing with her. He was anxious that she would not be in the station any longer than was necessary as she had not taken her epilepsy medication that morning. Dr Alleyway further indicated that the Deceased had informed him that she had numerous medical issues together with problems with alcohol. Dr Alleyway did not focus on her hair loss as he felt that this may have been associated with the Deceased’s anorexia. Dr Alleyway told the Inquest that he asked the Deceased about having a head injury but that she denied this.  She did however tell him that her hair had been pulled, as noted on his PACE 15/2 examination form.
40.	Dr Alleyway accepted that if he had been informed of the allegation of the Deceased having had her head banged off a wall he would have been more persistent with this line of questioning with the Deceased. He further accepted that he did not actively make enquires from the investigating officer regarding the specifics of the allegation.
41.	I find on balance that Dr Alleyway did enquire from the Deceased about a possible head injury on the basis of his evidence about this and because this would form part of any routine questioning. I find that the Deceased replied in the negative.
42.	Professor Farnan was engaged as an expert on behalf of the Coroner. He explained how he has been involved in delivering the training to Custody Sergeants and Civilian Detention Officers for many years and that part of his training highlights the issue of alcohol potentially masking the symptoms of a head injury. He described how individuals who have received a head injury could have a lucid interval before serious symptoms started to manifest themselves. 
43.	Professor Farnan told the Inquest that if he had been made aware of an individual suffering a head injury he would press that person for more detail on examination. 
44.	Both Professor Farnan and Dr Alleyway told the Inquest that they were aware of head injury advice cards being available in police stations. However, both Sergeant Sproule and Miss Carson stated that they were unaware of any such cards. 
45.	I find that there were no such cards available in Omagh Custody Suite on the day in question and the fact that no such cards were therefore given to the Deceased on leaving the station represented a further loss of opportunity in respect of her care.
46.	Professor Farnan also described how an FMO is required to carry out an examination without having access to all of the injured party’s or detained person’s medical notes and records. He did indicate that a limited medical record is now available but only in a few police stations.
47.	The evidence suggests that the PSNI and the Health and Social Care Boards should revisit this policy.    
48.	On the issue of training, the police officers were provided with different training to that delivered by Professor Farnan to the custody staff. Training records indicated that Constable Kilkey in particular had undergone first aid refresher training only a few days prior to the events in question. The first aid training materials supplied to the Inquest did not include any reference to the risks of alcohol when combined with head injuries. I directed that the PSNI respond to this issue post Inquest and they have indicated that some trainers might supply oral training about this, but they agreed that there is no reference to it in the training materials and it does not therefore form part of the standardised training.
49.	The evidence suggests that the training provided should specifically reference this and in particular how alcohol can mimic head injuries and vice versa.
50.	Following the ambulance being requested by Constable Kilkey, the Deceased was taken to the South West Acute Hospital, Enniskillen. The Deceased presented with a Glasgow Coma Scale of 3/15. A CT Scan revealed the extent of the subdural haematoma and following consultation with the Neurology department in the Royal Victoria Hospital, the Deceased was deemed unsuitable for surgical intervention. Life was pronounced extinct at 4.40pm on the 24th February 2014 in the South West Acute Hospital, Enniskillen.  
51.	In his evidence to the Inquest, Dr Brian Herron, Consultant Neuropathologist, stated that upon examination of the brain he found evidence of an “acute subdural haematoma”. This is an episode of bleeding which ultimately compresses the brain and caused death. Dr Herron described how he found signs of two possible previous episodes of bleeding on the brain but that these were minor. 
52.	Dr Herron was questioned on the possibility of the subdural haematoma being brought on by a “whiplash” type injury or indeed that it may have been a spontaneous bleed.
53.	Dr Herron felt that “on balance if not more”, the acute subdural haematoma was caused by a traumatic event and that the traumatic event most likely occurred within 48 hours of death. In addition, Dr Herron was able to state that lucid intervals following a trauma could last for 2-3 days before the onset of a rapid deterioration and death.
54.	I find that there was a lucid interval in the case of the Deceased.
55.	Dr Peter Ingram, Assistant State Pathologist for NI, gave evidence to the Inquest. Dr Ingram performed an autopsy in relation the Deceased and found after some detailed examination, a bruise on the underside of the scalp. Dr Ingram stated that this bruise would have started to appear from the point of trauma and onward. He indicated that the traumatic event would have occurred some 24-36 hours prior to death.  The under-scalp bruise developed into an external scalp bruise.
56.	Dr Ingram was also questioned about the possibility of a “whiplash” type injury or a spontaneous bleed. Dr Ingram was of the view that this bruising was evidence that the subdural haematoma was caused by trauma involving an impact with a solid unyielding object. Dr Ingram was also of the opinion that given the Deceased’s medical conditions an impact on a lawn could also have caused the subdural haematoma.
57.	I find that Dr Alleyway would not have been able to detect this bruise even if an examination of the head and scalp had taken place. 
58.	Dr Ingram further stated that if the Deceased had have been taken to hospital initially as opposed to the FMO, the outcome for the Deceased would have been no different.  
59.	The post mortem recorded and I find that the cause of death was:
1(a) Subdural Haematoma.
60.	I find on the balance of probabilities that the Deceased sustained a trauma which led to the fatal subdural haematoma.
61.	I find that from approximately 11.45am on the morning of Sunday 23rd February, the Deceased was in the company of either police, a civilian detention officer or a medical practitioner. At other times she was waiting in the police station and this has been captured on CCTV. The only exception is whenever the Deceased had gone to use the bathroom in the enquiry office at the police station and I find that the Deceased did not suffer any traumatic event during that short time in the bathroom.
62.	Similarly there was no evidence presented to suggest that the Deceased sustained a traumatic event during her time alone from the afternoon of Saturday 22nd February to the morning of Sunday 23rd February. Whilst the Deceased’s pre-existing health difficulties may have made her more susceptible to falling or having seizures which in turn could cause an acute subdural haematoma, I find on the balance of probabilities that there was no such traumatic event.
63.	Whilst I find that it did not play any part in triggering the subdural haematoma, I find that the Deceased did have some hair pulled out of her head with the roots attached and that this was the hair being proffered to Constable Waddell in the police car by the Deceased.    
64.	I find that the trauma sustained was an impact to the Deceased’s head and that it occurred on the morning of Sunday 23rd February 2014 whilst the Deceased was being removed from 6 Castleview Court by her then partner.