Coroner makes critical recommendations

Coroner makes critical recommendations for SERCO, Metropolitan Police Service and the Forensic Medical Examiner in her report to prevent future deaths, following the inquest into the death of Sivaraj Tharmalingam at Thames Magistrates Court.

The Inquest into the death of Mr Tharmalingham, that concluded on Friday 4 March, heard evidence of the dangerous systems that were in place at the time that Sivaraj Tharmalingham died. Mary Hassell, Senior Coroner for Inner London North produced a report to Prevent Future Deaths (PFD) which has sought to address these failures and recommend areas that need action by the agencies to ensure that these gaps and dangerous practices do not continue. The Coroner highlighted the following issues and representatives for each have been sent a copy of her report to address these points. The main points were:


• There was a failure to carry out any checks by SERCO whilst Mr Tharmalingham was in their custody and the observations recorded on the computer system bore no relation at all, either in terms of frequency or identity of observer, to the observations actually made of the detainees.
• There was no clock at Thames Magistrates’ cell area and not all staff wore watches, so it was not possible to accurately time and record observations.
• There was confusion by staff over who was meant to be doing what, in terms of responsibility for detainees.
• There was confusion amongst SERCO staff over how a detainee’s warning markers and requirement for increased observations were communicated those carrying out checks
• There was no clear SERCO Standard Operating Procedure (SOP) stipulating that the custody manager was responsible for ensuring that officers knew who was responsible for doing what level of observations, nor one describing how a custody manager will deliver any instructions to officers.
• There is still no list of detainees with their warning markers indicated, in the cell area of Thames Magistrates’ Court.
• No SERCO SOP for specifying the observations, signs and symptoms and actions to be taken when dealing with custodies that have epilepsy or alcohol withdrawal or a detainee found unresponsive in a cell.
• There was and remains no SERCO SOP for what action a Prison Custody Officer should take if another officer is occupied with the particular needs of a detainee and cannot attend to their duties.

Forensic Medical Examiner (FME)

• The FME he did not ask to see Mr Tharmalingham’s medication or consider it all as part of the consultation, which is a significant omission in respect of any detainee.
• Forensic Medical Examiner (FME) while in police custody conducted a consultation with Mr Tharmalingham which lasted less than a minute and failed to make any meaningful connection with him.

Metropolitan Police Service

• There was no set place at a police station to store a detainee’s medication.
• A detainees medication should be brought to the FME who has been called to see that detainee
• Forms were not adequately completed in particular there was confusion by police officers who was responsible for completing certain sections of the Person Escort Record (PER) form and it was clarified during the inquest that it was the PER should be completed with a description of the forms enclosed with it by police.

A response is due from the agencies by 9 May 2016.

The family is represented at the hearing by INQUEST Lawyers Group members Jo Eggleton and Christina Juman from Deighton Pierce Glynn solicitors and barrister Jesse Nicholls of Doughty Street Chambers.

Share this story