Mr Julian Cole

Investigation into the restraint and arrest of Mr Julian Cole by Bedfordshire Police on 6 May 2013

Independent Investigation Final Report

IPCC Reference: 2013/007452

Please note, this investigation was completed and submitted to the decision maker before 8 January 2018, while we were still the IPCC. Therefore, the report will contain the investigator’s opinion, which may differ from the final outcome. The report refers to the IPCC and the Commission throughout, and does not reflect the new structure of the IOPC.

Contents Introduction ...... 5 Terms of reference ...... 5 Subjects to the investigation ...... 6 Chronological summary of events ...... 7 The events prior to Mr Cole's ejection from the nightclub ...... 8 Mr Cole’s ejection from the nightclub ...... 10 The initial events after Mr Cole’s ejection from the nightclub ...... 12 The initial police attendance at the nightclub ...... 20 Mr Cole’s temporary removal from the nightclub ...... 23 Mr Cole’s return to the nightclub ...... 27 The restraint and arrest of Mr Cole ...... 34 The initial physical contact with Mr Cole ...... 34 The first indicated period on the ground ...... 41 The second indicated period on the ground ...... 47 Mr Cole’s removal from the ground ...... 56 Mr Cole's passage to the police van ...... 58 The events at the rear of the police van ...... 62 Mr Cole’s passage into the cell of the police van ...... 71 Mr Cole's transport to Greyfriars police station ...... 75 Mr Cole’s arrival at Greyfriars police station and removal from the police van ...... 77 The request for an ambulance ...... 82 The arrival of paramedics ...... 82 The application of cardiopulmonary resuscitation (CPR) to Mr Cole ...... 85 Mr Cole’s removal to Bedford Southwing Hospital by ambulance ...... 89 Chronological summary of post-incident events ...... 90 Expert opinion ...... 105 First medical expert opinion ...... 105 Second medical expert opinion ...... 109 Toxicology report ...... 114 Legislation ...... 116 Police and Criminal Evidence Act 1984 (PACE) ...... 116 Criminal Law Act 1967 ...... 116 Public Order Act 1986 ...... 116 Violent Crime Reduction Act 2006 ...... 117 Health and Safety at Work etc Act 1974 ...... 117 Police (Conduct) Regulations 2012 ...... 117 National guidance ...... 118 ACPO Authorised Professional Practice: Detention and Custody ...... 118 ACPO Guidance on Personal Safety Training ...... 120 NPIA Personal Safety Training Programme version 1.0 ...... 121 Module 5: Refresher/Development Training Learning Descriptor ...... 122 ACPO Personal Safety Manual of Guidance ...... 122 NPIA First Aid Learning Programme version 1.0 ...... 125 National Policing Curriculum: First Aid Skills Police ...... 127 National Policing Curriculum: First Aid at Work Police ...... 128

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FALP Modules 2 and 4 First Aid Refresher Training ...... 130 Bedfordshire Police training ...... 130 Personal Safety Training ...... 130 Subject officer Personal Safety Training histories ...... 131 First Aid Training ...... 131 Subject officers first-aid training histories ...... 132 Subject officers’ comments regarding policies, procedures and training ...... 134 Legislation and guidance relating to post-incident events ...... 136 Police Reform Act 2002 ...... 136 IPCC Statutory Guidance ...... 136 ACPO Authorised Professional Practice: Detention and Custody ...... 137 Authorised Professional Practice on Armed Policing ...... 140 Bedfordshire Police post-incident investigation policy ...... 141 Conclusions ...... 141 Chronology of events ...... 142 The events prior to Mr Cole’s ejection from the nightclub ...... 142 Mr Cole’s ejection from the nightclub ...... 142 The initial events after Mr Cole’s ejection from the nightclub ...... 143 The initial police attendance at the nightclub ...... 145 Mr Cole’s temporary removal from the nightclub ...... 146 Mr Cole’s return to the nightclub ...... 148 The restraint and arrest of Mr Cole ...... 152 The initial physical contact with Mr Cole ...... 153 The first occasion Mr Cole went to the ground ...... 155 The first period of restraint on the ground ...... 159 Mr Cole’s return to his feet ...... 166 The second occasion Mr Cole went to the ground ...... 168 The second period of restraint on the ground ...... 169 Mr Cole lifted from the ground ...... 177 Mr Cole’s passage to the police van ...... 184 The events at the rear of the police van ...... 187 Mr Cole’s passage into the cell of the police van ...... 198 Mr Cole’s transport to Greyfriars police station ...... 201 Mr Cole’s arrival at Greyfriars police station and removal from the police van ...... 203 The request for an ambulance ...... 206 The arrival of paramedics ...... 207 Subject officers’ conduct ...... 208 PC 322 Hannah Ross, PC 5741 Nicholas Oates and PC 5890 Sanjeev Kalyan ...... 208 PS 634 Andrew Withey ...... 212 PC 381 Peter Spicer ...... 214 Inspector 5461 Lee Fosbury ...... 216 Suspect door staff actions ...... 217 Mr AA ...... 217 Mr BB ...... 218 Conclusions relating to post-incident events ...... 218 Identification of the need for post-incident procedures ...... 218

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Collection and preservation of evidence ...... 219 Notification to PSD ...... 220 Notification to the Police Federation ...... 222 Notification to IPCC ...... 222 Obtaining officer evidence ...... 223 Application of post-incident procedures ...... 224 Identification of Mr Cole and notification of his next of kin...... 225 Family liaison and the provision of information ...... 226 Initial family liaison meeting ...... 227 Officer conduct during post-incident events ...... 228 Performance ...... 229 Provisional organisational learning recommendations ...... 229 Bedfordshire Police ...... 229 Greyfriars police station CCTV ...... 229 Personal Safety Training ...... 230 First-aid training ...... 230 College of Policing Review ...... 232 Post-incident events ...... 233 Recommendations ...... 233 Other organisations ...... 234 East of England Ambulance Service (EEAS) ...... 234 Security Industry Authority ...... 234 Appendix: Map of the area around the nightclub (D683) ...... 235 Appendix: Letter from DCC Boutcher 25 April 2016 (D690) ...... 236 Appendix: List of subsidiary findings ...... 238 Appendix: Summary of subject officer case to answer decisions ...... 247 police station police station police station police station police station

Addendum to the report – Summary of allegations and outcomes after gross misconduct hearing ...... 247

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Introduction 1. At approximately 1.25am on Bank Holiday Monday, 6 May 2013, an incident inside a nightclub in the town centre of Bedford led to the door staff ejecting Mr Julian Cole, aged 19, and three of his friends. 2. Outside the front entrance of the nightclub there was an altercation involving Mr Cole and the door staff, and police officers of Bedfordshire Police were called to assist, ultimately resulting in Mr Cole being restrained and arrested. 3. Mr Cole was transported to Greyfriars police station, but shortly after his arrival in the rear parking area of the police station, an ambulance was called to attend to Mr Cole. 4. Mr Cole was taken by ambulance to Bedford South Wing Hospital, before later being transported to Addenbrooke’s Hospital, Cambridge. 5. Medical examination established Mr Cole had broken vertebrae in his neck. He has been left in a vegetative state as a result of the injury, which is likely to be permanent. 6. A telephone referral to the IPCC was made at 1.30pm on 6 May 2013, and an IPCC independent investigation was declared on 7 May 2013.

Terms of reference 7. The terms of reference for the investigation were: 1. To investigate all the circumstances in relation to this incident including:  The actions of the door supervision staff.  The actions of police officers in attendance outside the club.  The actions of police officers who transported Mr Cole to Greyfriars police station and dealt with him in the yard prior to him being taken by ambulance to hospital.  The policies and procedures of Bedfordshire Police relevant to the incident. 2. The actions and decisions made by police officers in relation to the capture of evidence post incident up to and including how the matter was notified to the family and the IPCC, and whether this was in line with policy and procedure. 3. To assist in fulfilling the state’s investigative obligation arising under the European Convention of Human Rights by ensuring as far as possible that the investigation is independent, effective, open and prompt, and that the full facts are brought to light and any lessons are learned. 4. To identify whether any subject of the investigation and/or Bedfordshire Constabulary may have committed a criminal offence and, if appropriate, make early contact with the Director of Public Prosecutions (DPP). On receipt of the final report, the Commissioner shall determine whether the report should be sent to the DPP. 5. To identify whether any subject of the investigation, in the investigator’s opinion, has a case to answer for misconduct or gross misconduct, or no case to answer. 6. To consider and report on whether there is organisational learning, including:

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 whether any change in policy or practice would help to prevent a recurrence of the event, incident or conduct investigated;  whether the incident highlights any good practice that should be shared.

Subjects to the investigation 8. Before the investigation was declared independent, Bedfordshire Police took steps to investigate the injuries received by Mr Cole, and arrested two members of the door staff working at the nightclub who were indicated to have been in contact with Mr Cole around the material time. 9. Head Door Supervisor Mr AA was arrested in the evening of 6 May 2013 and Door Supervisor Mr BB was arrested on the morning of 7 May 2013, both on suspicion of assault causing grievous bodily harm. 10. They were both interviewed by Bedfordshire Police and bailed to return to custody on 11 July 2013. 11. After the declaration of an IPCC independent investigation, the known circumstances of the incident were considered, and the involvement of Mr AA and Mr BB was deemed to be so closely connected with the actions of Bedfordshire police officers that a separate parallel investigation into the non-police suspects would be unworkable. 12. Therefore on 8 May 2013 it was decided the investigation into Mr AA and Mr BB on suspicion of assault would be included in the remit of the IPCC investigation. 13. The recordings and transcripts of the Bedfordshire Police interviews of Mr AA and Mr BB were obtained by the IPCC. 14. Six police subjects were identified and notices of investigation were served on Inspector 5461 Lee Fosbury, PC 322 Hannah Ross, PC 5471 Nicholas Oates and PC 5890 Sanjeev Kalyan on 11 May 2013 and on PS 634 Andrew Withey and PC 381 Peter Spicer on 14 May 2013. 15. The conduct subject of the investigation was specified within the notices as concerning the force used to restrain Mr Cole and effect his arrest, which may have caused or contributed to his injury, and for the responsibility over Mr Cole’s welfare while in police custody after arrest. All of the above notices were served for both use of force and welfare responsibilities apart from the notice for PC Spicer, whose notice was regarding welfare responsibilities only. These notices specified that this conduct, if proven, would be at the level of gross misconduct, meaning that dismissal may be justified. 16. On 14 May 2013 all six subject police officers were interviewed under criminal caution. All police officers were co-operative and provided first accounts. 17. On 11 September 2013 Mr AA and Mr BB returned to Greyfriars police station to answer bail and were interviewed under criminal caution by the IPCC. Both co- operated and expanded on the initial accounts they provided when interviewed by Bedfordshire Police. Following the interviews they were re-bailed. 18. Over 6 and 7 November 2013, all six subject police officers were re-interviewed under criminal caution by the IPCC, with disclosure of certain evidential materials. The police officers broadly provided no comment to questions until they were

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shown part of the CCTV evidence of the incident. Following disclosure of this CCTV evidence, the police officers then responded to further questioning. 19. On 28 November 2013 Mr AA and Mr BB returned to answer bail at Greyfriars police station and were further interviewed under criminal caution by the IPCC, with disclosure of certain evidential materials. Both were co-operative and provided further accounts. Following interview they were re-bailed. 20. On 7 January 2014 the requirement for Mr AA and Mr BB to return to answer bail was cancelled, with the justification that no further questioning was anticipated, and therefore it was unnecessary to ensure their surrender to custody to facilitate evidence through questioning. 21. Mr AA and Mr BB were informed of the cancellation of their requirement to answer bail, with the caveat that they both remained suspects of the investigation. 22. Between 13 January 2015 and 28 March 2015, the six subject police officers provided written adoption of their criminal interview evidence for the purposes of misconduct matters. 23. It should be noted that on 16 October 2015 PC Spicer retired from Bedfordshire Police. 24. While legislation introduced within the Police (Conduct) Regulations 2012 (as amended) would prevent an officer who is alleged to have breached the standards of professional behaviour from retiring without consent from the appropriate authority (Bedfordshire Police in this case), this regulation would not apply to any allegation which came to the attention of the appropriate authority before 12 January 2015. 25. As such the new regulation would not apply in this case and PC Spicer could not be prevented from taking retirement. 26. On 7 July 2016 the above notices of investigation served on PC Ross, PC Oates and PC Kalyan were amended and reissued to notify them that their accounts of the incident were under consideration in relation to a possible breach of standards of honesty and integrity1. 27. No further interviews were deemed necessary in relation to these matters, and the officers chose not to provide any further response to the amended notices.

Chronological summary of events 28. Where CCTV timing is stated below, this has been adjusted to correct for inaccuracies on the clocks of the different CCTV sources. 29. An index of the contributing witnesses has been provided as an appendix for ease of reference.

1 A similar amended notice was to be provided to retired officer PC Spicer to allow him the opportunity to respond to the content, albeit there could not be any disciplinary outcome due to his retirement. However, he has not engaged with the attempts to contact him, and therefore it has not been possible to provide him the amended notice or opportunity to respond.

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The events prior to Mr Cole's ejection from the nightclub 30. On Sunday, 5 May 2013 from approximately 10.30pm, Mr Cole was among a group of friends who were drinking at the student accommodation of Bedfordshire University. 31. The group included: Witness 24, Witness 31, Witness 11, Witness 28, Witness 20, Witness 40, Witness 32, Witness 17, Witness 26 and Witness 30, all of whom later attended the nightclub together. 32. Witness 24, Witness 31 and Witness 11 all described Mr Cole as drinking brandy or whisky and that he was drunk. 33. Between approximately 11.30pm to midnight, 6 May 2013, the group took several taxis to travel to the nightclub on Mill Street in Bedford town centre, which was a journey time of approximately three minutes. 34. On arrival at the nightclub the group split while Mr Cole and several others went to a nearby cash point, before they entered the club. 35. After entering the nightclub, Mr Cole was initially with Witness 31, Witness 11 and Witness 24, while the others had moved elsewhere inside the club, until a point where Witness 24, Witness 11, Witness 31, Witness 17 and Witness 30 described being in the main room of the club with Mr Cole. They stated a female singer performed on stage, and during the performance Mr Cole stepped onto the stage, and held onto a barrier which separated the performer from the crowd. 36. The CCTV system operated by the nightclub was a time-lapse recording system. The rate of the system was confirmed as one frame recorded per second. 37. Footage from the CCTV camera above the stage in the main room of the nightclub showed that at approximately 1.24am, a female singer started a performance on the stage, and approximately one minute later a male believed to be Mr Cole stepped up onto the edge of the stage in front of the singer and held onto the barrier that separated them. The footage showed that at 1.25am, a member of the door staff, identifiable as Mr AA, walked up the steps at the side of the stage, and stood at the base of the stairs leading from the back of the stage to the first floor of the nightclub. He was facing the crowd and started leaning out, apparently gesturing in Mr Cole’s direction. Mr Cole was still at the front of the stage holding onto the barrier. 38. In interview Mr AA said there was a live act on the stage and he was halfway up the stairs. He said he saw two males on the stage area while the performer was on stage. He explained the stage had a barrier going across it and a lip which they had climbed onto, and they were hanging off the barrier. He said he instructed them to get off the stage, and one complied straight away while the other, who he identified as Mr Cole, made a dismissive gesture towards him. 39. Witness 30, Witness 17, Witness 11 and Witness 31 all stated a doorman instructed Mr Cole to get down from the stage, however Mr Cole was dancing and either did not notice or did not want to get off the stage. 40. Door Supervisor Witness 19 said a male, identifiable from his description as Mr Cole, got onto the stage. He said Mr AA asked Mr Cole to get down and Mr Cole then waved his arms around aggressively. He thought Mr AA’s gestures indicated

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he asked Mr Cole to leave the stage on two occasions, and it looked like Mr Cole started to abuse Mr AA. 41. Footage from the CCTV camera above the stage at 1.25am showed Mr AA continued to gesture in Mr Cole’s direction but after 30 seconds he moved to the stage and stood behind the singer’s left side. Mr AA then leant forward and pointed towards Mr Cole. A matter of seconds later Mr Cole was no longer visible on the stage. Mr AA then walked down the steps from the stage and into the crowd. He was followed by a colleague who was standing at the back of the stage, and moments later by another colleague who walked down the stairs from the first floor, both identifiable due to their high-visibility vests. 42. Witness 11 stated he indicated to the door staff that he would remove Mr Cole from the stage but before he could reach him the door staff had already run to Mr Cole, and he was no longer on the stage. Witness 31 also stated that Witness 11 told the door staff he would remove Mr Cole from the stage, but the doorman acted before he did so, came over to Mr Cole from behind, and wrapped his arms around Mr Cole’s body, aggressively pulling him back and hard down towards the floor. Witness 31 noted that this did not cause Mr Cole to fall. 43. Witness 30, Witness 17 and Witness 19 stated that, after Mr AA’s instructions, Mr Cole got down from the stage of his own volition. 44. Witness 24 did not describe seeing Mr Cole get off the stage, but stated he then saw several members of door staff surround Mr Cole and Witness 11. 45. Witness 17, Witness 11 and Witness 30 said the door staff took hold of Mr Cole from behind, by grabbing hold of one or both of Mr Cole’s arms and/or torso. Witness 17 said Mr Cole attempted to pull his arm free but the doorman did not let go, and he was taken towards the exit. Witness 11 said Mr Cole looked angry as he knew he was going to be ejected. 46. Mr AA said by the time he reached Mr Cole, one of his friends had removed him from the stage. He said he asked Mr Cole to stay off the stage but Mr Cole became verbally abusive. He said he warned Mr Cole but he continued to be abusive, so Mr AA made the decision to eject Mr Cole. 47. Witness 19 said he walked over after Mr Cole got off the stage because he saw Mr Cole became abusive and aggressive to Mr AA. He said Mr Cole’s friends then started to get involved, and were also aggressive, although one tried to hold Mr Cole back and calm him down. He said Mr Cole shouted at his friend to let him go, and kept shouting “this bouncer’s a bad man”. He said there were a few doormen in the area at that point. 48. Witness 24 and Witness 31 stated they went over to where Mr Cole and the door staff were and started to physically intervene. 49. Witness 24 said he pulled at the doorman’s clothing and told him to get off Mr Cole. Witness 31 stated that, after he saw the doorman grab Mr Cole from behind, he pushed the doorman back and challenged him for his actions. He said the doorman immediately got on his radio to call for assistance, and then around eleven door staff arrived. Witness 17 stated one or two more door staff ran towards the area to force Mr Cole, Witness 11, Witness 24, and Witness 31 out of the club. He said it was not a physical struggle, but they tried to free themselves and asked the door staff why they were being ejected.

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50. Witness 30 also stated more door staff arrived and Mr Cole, Witness 31, Witness 11 and Witness 24 were all ejected. He said he remained inside the club with Witness 17 and Witness 26 until 2.40am and did not see the other events involving Mr Cole. 51. Witness 31 stated the door staff grabbed him by the arms. He said he tried to resist being ejected and said he should be given his money back. 52. Witness 24 said he saw Mr Cole being taken outside by the doorman and all seemed amicable.

Mr Cole’s ejection from the nightclub 53. The nightclub’s General Manager Witness 36 said he was in the corridor when he saw a doorman walk Mr Cole to the side exit. He confirmed he knew Mr Cole by sight due to the club affiliations with Bedfordshire University and because he was a regular customer. He said the doorman told Mr Cole he needed to go, but Mr Cole argued and seemed quite irate. He said Mr AA, Witness 1 and Witness 19 were also there. He said Mr AA spoke to Mr Cole and tried to calm him down. He said Mr Cole went through fluxes of being calm and then irate when his friends tried to get involved. He said the door staff did not put hands on Mr Cole, but Mr Cole’s friend in a navy blue t-shirt kept trying to pull the door staff away. Witness 36 and his colleague pulled the friend away to calm him down. He said Mr Cole agreed to leave by the side exit and walked away voluntarily. He said the door staff walked behind Mr Cole and he did not see them touch him. 54. Footage from the CCTV camera in the corridor between the main dance room and the front of the club at 01:26:24 displayed a single frame of a male in a white top, believed to be Mr Cole, exiting the dance room, closely followed by a doorman believed to be Mr AA. It appeared Mr AA had his left hand near Mr Cole’s left elbow to either guide or hold him. The subsequent frames showed them move towards the side exit. 55. Mr AA said Mr Cole was very compliant as they walked out and he did not have to restrain him in any way. He said they walked through the side door into the corridor then turned right towards the lobby bar. He said when they got to exit six a ‘code red’ was called, which meant that a fight had broken out, so he put Mr Cole out of exit six and went back inside to the dance floor. 56. Witness 36 said he saw Mr Cole outside exit six when a ‘code red’ was called over the radios and the doormen needed to go back into the club to deal with another incident. He said they told Mr Cole to leave then went inside and the door of exit six was closed. He said the friend in the navy blue t-shirt stayed inside the club. 57. The nightclub’s manager, Witness 18, said she was in the corridor next to the main room with some other staff members when she saw three or four staff remove a male she recognised as Mr Cole. She said there was another male with Mr Cole in a blue t-shirt and the staff were Witness 1, Witness 19 and Witness 36. She said Mr Cole argued with the door staff, flung his arms about and had an angry look on his face. The male in the blue t-shirt tried to mediate or calm the situation down. She said Mr Cole walked with the door staff as far as she could see, but he was angry and protested. The door staff ushered Mr Cole down the main corridor and she did not see the door staff touch Mr Cole.

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58. Nightclub staff Witness 15 said he was in the lobby bar and saw Mr AA and three other door staff eject a black male in a white t-shirt via the fire exit. He said the male was shouting and the door staff were shouting back. He said one of the door staff ushered him out by the upper arm or shoulder blade, but the male did not resist and walked out of the club. 59. The floor plan of the nightclub and evidence from door staff demonstrated exit six to be a side exit at the north west side of the building, with an internal CCTV camera above it. Accounts from multiple witnesses all stated that this was the side exit from which Mr Cole was ejected. 60. Footage from the internal CCTV camera above the side exit showed the door was opened at 01:26:36, however it was not possible to see who, if anyone, went through it. 61. Mr AA said that, when he got back inside, he found the code red was due to Mr Cole’s three friends, who were angry because Mr Cole had been ejected and were causing a problem with the door staff. He said they were then also ejected. 62. Footage from the CCTV camera in the corridor between the main dance room and the front of the club at 01:26:39 showed a member of door staff apparently pull a male in a white top, believed to be Witness 24, from the main room into the corridor. The next few frames appeared to show that Witness 24 resisted the doorman, who was pulled back into the doorway of the main room. Between 01:26:39 and 01:27:11 there appeared to be a struggle which involved several door staff, before a group of door staff and others moved away towards the front of the club. It was not possible to discern who or how many people were involved. 63. Footage from the CCTV camera above the front entrance of the nightclub at 01:26:56 showed Mr Cole walked unaccompanied from the side of the club towards the front entrance. 64. Door Supervisor Witness 16 said he heard a ‘code red’ over his radio, so he responded to an incident on the dance floor. He saw some of his colleagues evict a black male wearing a white t-shirt. He said he could not remember how the male was held. He said he followed the male out and spoke to him briefly. Mr AA then shut the door and went back inside. 65. Door Supervisor Witness 1 said he heard a ‘code red’ on his radio and went to the main room of the club. He said that, by the time he arrived, his colleagues were already dealing with the incident. He said he escorted out two males whose descriptions indicate them to be Witness 11 and Witness 31. He said they asked him why their friend had been kicked out but Witness 1 did not see their friend being ejected. He said they were not being aggressive, they were friendly and calm. He took them out using side exit six. 66. Door Supervisor Witness 6 said he saw Witness 1 and another door supervisor escorting a black male to the emergency exit. He said Witness 1 was on the male’s left side with his right hand on the male’s left shoulder, and holding the male’s left wrist. The other door supervisor was holding the male’s right wrist with his right hand and had his left hand behind him. He said there was no trouble as they walked towards the exit. He saw some males followed who he believed were friends of the male being ejected so he walked between his colleagues and these males as a precaution. He said that, after the male was released out of the emergency exit, he heard him say “I’m not going, I need my money back”.

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67. Witness 19 said he and a colleague took two or three of Mr Cole’s friends out, while another person took Mr Cole out. He said they were walked out, while he walked behind and did not touch them. 68. Nightclub staff Witness 29 said he saw people gathered watching a commotion in the corridor next to the main room. He said a male, indicated to be Witness 31, put his hands up and said “There is no need to touch me, I’ll escort myself out”. Witness 29 said he went to the corridor and moved customers against the wall to prevent them being injured. He said there were four door staff who tried to remove five or six males from the club. He said the males then made their way towards the fire exit and the door staff formed a line between them and the double doors. He said he saw a doorman grab the arm of one male in blue jeans and a beige jumper and he heard one of the males ask “Why am I being chucked out?” 69. Nightclub staff Witness 22 stated that around 1.30am, she saw a fight occurring in the club. She described a black male wearing a white t-shirt, who she recognised as a club regular. She said he was carried out of the club by the fire exit. She said door staff held his arms and, although she could only see his upper body, she had the impression his legs were being held up too because he was more horizontal than vertical. She thought he was very violent because he moved his arms as if to punch the door staff. She said the male’s friends ‘kicked off’ too and protested at their friend being escorted out of the club. 70. Bystander Witness 4 said she was in the corridor next to the main room, when she saw three doormen take a black male wearing a white or grey t-shirt out the main room into the corridor. She said one doorman held the male’s right arm by the bicep area, and another took his left in the same way. She said he was held normally, not aggressively. She said the male struggled and was agitated but appeared normal and his eyes were focused. She said a third doorman tried to lift his legs, but she thought the male kicked so the doorman could not do so and did not attempt it again. She said as the male walked past her it seemed that he calmed down and had stopped struggling. 71. Footage from the internal CCTV camera above the side exit at 01:27:26 showed a male identifiable as Witness 24 was escorted towards the front entrance of the club by a member of door staff. At 01:27:30 the side exit partially covered by the internal camera opened and several people appeared to exit, but it was not possible to see how many or who. 72. Footage from the internal CCTV camera of the front entrance at 01:27:37 showed Witness 24 walked down the steps and out of the front entrance, after being escorted to the steps by a doorman. The doorman stayed inside the club. 73. Witness 24 said he and Mr Cole were ejected from the club via the front entrance and Witness 31 and Witness 11 via the side exit.

The initial events after Mr Cole’s ejection from the nightclub 74. Footage from the CCTV camera above the front entrance of the nightclub at 01:26:56 showed Mr Cole walking from the direction of the side exit, through the metal detector and towards the front entrance. He walked up to two door staff, identifiable as Witness 35 and Mr BB, who appeared to engage him in conversation. Mr Cole appeared to try to re-enter the front entrance, and the two door staff blocked him, then Mr BB ushered him away, with his arms held wide

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and in apparent minimal contact. Mr BB ushered Mr Cole past a rope cordon and Mr Cole then remained on the other side of the rope cordon, apparently calm, standing still facing the entrance. 75. Door Staff Witness 35 said Mr Cole told her he had only been in the club a little while and wanted his money back. 76. Mr BB stated Mr Cole came from the side of the club unescorted, and Mr BB asked him to move to the other side of the rope barrier, which he did. He said Mr Cole asked for a refund and was told he would not get a refund because he had been ejected. He said Mr Cole was quite annoyed but not aggressive. He said it appeared Mr Cole had been drinking but was not drunk. He said there were no signs Mr Cole had taken drugs. 77. Footage from the CCTV camera covering the forecourt of the nightclub showed that Witness 24 exited from the front entrance at 01:27:47. After he exited he walked away from the club and out of view before he returned to where Mr Cole was standing at the entrance. Witness 24 then touched Mr Cole’s right arm from behind and Mr Cole stepped back. Witness 24 then appeared to remonstrate with the door staff, with confrontational body language. Mr Cole appeared calm and intervened by standing between Witness 24 and the door staff, and then Mr Cole guided Witness 24 away from the entrance. Mr Cole then returned to the rope cordon and appeared again to be calmly speaking to the two door staff. 78. Local resident Witness 25 said she heard a noise so looked out her window. She said she saw a male she recognised from university, who she later saw arrested, indicating this to be Mr Cole. She said he was escorted out the nightclub and was arguing with the door staff, until one of his friends pulled him back and took him away. 79. Witness 24 said that, while they were outside, their tempers flared. They wanted to know why they had been kicked out. He said Mr Cole demanded his money back, was very angry and at one stage tried to push his way back in through the door staff, but was pushed back. Witness 24 said he was also angry and demanded to speak to Witness 18 to have his money returned. He said the door staff pushed them back and told them to go home. 80. Footage from the CCTV camera above the front entrance of the nightclub at 01:28:32 showed that Mr AA exited the club and stood by the two other door staff, then appeared to speak to Mr Cole. Mr Cole appeared to be become more animated and gesticulated towards them. Witness 24 returned briefly and also pointed at Mr AA, but then walked away moments later, before Mr AA returned inside at 01:29:04. Mr Cole then appeared to try to push back into the club, but was blocked by Mr BB. Mr Cole then stood behind the rope cordon, pointing towards the entrance apparently still speaking to Mr BB and Witness 35. 81. Witness 35 said Mr Cole’s two friends followed Mr Cole out. She could only describe them as a dark-skinned black male and a tall black male wearing a cagoule jacket. She said Mr AA told Mr Cole there was no refund policy and, on hearing this, Mr Cole’s eyes became wider and he became verbally abusive. 82. Mr AA said that, after Mr Cole’s friends were ejected, he went out the front entrance and saw Mr Cole standing at the ropes quite compliant, quite calm and not being abusive or talking to the door staff. Mr AA said Mr Cole was then joined by his friends and the mood changed. He said Mr Cole suddenly became very agitated, started to swear and said he wanted his money back. Mr AA said he told

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Mr Cole if he “wasn’t being so silly” he would still be in there enjoying his night, and said the best thing he could do was go home. He said Mr Cole’s friends were quite calm to Mr Cole but quite aggressive towards the door staff. He said they told Mr Cole he should get his money back. 83. Footage from the CCTV camera above the front entrance of the nightclub at 01:29:56 showed two males identifiable as Witness 31 and Witness 11 walking from the direction of the side exit, through the metal detector and towards the front entrance. Three members of door staff followed them. 84. Witness 1 said he and his colleague Witness 6 took two males, identifiable as Witness 31 and Witness 11, around to the front of the club so they could speak to Mr AA. He believed Witness 6 then went back inside the club. He said this was the first time he saw Mr Cole and he was by the barriers at the front of the club and was shouting. He said Mr AA and Mr BB tried to calm him down. 85. Witness 16 said he walked two males to the front of the club along with a colleague. He said one of the males wanted to get back into the club and complained about his treatment from Mr AA. He said one of the males, identifiable as Witness 31, tried to take the other away, but also complained about the treatment from Mr AA. He said the male directed his anger and frustration verbally towards Mr AA who was now out the front of the club. 86. Mr BB said that, when Mr Cole saw his three friends, he became a lot more aggressive towards everyone. He said they argued and said they wanted their money back, but were told they would not get it. He said they had an issue with Mr AA. He said Mr Cole jumped around and said “somebody is gonna get hurt”. He said Mr Cole and his friends were kicking, shouting, and pushing barriers. He said he thought Witness 35 and Mr AA were also at the front door. He said one of Mr Cole’s friends, identifiable as Witness 31, tried to calm Mr Cole down, but they were all very aggressive; some of them tried to calm Mr Cole down and then became aggressive themselves. 87. Bystander Witness 34 was in the external smoking area, positioned to the east side of the nightclub and separated from the forecourt by barriers. Witness 34 said she saw four boys coming out of the club, three of whom she recognised as Mr Cole, Witness 24 and Witness 31, whom she knew from Bedford University. She said a few door staff followed them out. 88. Witness 25 said at least two door staff were at the top of the stairs and she said she could see Mr Cole was angry, speaking quickly and making hand gestures as he moved towards and away from the door staff. As he argued with them, the door staff just stood there. Mr Cole’s friends intervened and pulled him to the right of the club. One friend stayed to speak with the door staff and tried to calm the situation down. 89. Bystander Witness 3 said she saw a black male arguing with a doorman, indicated to be Mr BB, and she thought he had some friends behind him. She said the doorman gestured for the male to move away and he asked him to leave. She said the male confronted the doorman but was not let in. 90. Footage from the CCTV camera above the front entrance of the nightclub at 01:30:06 showed that Witness 31, Witness 11 and the three door staff went through the metal detector. As they reached the front entrance Mr Cole appeared to try to push his way back into the club, but multiple door staff blocked him. The metal detector was dislodged and was at an angle. Mr Cole was then physically

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moved away from the entrance by Witness 11, and a white male in a black top, who was an apparently unconnected bystander. The white male in a black top appeared to try to hold Mr Cole’s arms for approximately five seconds before he disengaged and had no further involvement. During this time Witness 11 held Mr Cole from behind with his right arm over Mr Cole’s right shoulder, before Mr Cole appeared to twist and Witness 11 fell to the ground. Mr Cole then appeared to move back to the club entrance before Witness 24 and Witness 31 intervened. Witness 24, Witness 31 and Witness 11 then collectively moved Mr Cole away from the club and held him against the metal barriers by the pavement. There were three door staff standing within a few metres who watched, but did not intervene. Mr BB and Witness 35 were behind the rope barrier. At this time witnesses identifiable as Witness 13 and Witness 38 were visible on the footage. 91. Witness 11 said Mr Cole was at the front of the club when he walked round. Mr Cole was screaming and shouting at the doorman who ejected him, asking for his entrance fee back. Witness 11 said Mr Cole was really angry and he had to trap Mr Cole by a barrier to calm him down. He said Witness 31 and Witness 24 also tried to calm Mr Cole down. 92. Witness 31 said Mr Cole and Witness 24 were already outside in front of the main entrance before he and Witness 11 got there. He said a female police officer was outside and she told them to go. In his description of the police officer Witness 31 said she was similar in appearance to the female door staff. 93. Witness 35 said after Mr Cole was told there was no refund his friend, indicated to be Witness 31, walked him away in the direction of the road. She said Mr Cole was angry and had his arms out as though he wanted his friend to get away from him. 94. Bystander Witness 13 said she was with her friend when she saw a black 22–23- year-old male, 5ft 4in, with short black hair and a slim, athletic build wearing a black shirt and black trousers. She said he was angry, aggressive and was demanding his money back from the door staff. She said he tried to shove his way back into the club and used his elbows to gain contact with the door staff. She said he said “Eight fucking pounds to get in, I want my money back”. Witness 13 said that, in response to the male’s attempt to get in the club, he was pushed away by two door staff. She said then a second black 22–23-year-old male, 5ft 5in, black hair, athletic build and a white shirt and black trousers put his arms around the first male from behind like a hug, and bent him forwards. She said the second male’s arms were around the first male’s upper arms, and he pulled the first male back down the stairs of the club. The first male tried to break free and continued to shout and swear. Witness 13 said that approximately three further door staff appeared in the doorway but they did not get involved with either male. She said that, as the second male pulled the first away, she got the impression he was trying to calm him down. She said she did not want to be around the situation, which she thought was escalating because the door staff were engaging and pushing the first male. She said that, as she walked away, she heard sirens but did not see any police. 95. Witness 13’s friend said she saw a group of five or six boys, one of whom she said was agitated and wanted to get back inside the club. She described him as a short black male wearing a black t-shirt. She said he was shouting and was being stopped by his friends. One of his friends was 5ft 5in or 5ft 6in tall, wearing a white ‘hoody-style’ jumper and had longer hair than the agitated male. He had his arms wrapped around the first male like he was hugging him face on. She said

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the agitated male tried to pull himself away, and there was a line of four door staff who stopped him from getting in the club. She said that, at one stage when they were near the door staff, the agitated male shouted, “I want to fight! I want to fight!” and his friends told him to calm down. She said she then saw two door staff lift the male off the ground from under his arms and place him down further away, and then they pushed him away. She said the agitated male then took a swing for his friend who tried to calm him down. 96. Bystander Witness 27 said that, as she walked past the nightclub, she saw a short black male wearing a white shirt who was shouting. She said he went towards the door staff at the entrance of the nightclub and tried to jump over the barriers, she believed in order to get in. She said the door staff did not appear to touch him. She said he then punched the metal detector and it nearly fell down, but a doorman prevented it from falling over. She said she then saw him on the forecourt of the nightclub and he screamed as two or three others tried to calm him down. She said one of them hugged him from behind with both arms wrapped around his waist area. She said another male had his arms out looking to do something to calm him down. She said that, while the male was being hugged, his arms were punching the air. 97. Witness 19 said that, about 10 minutes after he had escorted Mr Cole’s friends from the club, he heard a ‘code red’ which directed him to the front door. He said as he got to the front door he saw Mr Cole and the three people he ejected. He said Mr Cole was being aggressive towards the staff and a white male held him back and said his name. He said the white male grabbed Mr Cole two or three times but he kept getting away, and the white male then gave up. He said he was in a line with other door staff and the four males gave them verbal abuse while someone pushed and kicked at the barriers. He said he told one of the males to calm down, talk to his mates and go home, and the male responded “It’s not you, it’s him. It’s always him.” 98. Witness 12 said he heard a ‘code red’ and went to the smoking area, where he could see Mr BB and Witness 35 at the front entrance. He said there was a black male wearing a white t-shirt or jumper. He said this male looked like he had been ejected. He stated the male was kicking, screaming and ‘going mad’. He said there were two or three others with him. Witness 12 said he jumped over the metal barrier to join his colleagues at the front entrance, but his colleagues managed to get the male away without actually touching him. He said the male was swinging for the door staff, while his friends tried to calm him down and pulled him away. He said Witness 1 and Witness 19 also joined them at the front entrance. 99. Footage from the nightclub’s forecourt camera showed Witness 11 took Mr Cole away from the club at 01:30:41 and off camera while Witness 24 and Witness 31 remained to talk to three of the door staff. At 01:31:17 Mr Cole appeared to run back to the entrance, before Witness 11 intercepted him and pushed him away. Mr AA was then outside the entrance, on the club side of the entrance barriers. Witness 11 wrapped his arms around Mr Cole’s waist and held him against the barriers by the pavement. 100. Footage from the nightclub’s forecourt camera at 01:32:05 showed Witness 31 moved away from the door staff and approached Mr Cole where Witness 11 held him against the barrier. At this point Mr Cole broke away and ran around the door staff back towards the rope barrier. He was blocked by the door staff before

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Witness 11 and Witness 31 took hold of him and moved him back to the barriers next to the pavement. 101. Witness 25 said Mr Cole came back to fight with the door staff and ran towards them as if he was going to jump on them, but one of his friends pulled him back. She said the black doorman started to egg Mr Cole on to fight as his hand gestures were beckoning Mr Cole. 102. Witness 16 said Mr Cole kept approaching the barriers and shaking them. He was uncontrollable so one of the males, indicated to be Witness 31, tried to restrain him by standing in front of him and speaking to him. He said Witness 31 was a lot calmer. Witness 16 said he then went back into the club on Mr AA’s instructions. 103. Witness 1 said Mr Cole was trying to move and throw the metal barriers and shouted at Mr AA “I want my money back, why did I get kicked out, someone is going to get hurt tonight”. He said Mr Cole tried to force his way back into the club, but Mr AA and Mr BB told him he could not go in and Mr AA put his hand up in front of him to stop him, although Witness 1 did not see Mr AA touch Mr Cole. Witness 1 said at this time Mr BB called the CCTV office to say there was a black male in a white top being aggressive. He also called the police for assistance. 104. Mr AA said Mr Cole became quite agitated and his friends started to pull him away, grabbing him by the arms, but because they were pulling him away he became more agitated and started to struggle with them to break free. He said Mr Cole’s actions escalated; at first he just pulled one arm free and then shouted at the top of his voice at them to let him go. Mr AA said they started to make threats of “name the time and place“, directed at him. He said Mr Cole screamed that he wanted his £8 back. He said Mr Cole had gone back to the road by the bollards and then charged to the front door. One of his friends grabbed him but he stopped himself at the ropes. Mr AA said that, at that stage, he used the ‘Bedsafe’ radio to ask for police support for a possible disturbance at the nightclub. He said this was so they would turn the cameras on to the nightclub and send police assistance to move Mr Cole on. 105. Mr BB said Mr Cole took his necklace off and wrapped it around his fist and then put it into his pocket like he was trying to hide it. He said they then used the ‘Bedsafe’ radio to call the CCTV control, which was the safe radio for police assistance. He said this was to have the police remove the males from the town centre. He said it was either him or Mr AA who radioed. 106. ‘Operation Bedsafe’ was the term used for the policing of the night-time economy in Bedford and the surrounding areas, in order to respond quickly to any public disorder on Friday and Saturday nights, and on this occasion due to the Bank Holiday. It involved police officers on foot as well as a number of patrolling vans. ‘Operation Bedsafe’ used a radio network accessed by the police, Local Authority CCTV operators and some door staff of venues affiliated with ‘Operation Bedsafe’. There were a number of ‘Bedsafe’ radios held by the police officers assigned to the operation, and transmissions would not be heard on normal police radios. 107. The Bedfordshire Police Incident Log referenced an anti-social behaviour incident at the nightclub reported by CCTV/third party at 01:34:07, followed by an entry at 01:35:54 which allocated the incident to unit BH112, which was the allocation of PC Ross and PS Withey.

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108. At 01:38:03 the Bedfordshire Police Control Room made a radio transmission to unit BH103, which was the allocation of Inspector Fosbury and PC Kalyan. The transmission content was “103 you’ve got trouble in [the nightclub] on Mill Street now, over”. The response stated “Copied heading down there now”. A transmission at 01:38:40 from unit 112, allocated to PC Ross, PC Oates, PC Spicer and PS Withey stated “At [the nightclub]”. 109. PC Oates, PC Ross and PC Spicer confirmed they were crewed together in a police van, and PC Oates was the driver. They received a report of a disturbance outside the nightclub from the Control Room and drove down Mill Street towards the nightclub on emergency lights. 110. In his police notebook PS Withey noted that he was crewed with PC Ross, PC Oates and PC Spicer, but he left their van at 1.05am and was with PC E on the High Street. 111. Inspector Fosbury said he was crewed with PC Kalyan in a patrol car, and at 1.30am there was a call from the Control Room regarding a disturbance or a fight outside the nightclub. 112. Witness 14 was working at A1 taxis, situated immediately to the west of the nightclub’s forecourt. Witness 14 said that, between midnight and 1am, he was outside the taxi office and saw three males. He described a black male in a white t-shirt, who was with two other black males wearing black t-shirts. He said they were shouting “We want our money back.” He said that, as they were shouting, they and the door staff were moving the barriers on the nightclub’s forecourt. He said the situation was heated and the area felt busy. 113. Witness 11 said Mr Cole called the bald doorman “a prick”, and the doorman encouraged Mr Cole to hit him and adopted a stance as if he was ready to hit Mr Cole. Witness 11 said he also got angry with this doorman and swore at him because he was encouraging trouble to start. 114. Footage from the the nightclub’s forecourt camera at 01:32:52 showed Witness 24 and Witness 31 move Mr Cole away west on Mill Street, while Witness 11 walked back to the entrance. Mr Cole, Witness 24 and Witness 31 were out of view and Witness 11 appeared to be arguing with the door staff. Witness 11 then appeared to bend down as if he picked something up, before a rope cordon post could then be seen rolling away on the floor towards the pavement. 115. Door Supervisor Witness 10 said he thought he heard a code red over the radio but he did not react because he was on his own in the smoking area. He said that, after the code red, he saw a short black male in what he thought was a light- coloured t-shirt pick up one of the temporary barriers and throw it on the floor. 116. Witness 12 said he had returned to the smoking area when he heard the male say “Fuck that! I want my money back”. He said he saw the male had returned with his friends again. He said the male swung for Mr AA and said “I want you! I want you!” He said the male then disappeared again with his friends going east towards the XXXXXXXXXX pub. 117. Footage from the forecourt camera at 01:33:04 showed Mr Cole, Witness 24 and Witness 31 had returned to the front of the club and, along with Witness 11, it appeared they tried to get back to the entrance of the club, but the door staff blocked them. At 01:33:17 Mr Cole walked off camera towards the taxi rank, while Witness 11 moved around the forecourt, apparently moving the barriers, and Witness 24 appeared to confront the door staff who were keeping them away

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from the front entrance. Witness 31 appeared to intervene and stood between Witness 24 and the door staff. 118. Witness 14 said that, after approximately five minutes of arguing, the black male in a white t-shirt walked past him and hit a taxi bonnet with both hands in either a slapping or punching motion. The male picked up an empty, clear glass vodka bottle. He said that a female said “Don’t do it”, and the male replied “If you don’t move I’m gonna bottle you”. He said the male then walked past him and ran over to a black male, who he identified as Mr AA. Witness 14 said he got the impression the male was going to hit Mr AA with the bottle as he appeared to have struck the bottle at him. He said the male’s right hand was raised to shoulder level and he perceived this as a threatening position. He said Mr AA was on the top step outside the nightclub and was on his radio. Witness 14 said he was then told to come back by his boss and could not see the front of the nightclub. 119. Witness 12, Witness 35 and Mr BB all described Mr Cole returning to the club holding a clear glass Smirnoff bottle by its neck. Witness 12 said the male appeared to be going for Mr AA or Witness 19. 120. Footage from the Local Authority CCTV camera at 01:33:38 showed Mr Cole walked from outside the taxi office towards the nightclub, and held what appeared to be a clear bottle by the neck in his right hand. He walked around the corner of the taxi rank towards the entrance to the nightclub and out of view. In the same footage Witness 11 could be seen on the forecourt throwing a metal rope barrier to the ground as a member of door staff tried to intervene. 121. Witness 1 said one of the males, indicated to be Witness 11, was getting aggressive and moving the metal barriers. Witness 1 said he went to calm him down. 122. Footage from the CCTV camera above the front entrance of the nightclub at 01:33:54 showed Mr Cole walked from the direction of the taxi office up to Mr AA and Witness 35 at the front entrance. 123. Mr AA said he asked a couple of door staff to come to the front door then Mr Cole disappeared for a few minutes. He said Mr Cole came back with a transparent Smirnoff bottle in his hand, held by the neck, down by his side in his right hand. He said Witness 35 put her hands out to stop him and Mr Cole said “I'm not going to use it. I'm only going to use the bottle if I don't get my money back”. Mr AA said Mr Cole was at Witness 35's arms length because she put her hands out to stop him getting closer. Witness 35 then pushed Mr Cole away to protect him. Mr AA said he made another call on the ‘Bedsafe’ radio to say Mr Cole had returned and was threatening them with a bottle. 124. Witness 35 said she noticed the bottle when Mr Cole was in front of her at the entrance. She said she felt threatened by his actions and it was at this point she noticed he had bloodshot eyes and dilated pupils. She said Mr Cole appeared to be heading more towards Mr AA than her, and he spoke to Mr AA again. She said she pushed him and Mr AA away from each other, by placing her left hand towards Mr Cole’s nearest arm. She said Mr Cole told her he was not going to use the bottle. 125. Footage from the CCTV camera above the front entrance of the nightclub at 01:34:10 showed Witness 35 standing by the metal detector with her arms

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outstretched, separating Mr Cole and Mr AA. Witness 24 then intervened and moved Mr Cole away. 126. Mr BB said Mr Cole’s friend got in front of him and pulled Mr Cole away off the forecourt. 127. Footage from the Local Authority CCTV camera at 01:34:15 showed Mr Cole walked into view from the direction of the nightclub. It appeared he was still holding the bottle. Witness 11, Witness 31 and Witness 24 were behind him, apparently being ushered away from the entrance by three doormen. 128. Witness 35 said that, after Mr Cole said he would not use the bottle, she heard sirens, and another male came back and placed his arm over Mr Cole, ushering him away. She then heard a smashing sound, and saw that Mr Cole did not have the bottle in his hands anymore. 129. Witness 12 said a friend of the male came over and took the bottle from him. The friend then dropped the bottle onto the ground and kicked it towards the road, where Witness 12 heard it smash. He said police officers were in the vicinity. 130. Mr BB said Mr Cole and his friend walked between some cars, and his friend, indicated from his description to be Witness 11, snatched the bottle out of Mr Cole’s left hand and smashed it on the floor. He said Mr AA stayed at the front door and Mr BB had moved out and was five yards away from Mr Cole when this happened. Mr BB said that, as the police turned up, he stamped on the broken glass so nobody could pick it up. He said he and other door staff had ushered Mr Cole and his friends away with open-palmed actions to guide them in the right direction. 131. Mr AA said that, as police pulled up, one of Mr Cole’s friends pulled him back, and either Mr Cole threw the bottle or his friend took it off him, and the bottle landed in the road. Mr AA said it may have been an assumption Mr Cole threw the bottle, but he heard the sound of breaking glass at the same time as the police exited their van. 132. Witness 14 said he heard a smashing sound and the male in the white t-shirt was on the road. He said that, soon after, a police van pulled up and four or five police officers in high-visibility clothing got out and ran straight to the nightclub. He could not see what they did when they got there. 133. Footage from the Local Authority CCTV camera at 01:34:25 showed a police van approach the nightclub from the High Street with its emergency lights activated. 134. Witness 1 said the police arrived while he spoke to Witness 11. He said two police officers came from the side door of the van and one from the front of the van. He said the police took Mr Cole back to the van to speak to him. At that point Mr AA instructed everyone back to their locations inside the club.

The initial police attendance at the nightclub 135. Footage from the Local Authority CCTV camera at 01:34:26 showed Mr Cole, Witness 11 and Witness 24 walked away from the nightclub, between the parked cars, and pushed each other forwards across the road. They appeared to be ushered away by two door staff and Mr Cole cannot be seen holding the bottle. At 01:34:41 the camera panned left and a police van was parked opposite the

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nightclub. The driver, identified as PC Oates, wearing a black short-sleeved top and black stab vest, exited the van, which had a black cab parked in front of it. 136. In his police notebook PC Oates wrote “I saw a large group of people outside the club. In this crowd I saw an IC3 male wearing a grey t-shirt and dark trousers [unreadable] from the crowd and smashing a glass object on the ground which may have been a drinking glass.” PC Oates wrote that he ran over to the male, identifiable as Mr Cole, who was in a state of “hyper activity”. He wrote “He was very excitable and was acting in an aggressive manner. He was waving his arms about and saying something but I could not make out what was being said due to noise on [unreadable]. Myself and PC Ross approached the male and the other IC3 males who was with him in order to try and establish what was going on. The other males was pushing the male away and preventing us from speaking to him. The male himself would not cooperate with us. The males was [sic] saying that it was ‘cool’ and leave him alone and it was my understanding that they were trying to diffuse the situation by taking the male away from [the nightclub]. I saw they kept pushing him away and was [sic] saying something to him, again I could not hear what. The male was advised to leave and not return back. Although the male did not take any notice of us the other males said this would happen.” 137. In interview PC Oates said that, as he parked opposite the nightclub, he saw a male, who he later knew to be Mr Cole, run from outside the club and smash a glass or glass bottle on the road. He said there were many members of the public about outside the club, and at first he was unsure if Mr Cole had any associates with him. PC Oates said that, when he saw the glass bottle smash, he assumed Mr Cole was one of the males causing trouble at the nightclub. He said he got out of the van along with PC Ross and PC Spicer and approached Mr Cole with PC Ross. He said PC Spicer walked into the crowd and believed he was talking to other members of the public to establish what was going on. 138. In his police notebook PC Spicer noted a report of a fight at the nightclub and wrote “Upon arrival IC3 male in white t-shirt and black trousers being pulled away by friends appeared to be trying to get to door staff, very angry/aggressive.” 139. In interview PC Spicer said that, as they went towards the nightclub, there were people milling around outside the club. He said they parked opposite and he got out the sliding door onto the pavement. PC Spicer said he noticed a group of youths and his first impression was they were fighting, but it was very quickly apparent that the majority of them were trying to grab hold of and restrain one, indicated to be Mr Cole. 140. In her police notebook PC Ross wrote that she attended a disturbance at the nightclub and she noted “one black male being escorted away from Embassy [sic].” She wrote a description of Mr Cole then wrote “Male two and others escorting male one away as he was very aggressive”. 141. In interview PC Ross said that, on arrival, she saw that a group of black males, no more than five, were restraining a male she identified as Mr Cole. She said they restrained him aggressively; one had an arm around his neck and another held him by his waist and they tried to pull him away from the nightclub. She said Mr Cole was moving his arms around and they tried to grab him in any way to stop him. 142. Witness 23 was in the smoking area and said he heard a crashing sound of the barriers outside the club and also heard aggressive shouting and swearing. He said he saw a black male who was shouting and appeared intoxicated and

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aggressive. He said the male walked east along the road and a police officer followed within a metre behind him. He said the police officer appeared calm. Witness 23 saw a taxi heading west but stopped in the road, which the male approached. The male then hit the taxi bonnet with his hands in a shoving motion. He said after the male hit the taxi he turned and walked to a white parked vehicle, which Witness 23 believed he kicked. He said that, as soon as the male kicked the vehicle, the police officer behind him placed his hand onto the male’s shoulder. The male then turned around and used both hands to push the police officer in his chest. He said the police officer stumbled back a couple of steps and did not fall over but appeared shocked. He said the male then turned back around but at this point Witness 23 walked away. 143. Witness 14 said that, at some point after the arrival of the police van, he saw the male push a police officer. He said the male used both hands to push the police officer in the chest and said “Move out of my fucking way”. 144. Witness 10 said that, when he looked back over from the smoking area, the police had arrived. He could not remember how many police officers but said he saw a youth in a light-coloured t-shirt shove or push a police officer. He said the police officer did not react to this. 145. Witness 12 said the police were following the male around and at one stage the male pushed both his palms into the chest of one police officer, shoving the police officer back. He said the police officer did not go back for the male again. 146. Bystander Witness 34 said she saw either Mr Cole or Witness 24 run into the road and some police officers came out of the side of a police van and tried to grab him. She said the male (either Witness 24 or Mr Cole) turned around and swung with his right hand and the police officer tried to grab him. She said the male’s hand was a closed fist and he aimed for the police officer’s face, which was blocked by the police officer. She said the police officer tried to protect himself and grab the male. She described the police officer as trying to simultaneously keep the male away but keep him within reach to control him. She said the police officer’s hands were open and he did not try to punch the male. She said it was like he smacked the male on the top part of his body in the chest and shoulder area, and tried to grab the clothing of the male. 147. Mr AA said one male and one female police officer went directly to Mr Cole and his friends in the road. They engaged with Mr Cole, but he was still being quite aggressive and he pushed the male police officer away by a push to the chest. Mr AA said the police officer staggered backwards and then Mr Cole went east on Mill Street towards the George and Dragon. Mr AA said he told his door staff to go back inside at that time. 148. Mr BB said the police driver saw Mr Cole and his friends run along the road onto the footpath past the George and Dragon, and he went at a slow jog after them. He said the female police officer walked behind him in the same direction. Mr BB said the male police officer had what he thought was a can of pepper spray in his right hand. He said he then moved to the front door and did not see any contact between them. 149. Footage from the Local Authority CCTV camera at 01:34:49 showed Mr Cole walked back towards the nightclub, followed by a police officer identifiable as PC Spicer. The footage showed PC Spicer either pushed or attempted to take hold of Mr Cole’s shoulder. Mr Cole spun around and pushed PC Spicer’s arm off of him. There was then a brief moment where they appeared to grip each other around

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the arms/torso area, before Witness 11 and Witness 31 intervened. PC Ross and PC Oates joined PC Spicer and ushered Mr Cole, Witness 11 and Witness 24 away east on Mill Street. Witness 31 then caught up with the group and it appeared that Mr Cole was physically moved away by Witness 31, Witness 11 and Witness 24, but the manner in which they did this could not be seen with any clarity. 150. In his first interview PC Spicer said he approached to within a yard when the one they were trying to grab, identified as Mr Cole, shouted out, “Don’t touch me”. PC Spicer said he was ducking, diving and swerving about like somebody dodging tackles. He did not lash out but violently shrugged them off. 151. In his second interview PC Spicer said that he ‘bottled out’ that night. He said he got scared in the van when they arrived and when Mr Cole came between the cars he saw the look of anger on his face, and so he stood back. PC Spicer said since the incident he had thought maybe if he had arrested Mr Cole then the rest of the incident would not have happened. He said he told himself Mr Cole would not have passed the threshold test for custody and breach of the peace would not have been appropriate because his friends were trying to get him away, but he said the bottom line was that he was afraid.

Mr Cole’s temporary removal from the nightclub 152. Witness 24 said the police arrived and due to Mr Cole being angry and very agitated the police told them to take Mr Cole away or he would be arrested. 153. Witness 11 said the police arrived and a female police officer told them to calm Mr Cole down, get in a taxi and go home. He said they took the police officer’s advice, Witness 31 and Witness 24 took hold of Mr Cole and walked him away. 154. Witness 25 said that two male police officers in flat hats and high-visibility jackets arrived. She said one went to speak to Mr Cole and the other spoke to the door staff. She said Mr Cole was now with three friends and a police officer and it appeared calm. 155. Witness 36 said that, at about 1.30am, he went out the front and there were two police officers in the road, one in a prominent position on the footpath in a high- visibility jacket. He said Mr Cole was quite irate and was shouting from the footpath, and he was surrounded by three or four friends. Witness 36 said that one minute Mr Cole’s friends would be fine and the next they would get quite irate, although he noted that one of them, indicated to be Witness 31, seemed to be quite balanced and tried to calm Mr Cole down. He said every time Mr Cole came forward to speak with Mr AA or the other doormen Witness 31 tried to pull Mr Cole away, whereas some of Mr Cole’s other friends encouraged him. 156. PC Oates said he and PC Ross approached Mr Cole outside a hairdressing shop situated adjacent to the east side of the nightclub’s forecourt. He asked Mr Cole what was going on but Mr Cole would not speak to him or make eye contact. PC Oates said Mr Cole was in a state of anxiety and excitement; his body movements were aggressive and he was clearly upset. PC Oates said he then became aware that Mr Cole had a group of friends: four or five black males. He said they assured him and PC Ross that everything was fine and asked to let them take Mr Cole home.

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157. In his police notebook PC Spicer wrote “[The male was] lead [sic] away by friends past George and Dragon they then pinned him in corner.” 158. In interview PC Spicer said three of Mr Cole’s friends had hold of him and one of them took Mr Cole in a headlock and led him away in the direction of the George and Dragon. PC Spicer described the headlock as Mr Cole being under the friend’s arm, like in a rugby scrum. He said the friend held him in the headlock with his left arm at about midriff level. He said the others just pulled and tugged on him. 159. Footage from the Local Authority CCTV camera at 01:35:15 showed a police patrol car arrived from the direction of the High Street and parked behind the police van. A police officer identified as PC Kalyan exited the passenger side and walked to the other police officers. PC Ross, PC Oates and PC Spicer had followed Mr Cole, Witness 24, Witness 31 and Witness 11 down the street but stopped at the end of the parked cars and apparently monitored the situation. Mr Cole, Witness 24, Witness 31 and Witness 11 continued to move away as a close unit, consistent with one of them being physically moved away by the rest. They moved into a corner on the right side of the road. Their movements at this point were not clear but it appeared Mr Cole was restrained in the corner of the buildings by the other three. At 01:35:28 Inspector Fosbury exited the driver seat of the patrol car and walked towards the other police officers. 160. In his police notebook PC Kalyan wrote he attended an incident outside the George and Dragon on Mill Street. He wrote there was a black male in a white t- shirt who was very agitated and angry. He wrote “Being held back by friends. Very aggressive. Taken away by his friends. CCTV has been asked to watch the male as he is dragged along side street.” 161. In his first interview PC Kalyan said that, when he arrived, PC Ross, PC Oates and PC Spicer were talking to one of Mr Cole’s friends, indicated to be Witness 11, outside the George and Dragon. He said the male he later knew to be Mr Cole was on a street corner with a handful of friends and he could see them struggling with him. He said four to six friends tried to get him under control and take him away from the incident but he was not listening to them. He said he could hear lots of shouting coming from them. He said one of them had Mr Cole in a headlock, which he said was a “half-nelson”. He described this as Mr Cole with his arms out and the friend’s hands went around the back of Mr Cole. He said Mr Cole was sliding all over the place, ducking and trying to get away from his friends. 162. In his second interview PC Kalyan declined to answer any further questions regarding the ‘half-nelson’ headlock or use of force by Mr Cole’s friends. After being shown CCTV footage he said Mr Cole was either in a headlock or a “half- nelson” and he could not remember which, but they dragged him down the street. 163. PC Spicer said he said he stayed on the road near the cars and monitored the group to make sure Mr Cole did not come back. He then went to the pavement outside the club and patrolled near the taxi office. 164. In his police notebook Inspector Fosbury wrote “Upon arrival [at the nightclub] troublesome male being led away from location by his friends. Briefing from PC Oates re bouncers at location.” 165. In interview, Inspector Fosbury said that, when he parked, there was a large crowd of people outside the nightclub but, before he could get out, a man came

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across from the taxi rank asking for assistance and he spent some time dealing with an unrelated matter. He then got out of the car and stood on the path opposite the nightclub. He said there were lots of people coming out of the pub and lots of people milling around in front of the nightclub. 166. Footage from the Local Authority CCTV camera at 01:36:05 showed Mr Cole and two others moved further down the street and over the road, out of view. Witness 11 broke away from the group and remained to speak to PC Ross and PC Oates. 167. Witness 24 said that, along with Witness 11 and Witness 31, he dragged Mr Cole across the road and to a side street. They tried to calm Mr Cole down but he was not listening and was angry. 168. Witness 11 said he spoke with a police officer and then went over to Mr Cole, Witness 31 and Witness 24, who were up a side street opposite the nightclub. 169. In her police notebook PC Ross wrote “Spoke with male two outside George and Dragon. Informed me that his friend (male one) had a problem with the bouncers two weeks ago. They were dancing on the podium and they were asked to step down which male two did and he informed me that male one was a bit ‘cockey’ with bouncer and they were both ejected. There was also friends who I cannot provide any description off [sic] there. I advised male two to take his friend, male one away from the town due to his behaviour. He agreed and I informed him that if he wanted to make a complaint about the bouncers then to take it up with the management of [the nightclub] on the following day”. 170. In interview PC Ross said she went over to the group and spoke to one of Mr Cole’s friends. She said he clearly had been drinking because his breath stank of alcohol. He told her there had been an altercation with his friend and the door staff from the nightclub and explained how they had been ejected. He also told her about a previous incident and it was evident there was an issue between the doorman and either the group or just Mr Cole and the friend. She told him that at that time there was no way they would be able to resolve anything between him and the nightclub, so they needed to go out of town. She said Mr Cole was still being restrained at this point. She said there were a lot of people around, members of the public were standing on the pavement waiting for taxis and it was a busy road. She then withdrew from the friend in the hope they would take Mr Cole away. 171. PC Oates said he was aware one of the males spoke to PC Ross and complained about how they had been ejected from the nightclub, which was the cause of Mr Cole’s behaviour. PC Oates said that, as there were no complaints forthcoming from anybody about Mr Cole’s behaviour, he and PC Ross agreed that if his friends took him home that would be the end of the matter. PC Oates said he noted the potential for a breach of the peace. He said that, as Mr Cole’s friends tried to calm him down, Mr Cole waved his arms and tried to physically break free from them. He said Mr Cole’s friends managed to keep a grip on him and started to walk him east along Mill Street. He and PC Ross watched them. He said that, as they walked up Mill Street, Mr Cole’s behaviour became more and more active, so one of the group placed Mr Cole in a headlock and had to physically drag him up the road to prevent him from breaking free. He said Mr Cole had his back to them and Mr Cole’s friend faced Mr Cole, had his arms locked behind Mr Cole’s neck and walked backwards. He said Mr Cole's body was hunched down. He said Mr Cole was then released and they continued to walk up the street, still restraining Mr Cole but the headlock had been removed.

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172. PC Oates said Mr Cole and his friends walked out of sight and PC Ross then walked away into the crowd. He said that, after a couple of seconds, he saw Mr Cole reappear at the bottom of Mill Street followed by the group, but they were not making their way back towards the nightclub they were just loitering, and at this time Mr Cole was not being restrained. PC Oates said that, as they were not happy about how they had been asked to leave the club, he decided to speak to the door staff. 173. Footage from the forecourt of the nightclub’s CCTV camera at 01:38:38 showed a police officer, identifiable as PC Oates, approached Mr AA. They then walked together out of view towards the taxi rank. 174. PC Oates said he spoke to the doorman who told him Mr Cole was “kicking off” in the club and had to be forcibly removed by the door staff. PC Oates said he asked whether excessive force had been used and they said the force had been reasonable. PC Oates said he told the door staff he intended to put a complaint to the licensing officer about the general attitude of the door staff as a whole in the town centre. PC Oates said that, while he had this conversation, he was aware that Inspector Fosbury and PC Kalyan were across the road. Afterwards Inspector Fosbury called him over to ask what the conversation with the doorman was about. PC Oates said he went over and explained. He said at this time he paid no attention to the crowd. 175. Mr AA said a police officer, who he identified by shoulder number as PC Oates, told him Mr Cole and his friends had complained about door staff being heavy- handed. Mr AA told PC Oates they were walked out of the club and were not restrained. He said PC Oates did not accept his explanation and said he was going to report it to the licensing officer. Mr AA said that was the end of the conversation and he walked away from PC Oates. 176. Inspector Fosbury said he saw PC Oates speaking to a doorman, and it was obvious PC Oates told him off. He said PC Kalyan stood next to him. He said he heard PC Kalyan on the radio ask the Control Room for CCTV to monitor a group of males. Inspector Fosbury said he then saw a group of three or four males, one of whom was wearing a white t-shirt, and was being restrained by his friends. He said they held him around the neck and shoulders, and tried to pull him in one direction. He said the male squirmed and at one point he broke free, but they grabbed him again and dragged him backwards by his head and shoulders up a side street, out of view. He said PC Oates then finished speaking to the doorman so Inspector Fosbury called him over. PC Oates told him the group of males complained about door staff being heavy-handed. Inspector Fosbury said he and PC Kalyan went back to the car and drove down Mill Street to check where the group of males had gone. 177. PC Kalyan said he did not have much interaction with Mr Cole and his friends on his first attendance because PC Oates, Ross and Spicer dealt with him. He said as he and Inspector Fosbury walked back to their car he made a radio request for CCTV to monitor them. 178. A Bedfordshire Police Incident Log entry at 01:38:04 from unit BH103 noted “Friends have taken the male away, can CCTV keep an eye on them in case of any further problems”. 179. A radio transmission from unit BH103 to the Control Room at 01:41:01 stated “Regarding the incident on Mill Street, one of the chaps was being dragged away

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by his mates. I think they’ve gone up one of the side streets. Can CCTV just keep an eye on them?” The Control Room replied “Yeah we’ll give them a call”. 180. Witness 24 said Mr Cole knew a manager at the nightclub, Witness 18, and kept saying “Let’s speak to her, we can either get back in or I can get my money back”. 181. Witness 11 said Mr Cole eventually calmed down and they agreed to walk him back to the nightclub to speak with Witness 18.

Mr Cole’s return to the nightclub 182. Footage from the CCTV camera in the doorway of the XXXXXXXXXXX pub at 01:41:02 showed Witness 31 walked towards the nightclub, followed by Mr Cole, Witness 24 and Witness 11. 183. Footage from the forecourt of the nightclub’s CCTV camera at 01:41:35 showed Mr BB was approached by Witness 31, Witness 24 and Witness 11. They then moved together as a group towards the taxi office and out of view. 184. Footage from the taxi office CCTV at 01:41:45 showed Mr Cole walked west along Mill Street past the nightclub’s forecourt. He appeared calm and had two phones; one in each hand. He walked past the taxi office out of view. At 01:42:40 Mr Cole could be partially seen on the west side of the taxi office before he then walked towards the nightclub and out of view at 01:42:56. 185. Witness 24 and Witness 11 said they returned to the club and spoke to a doorman named ‘[Mr BB]’. They asked to speak to Witness 18. Witness 11 said the doorman who ejected Mr Cole came outside and was telling Mr BB not to speak to them. Witness 11 said this doorman laughed at them and tried to encourage trouble, which caused Mr Cole to become angry again. 186. Mr BB said Mr Cole and his friends spoke to him about making a complaint to Witness 18, although he thought this happened before the police had arrived. He said Witness 18 was outside at that time so he asked if she would talk to them, but she said she was too busy. Mr BB said he could not remember if he said this to Mr Cole and his friends, but after that they went away for a minute or two, towards the XXXXXXXXXXX pub. 187. Footage from the forecourt of the nightclub at 01:44:32 showed Mr BB went to the entrance, followed by Witness 24 and a female identifiable as Witness 18 approached from the nightclub, then went with Witness 24 to the barriers by the pavement. 188. Footage from the taxi office CCTV at 01:44:32 showed Mr Cole in the road speaking on the phone, then Witness 31 approached Mr Cole and led him towards the nightclub. 189. Witness 32 stated he was in the nightclub when Mr Cole phoned him and told him to come outside. 190. Footage from the forecourt of the nightclub at 01:44:54 showed that Witness 31 and Mr Cole approached from the west side of the forecourt and spoke to Witness 18. 191. Witness 18 said she was outside the club when Mr BB told her Mr Cole’s friend wanted to speak to her. A male identifiable as Witness 31 then asked her to speak to Mr Cole, who walked towards the club. She said Mr Cole came over and seemed angry, immediately saying “I want my fucking money back or the door

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staff are gonna get hit” or “hurt”. She said she could not be sure whether Mr Cole said “hit” or “hurt”. She said Witness 31 tried to calm Mr Cole down. She was busy and reluctant to be spoken to like that so said something like “You need to calm down, I’m not putting up with that”, then went back inside. 192. Witness 24 said Witness 18 said she could not help; they would have to leave and would not get their money back. He said Mr Cole was very angry and all he wanted was his money back or to go back inside. He said Witness 18 refused to acknowledge Mr Cole and accused him of causing trouble in the club. 193. Footage from the forecourt of the nightclub at 01:44:57 showed Witness 18 walked back towards the entrance. Mr Cole, Witness 24 and Witness 31 were standing near to the barrier and all gestured towards the nightclub. Mr BB was in the middle of the forecourt and appeared to gesture back. A police officer identifiable as PC Ross approached from the west side of the forecourt, followed by a police officer identifiable as PC Oates. At 01:45:00 PC Ross and PC Oates approached Mr Cole and his friends and appeared to guide them away from the forecourt towards the road. PC Ross and PC Oates did not follow but turned back towards the taxi office and moved out of view at 01:45:11. Mr BB walked back to the front entrance. 194. In his police notebook PC Oates wrote Mr Cole had returned along with his friends. He wrote “They were talking to a member of the door staff at [the nightclub]. I saw that the doorman was talking to them in a calm manner and was trying to reason with them. I then saw that the male was starting to act aggressively again shouting and acting violently. Myself and PC Ross ran over whereby the male ran away and would not listen to what we had to say. I managed to take hold of him but he broke free. What I mean by taking hold of him is trying to grab his arm. He remained on his feet and the other males was intervening again preventing myself and PC Ross from apprehending this male. I could now see that this male was intent on getting to the door staff. He was swearing and running around dodging us and all of the time his associates still preventing me and PC Ross. The male was very fast on his feet and he kept dodging us at the same time.” 195. In interview PC Oates said he saw Mr Cole had returned to the nightclub with his friends and was speaking to a doorman in the smoking area. He said the doorman spoke to Mr Cole in a calm and rational manner. PC Oates said he went across the road and he heard Mr Cole say “I want my money back, I want my money back” in a state of anger. He said he could not hear what the doorman said back to him. PC Oates said he was joined by PC Ross and they decided there was going to be a breach of the peace. He said that, when they approached Mr Cole, he ran off and would not let them interact with him. He said there was a big crowd and he could not see where Mr Cole had gone but he ran towards the hairdressers at the east side of the forecourt. PC Oates said his friends assured them that everything was fine and they would sort it out. 196. In her police notebook PC Ross wrote “Male one returned trying to get towards the bouncers at the front of [the nightclub]. Male was again being restrained by others. Myself and PC Oates approached the male. He was aggressive, waving his arms around and clearly under the influence of drink or drugs. Myself and PC Oates tried to detain the male. His friends were obstructing us. Male one was swearing and appeared to me that he wanted to fight. Male one was warned and

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friends were ushered toward George and Dragon and again told to leave the area.” 197. Bystander Witness 39 said she was waiting outside the nightclub and could hear shouting from a male, identifiable from her description as Mr Cole, saying he was not going anywhere until he got his money back and he repeatedly said he wanted his money back. She said a few friends of the male were outside the club at the time. She said he walked back and forth and appeared drunk, although she noted he was not slurring or stumbling. She said his friend, a black male in a dark blue top, followed him around. She said the male continued to shout for a further two to three minutes. 198. Security staff Witness 35 said she saw Mr Cole near the railings and two police officers approached him. She said they spoke to him but he did not appear to listen, and he was abusive towards them. She said she did not watch constantly but the police officers tried to calm him down. She said the police officers tried to talk to him by putting a hand up towards his arm and leaning towards him, but she could not see if they gripped him at any stage. The male then shrugged off the two police officers and moved away towards the centre of the pavement outside the nightclub. 199. Bystander Witness 37 said he was in the smoking area and noticed a group of approximately ten people outside the club including a black male with short hair, possibly 5ft 8in and possibly wearing jeans. He said there were two or three police officers. He said it looked as if the police had just broken something up involving the male and one of the police officers, indicated to be PC Oates, tried to grab the male again, but the male shook him off. He said the male and the police officer appeared to be facing each other initially, then the police officer attempted to turn the male by his left arm, pulling it behind his back, but the male shrugged his shoulder and moved away towards the smoking area. 200. Witness 36 said Mr Cole had come back to the forecourt and started shouting at someone in the smoking area. He said Mr Cole’s demeanour at this point appeared quite aggressive. He thought a couple of his friends were still with him, but one of them was speaking to a police officer to the west of the forecourt. 201. In his police notebook PC Spicer wrote “Whilst monitoring club spoke to IC3 male, first name … [Witness 11] ... He states that they had been dealt with heavy- handedly by door staff two weeks ago and that this had happened again tonight – he said male one was on a stage and had been forcibly removed by door staff. Called male one [Mr Cole]. Advised that we are aware of allegations and that it would be in his best interests to leave town centre and leave door staff to police.” 202. In interview PC Spicer reiterated this content but said Witness 11 told him the door staff threw Mr Cole off the stage and threw him out of the nightclub. He told Witness 11 they would deal with the door staff through licensing. PC Spicer said Witness 11 seemed to accept that and he went off in the direction of the George and Dragon. 203. Witness 12 said the male came back to the entrance of the club and started to ‘kick off’ again. He threw barriers and kicked cones and the police only watched. His friends were saying, “No leave him alone, we’ll take him home.” He said the male approached again and tried to get into the club but Witness 12 blocked his way. The male then wanted to give his phone to a friend of his so he was allowed to do this.

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204. In interview Mr AA said he saw Mr Cole head towards the smoking area. He said Witness 12 was there but he walked over for support because he thought Mr Cole may try to get into the smoking area. He said Mr Cole did not say anything and was calm at that stage. Mr Cole had his phone in his hand and he gave it to a male standing on the other side of the barrier. Mr AA said Mr Cole did not engage with him or Witness 12. Mr Cole then moved away. 205. Witness 31 said they moved to the side of the entrance and were there for around two to three minutes. He said during this time Mr Cole gave his mobile phone and ID card to Witness 32. 206. Witness 32 said he went out and saw Mr Cole, who tried to pass him his phones. He said the police tried to stop him and Mr Cole said “I just want to give him my phone”. Witness 32 said he took the two phones. He said Mr Cole was not drunk when he handed him the phones. He said he saw at least five police officers, including one six-foot police officer with a hat on, a female police officer, and one short Indian or Asian police officer with a black police jacket, although he was unsure if he was a police officer as all the other police officers had high-visibility jackets. Witness 32 said he also recalled Witness 11, Witness 31 and Witness 24 trying to pull Mr Cole back as he was angry. Witness 32 believed him to be going towards the black doorman who ejected him. He said Witness 11 tried to restrain Mr Cole by wrapping his arms around Mr Cole’s torso but was unsuccessful as Mr Cole pushed Witness 11 away. 207. Witness 37 said the male came to the barrier of the smoking area and an item, possibly a phone, was passed between him and a second male who was inside the smoking area. He said they spoke for no more than 20 seconds before a doorman told the male to move on. 208. Footage from the forecourt of the nightclub at 01:46:01 showed males identifiable as Witness 28, Witness 40 and Witness 20 leave the club by the front entrance. They stood next to the barriers at the east side of the entrance, apparently looking towards the smoking area. At 01:46:51 they moved east out of view. 209. Witness 28 said he left the club at around 2am, and saw Mr Cole on the right hand side by the railings with Witness 24, Witness 11 and Witness 31. Witness 28 said Witness 32 was standing in the smoking area talking to someone on his phone and Mr Cole was trying to speak to him and pass his phone to Witness 32. Witness 28 said he walked down to join them. 210. Witness 20 said he left the nightclub with Witness 28 and Witness 40 and to his right he saw Witness 11 and Witness 24 struggling to pull back Mr Cole, who, he could see, was angry. He said Mr Cole walked over to Witness 32 who was in the smoking area and handed him two mobile phones, which he asked Witness 32 to look after. Witness 20 said he tried to calm him down and Mr Cole said “I wanna fuck them up”. He said Mr Cole handed him his necklace and ID card. Witness 20 said at this time there was a group of three or four door staff next to a group of five to eight police officers, one of whom was female. 211. Witness 37 said after the phone was passed over, the male moved away and stopped next to a wall on the east of the forecourt. He said the male began talking to another male, who looked like he tried to calm the first male down. He said at one point, the second male placed his hands on the other’s shoulders, holding him in a non-aggressive way, while the first male had his back against the wall.

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212. Bystander Witness 2 said he heard shouting and saw a black male, between 5ft 10in and 6ft, around 20 years old with short black hair and a blue t-shirt, was shouting while his friends tried to pull him away. His friend, who was black, in his twenties, taller and a skinnier build than the male with short hair, had his left hand on the male’s left shoulder with his right hand pulling the male’s left arm backwards. He said the friend then let go and stepped around the front of the male, grabbed the male’s shoulders and started to push him away. The friend walked the male backwards with both his hands on his upper arms and shoulders, while the male pulled away and resisted. He said that, as the friend pushed the male’s shoulders the male backed off a bit and stopped resisting, so the friend stopped walking him backwards. They then talked normally to each other. He said the male then backed off from the friend and ran to his right, around the friend, towards the entrance of the nightclub. The friend caught up with him, grabbed him and pulled him backwards by his shoulders from behind. The male tried to pull away then stopped and walked backwards, with the friend still holding him. 213. Witness 36 said he saw two police officers, one of them female, approach Mr Cole. He said he thought they initially tried to calm Mr Cole down but he was still going from calm to very aggressive. He said he saw the police officers try to restrain Mr Cole against the external wall of the hairdressers on the east side of the nightclub. He said he could not see how the police officers held Mr Cole but his back was against the wall. He said Mr Cole’s friends were also involved and it looked as though they tried to pull the police officers away. He said one of Mr Cole’s friends pulled the female police officer away and Mr Cole managed to get loose. He said there was another police officer in black clothes speaking to one of Mr Cole’s friends on the west side of the forecourt. 214. Door Supervisor from the XXXXXXXXXXX pub, Witness 21, said that, between 1.40am and 1.45am, he and two colleagues headed to the nightclub to speak to colleagues who were working there. He said that, as he walked towards the nightclub, he saw a black male in his 20s, wearing a white t-shirt, who was chatting with two police officers at the corner of the hairdressers situated in between the pub and the nightclub. He thought it was one male and one female police officer but could not be sure. 215. Mr AA’s incident report stated that Mr Cole had reappeared, still appearing to be in an aggressive mood. PC Oates attempted to arrest him but he struggled free. 216. In a second incident report Mr AA wrote that PC Oates and a female police officer tried to arrest Mr Cole, but with the aid of another black male he managed to avoid being arrested and ran back to the front of the club. 217. In interview with the IPCC Mr AA said that, as Mr Cole went away from the smoking area, it looked like PC Oates and the female police officer tried to arrest him but Mr Cole struggled free and went off again. He said there was a third police officer there in high-visibility clothing but he was to his left and the police officers and Mr Cole were to his right. 218. Bystander Witness 3 said she saw two or three door staff holding a black male up against the wall of the pub next to the nightclub. She said the male’s friend was saying “He’s done nothing wrong”. She said the male was facing the nightclub, and it looked like his hands were being held up by the door staff. She said one member of the door staff by the male’s waist area may have been female. Witness 3 said it looked like she was holding the male with her hands on his

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waist, pushing him up against the wall. She said the male’s hands were in the air, she thought they were held by a white male doorman in black clothing on each side. She said the male’s friend was nearby and asking the door staff to leave it. 219. Mr BB said Mr Cole had come back from the corner of the George and Dragon and went towards the smoking area. Mr AA was on the step to the smoking area with Witness 12 behind him. Mr BB said Mr Cole pointed, swore and shouted at Mr AA. He said a male and a female police officer then tried to arrest Mr Cole. He said they tried to put handcuffs on Mr Cole but he wriggled out of it and he walked off back round the corner towards the George and Dragon. He said he thought one of Mr Cole’s friends pulled him away. 220. Witness 2 said it looked like the male in the blue t-shirt was going to walk away but he then ran back towards the front of the nightclub. He said there was a group of police officers behind him and a male police officer ran out of this group towards the male and restrained him. He said the police officer grabbed the male’s right arm with his right hand and his left arm with his left hand, and then pulled the male’s arms behind his back. The police officer then turned him around and started to walk him away, holding both of the male’s hands in his right hand and using his left hand to push his left shoulder to turn him around. He said the male resisted and tried to get away. He said the police officer tried to keep a grip on the male as they began to walk towards a police vehicle. He said the male then managed to get his hands free and ran away from the police officer, back towards the entrance of the nightclub. 221. In his police notebook PC Oates wrote “The male then did a loop again and almost reached the entrance. We ran over to him and again he dodged us as me and PC Ross ran over to where the male was in the corner of outside [the nightclub]. For a brief moment we managed to grab hold of him and I removed my cuffs in order to restrain him but he pushed me away and ran back towards [the nightclub].” 222. In interview PC Oates said Mr Cole had returned to the nightclub. He looked for Inspector Fosbury and PC Kalyan but assumed they had left the location, so he was aware it was just him, PC Ross and PC Spicer. He said Mr Cole was acting aggressively and swearing. PC Ross said she was going to arrest him for a public order offence and he went to assist. PC Oates said Mr Cole ran into the corner at the side of the hairdressers, so PC Oates and PC Ross followed and PC Oates removed his handcuffs. He told Mr Cole he was going to be arrested and attempted to handcuff him, but Mr Cole was so fit and agile that he could not get hold of him. He said Mr Cole managed to break free and ran off. He said Mr Cole was also joined by his friends and when PC Oates tried to physically take hold of Mr Cole his friends interfered. He said Mr Cole’s friends physically manhandled him and PC Ross and told them to get away from Mr Cole. 223. In her first interview PC Ross said Mr Cole came back and was restrained by his friends again, but he was aggressive and was intent on getting away from them. She said she was by the George and Dragon, and Mr Cole’s friends almost had him held against the wall and had surrounded him. She and PC Oates approached and they decided that Mr Cole needed to be arrested. PC Ross said the decision to arrest Mr Cole was based on his behaviour as he was causing a disturbance in the town. She said she had already warned them about their behaviour, but Mr Cole was showing threatening behaviour and was aggressive. PC Ross and PC Oates attempted to approach Mr Cole to handcuff him, and PC Oates had his handcuffs out, but they could not get near because his friends

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obstructed them. She said Mr Cole’s friends blocked them from reaching Mr Cole, and he was still throwing himself around. She said members of the public were getting barged. She said there were more of his friends than there were police officers and they had no support at that time. Mr Cole’s friends stopped him from being arrested. She said Mr Cole was pushed up against the wall and his friends created a barrier between them and Mr Cole. She said PC Oates then called up on his radio for assistance. 224. In her second interview PC Ross explained she was going to arrest Mr Cole for a Section 5 Public Order Act offence because he had behaved in a manner which would cause any member of the public harassment, alarm or distress. She said she could not recall whether she considered a Section 27 (Violent Crime Reduction Act 2006) notice to leave the town centre at that time and she confirmed her awareness of that option. In interview she suggested it had gone beyond a Section 27 notice because they had attempted to ask him and his friends to leave the town but he persisted on his course of conduct and insisted on getting back to the doorman for some reason. 225. In his police notebook PC Oates wrote “I then made the decision that myself and PC Ross and Spicer could not handle this situation ourselves so I asked on my personal radio that more police officers was [sic] required at [the nightclub].” 226. In interview PC Oates said Mr Cole ran off again but he did not see where he went. PC Oates decided that he, PC Ross and PC Spicer would not be able to handle the situation on their own because Mr Cole was too fast and they were outnumbered. He said there was potential risk that one of them could have been assaulted due to how the males were behaving. He said Mr Cole was becoming more and more agitated and so were his friends. He said Mr Cole’s friends were no longer saying that Mr Cole was going to be taken home; they were fighting the police off of him. PC Oates said he thought Mr Cole was ‘hell bent’ on getting back into the nightclub. He said PC Ross had walked off into the crowd, while he remained static, composed himself and waited for the radio traffic to clear. He said he then managed to get through and requested more police officers at the nightclub due to a disturbance. He said he wanted to prevent something serious from happening at the club and was concerned for the safety of the nightclub’s staff, police officers and members of the public. 227. The Bedfordshire Police Incident Log contained an entry at 01:47:58 from PC Oates requesting more units. 228. A radio transmission was made at 01:50:53 from unit 112 which stated: “112 more units to [the nightclub] please” which was then acknowledged by several units. 229. PS Withey said he heard PC Oates call up requesting more units. He was on the High Street so ran around the corner towards the nightclub. 230. PC Kalyan and Inspector Fosbury said they heard a radio request from PC Oates for more police officers to the nightclub, and they were nearby so drove back to the nightclub. 231. PS G, PC A and PC C stated they were crewed together in a police van and at around 1.50am they heard a request for police officer assistance at a disturbance outside the nightclub.

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232. PC E said he heard a radio request from PC Oates for more units outside the nightclub. He left the incident he was dealing with to attend. 233. PC B said he heard a radio request for more units to Mill Street, so drove to attend the incident. 234. PC H said he responded to a call for assistance and drove to the nightclub.

The restraint and arrest of Mr Cole 235. The Local Authority CCTV footage showed that at 01:47:25 the camera panned back from covering the High Street and was positioned to view Mill Street and the front of the nightclub. As it did so a police officer in a high-visibility coat and peaked hat, identified as PS Withey, ran towards the nightclub from the High Street. There were crowds of people on the streets outside the taxi office and the nightclub, which prevented a clear view of the forecourt. 236. The footage showed that at 01:47:27 Mr Cole sprinted into the road from approximately four vehicles east of the forecourt of the nightclub. He then ran alongside the parked vehicles, before he looped through the parked cars directly towards the front of the nightclub and out of view at 01:47:33. 237. The footage showed that several people ran after Mr Cole. They were identified as Mr BB at 01:47:35, followed closely by PC Spicer, then PC Ross at 01:47:36, PC Oates at 01:47:37, and PS Withey at 01:47:39.

The initial physical contact with Mr Cole 238. The time-lapse footage from the nightclub showed that Mr AA was stood in the centre of the forecourt at 01:47:32. In the next frame at 01:47:33 Mr Cole was in contact with him. It appeared that Mr Cole and Mr AA had their arms interlocked, holding each other around the bicep area, and Mr AA appeared to have stepped forward with his right leg which was raised off the ground in front of him. Some individuals in high-visibility clothing could be seen approaching from the pavement at the east side of the forecourt. 239. In his police interview Mr AA said he was stood in front of the front entrance. He said he heard somebody shout very aggressively “And you” and when he looked to his right he saw Mr Cole charging towards him. He said it was clear by Mr Cole’s body language, his clenched fist and the look on his face that he was coming to try to hit him. He said he could see “pure hate” and aggression in Mr Cole’s face, and felt it was directed towards him. Mr AA said he waited for Mr Cole to get close enough, then he put his arms out and deflected Mr Cole across to the left where there were a couple of police officers. He said Mr Cole brought his hands back and, as he was bringing his arm forward, Mr AA caught him with both hands on both Mr Cole’s biceps, and pushed him to one side. He said he put his right leg out to use as a pivot, then turned Mr Cole round on his right leg while holding him. Mr AA said he guided Mr Cole to his left and pushed him at arms length, and as he pushed Mr Cole away the police officers then pounced on him. 240. In his first interview with the IPCC, Mr AA described Mr Cole coming towards him as in his police interview. He expanded on the contact stating he turned his open palms so that as Mr Cole came at him, Mr AA guided Mr Cole across his body to his left hand side. He said his palms were at chest level, about a foot in front of his chest. Mr AA said he stretched his arms out because Mr Cole was short, and

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at arms length Mr Cole would not get close enough to strike him. Mr AA said Mr Cole brought his hand back to throw a punch then lunged forward, and Mr Cole literally took off in the process of trying to hit him. Mr AA said he put his right leg forward to get a good base, and then he rolled Mr Cole around his leg. Mr AA said he did not think his leg was in contact with Mr Cole while he did this deflecting movement; otherwise it probably would have caused Mr AA to fall. He said he did not grab Mr Cole and push him away. Mr AA said Mr Cole then travelled towards Mr BB. 241. In his second interview with the IPCC, further detail was sought on Mr AA’s contact with Mr Cole. Mr AA said he pushed Mr Cole to one side with open palms, using Mr Cole’s pace to move him away. Mr AA said he half-turned and allowed Mr Cole to keep going to his left. He said he did not have to use any force at all because of the speed at which Mr Cole was running towards him. He said it was ‘just a little flick’ with his wrists and Mr Cole went to one side. Mr AA reiterated the contact was at his own chest height, and he said he made contact around about Mr Cole’s arms and chest area. He said Mr Cole was quite a bit shorter than him, so when he put his hands out it would have been straight out in front, and Mr Cole would have been a bit lower. He said Mr Cole tried to jump at him so it could have been Mr Cole’s chest height as well. When challenged Mr AA acknowledged in a normal standing position his chest height would have been at about Mr Cole’s shoulder height, but he said his contact was with Mr Cole’s chest area as the biggest mass to aim for. He said Mr Cole did not go backwards and did not go to the ground as a result of his contact. Mr AA said he did not go to ground with Mr Cole and did not have any further contact with him. He said he did not connect with Mr Cole’s face, neck or head. He said Mr Cole went to the side a couple of steps, and was then caught by Mr BB. 242. Mr AA wrote two incident reports regarding the events at the nightclub. In interview he explained that the incident reports were part of the protocol of his employer, and the reason there were two was because the first was written in brief immediately after his shift at 5am, and the second was a more detailed report written the next day. 243. In his first incident report Mr AA wrote that he was standing in front of the club when Mr Cole shouted at him “And you” and ran towards him with his fist clenched. He said he allowed Mr Cole to get close, then Mr AA grabbed him by both arms and “body-rolled” him to the ground. He wrote that the police officers who attended the earlier incident then arrested Mr Cole. 244. In a second incident report Mr AA wrote that he looked to his right and Mr Cole was charging towards him. He wrote it was obvious by the look on his face and the manner in which he was coming towards him that Mr Cole intended to cause him physical harm. He wrote that, as Mr Cole got closer, he was able to push Mr Cole away before any punches were thrown. He pushed Mr Cole away to the left where he was caught by the police who then wrestled him to the ground. He wrote there was a brief struggle in which Mr Cole lost his shoe. 245. In his police interview when challenged about the first incident report he wrote, Mr AA said he did not actually ‘body-roll’ him; Mr Cole stumbled back but did not actually fall, and did not go to the ground. 246. In his second IPCC interview Mr AA was also challenged on the content of his original report stating he used a hip throw. He said that was the technique he would have used, and because of everything that was happening he just wrote

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down his first reaction. However when he went through the report he thought that was not what he actually did, he just pushed Mr Cole away. He said before he would have hip-thrown Mr Cole and would have restrained him on the floor, but in this instance he did not. He said over the course of the night he would deal with many different things and write up many different reports and it was just a mistake on his part. He said the second report was correct, because he had more time to think about what actually happened that night. 247. In his police interview and first interview with the IPCC, Mr BB said he was moving barriers on the forecourt when Mr Cole came around from the George and Dragon, past two police officers and up to the front door. He said he had his back to him and first saw Mr Cole as he went to swing for Mr AA. He said Mr Cole raised an arm, though could not remember which, and he went to strike Mr AA. He said Mr Cole had a clenched fist and it looked like a full, over-arm punch, he assumed aiming for Mr AA’s head. Mr BB said Mr AA caught Mr Cole’s punch with his arm, locked his arm in, spun round and pushed Mr Cole away. He said it was not a firm push and Mr AA barely moved. Mr Cole travelled forward facing and did not fall down. Mr BB said Mr Cole may have put a hand to the ground but he was on both his feet. 248. When probed in second interview, Mr BB said he was sure Mr AA did not make any contact with Mr Cole’s head, face or neck. He said he was sure the contact was in the torso area. He said Mr AA used reasonable force and was not excessive. Mr AA spun Mr Cole round and moved him four to six foot away, and Mr AA did not make any further contact with Mr Cole. 249. Door Supervisor from the XXXXXXXXXX pub, Witness 9, said he finished work and went next door to the nightclub. As he approached he heard shouting and saw a man, indicated to be Mr Cole, attacking and jumping on Mr AA. He said that, when Mr Cole jumped on Mr AA, he was shouting aggressively. He said Mr Cole tried to punch Mr AA with his right hand aiming at Mr AA’s face, but Mr AA pushed him away with both hands. He said when Mr AA pushed Mr Cole he did not fall over. He said the only doorman he saw involved was Mr AA. 250. Witness 36 said Mr Cole ran around the barriers onto the footpath and then on the forecourt directly towards Mr AA. He said Mr AA was standing just in front of the steps on the forecourt. Mr Cole came charging at Mr AA and tried to punch him, but just as Mr Cole lifted his arm to punch Mr AA, Mr AA pushed him away to the left of the forecourt and towards the taxi area. He said Mr AA pushed Mr Cole with two palms on the chest. 251. Bystander Witness 39 said she saw the male, indicated from her description to be Mr Cole, run towards the smoking area and when he got nearer to the doorman he tried to jump but she did not know if this was at the doorman or if he was trying to get in up some steps. She said the doorman raised his arms up to the side of him at shoulder level to stop the male from getting past. The male then turned away from the doorman where he was met by two male police officers who ran across from their van. She said she thought there may have been another doorman near the front entrance, behind some barriers. She said she remembered this because he said something like “Leave it [Mr BB]”. Witness 39 said that, when the two police officers ran over to the male, she thought they made contact in some way but she did not know how. She said one of the police officers had his handcuffs out. She said one of the male’s friends stepped in between the police officers and shoed his friend away. Witness 39 stated Mr Cole went from the smoking area to the taxi rank, and then ran towards the doorman at

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the front entrance. She said it looked like he was aiming for the doorman. She said she thought the doorman and Mr Cole made contact but could not remember how, aside from that they were face to face and she thought the doorman put his arms around Mr Cole like a bear hug for a few seconds. She could only describe these two door staff as male, in their forties, wearing black with a fluorescent armband and she said the doorman by the smoking area was bald, whereas the doorman at the front entrance had hair. She stated neither was Mr BB, who she knew due to a mutual acquaintance. 252. The next frame of the the nightclub’s CCTV at 01:47:34 showed an individual in a high-visibility vest, believed to be Mr BB, approaching or making contact with Mr Cole from his left, slightly behind him. Two others in high-visibility vests were approaching from behind Mr BB, believed to be PC Spicer and PC Ross. Mr AA was in the centre of the frame in what appeared to be a combative stance with his left arm raised. There was clear separation between Mr AA and Mr Cole at that stage. Mr Cole was still on his feet, although he had a wide stance with his legs apart and his knees bent. Witness 11 could be seen approaching from behind PC Spicer. The frame at 01:47:36 showed an individual believed to be Witness 11 standing in the middle of the frame with his arms outstretched apparently separating and placing distance between Mr AA and Mr BB, who then had his back to Mr AA facing away from the club, and was at the edge of the frame. A police officer in a high-visibility jacket and police helmet, identified as PC Spicer, was behind Mr BB. Mr AA was standing in the middle of the forecourt, looking towards Mr BB and PC Spicer. Mr Cole was out of view at that stage. The next frame at 01:47:38 showed that Mr BB and Witness 11 had moved out of view. PC Spicer was at the edge of the frame to the west side of the forecourt. Mr AA remained in the middle of the forecourt, looking away from the club. 253. In his police interview Mr AA said that, after he pushed Mr Cole to one side, the police officers grabbed Mr Cole and there was a big struggle. Mr AA said Mr BB was there but as soon as the police started trying to arrest Mr Cole he called Mr BB back. 254. In his first IPCC interview Mr AA said Mr BB was to his left, slightly in front of him and two police officers, one of them female, were behind Mr BB’s left. He said once he pushed Mr Cole he took two steps and then went straight into Mr BB's arms. He said Mr BB caught him and almost stood him up. He said the police officers tried to arrest Mr Cole, and said that, when the initial arrest began, Mr Cole was still on his feet and was struggling with the two police officers. 255. In his second IPCC interview Mr AA said that, when Mr BB caught Mr Cole, he did not have a chance to react or do anything else. He said Mr BB had his hands at about chest height on Mr Cole, and did not have his arms completely around him; he thought Mr BB probably caught Mr Cole on the arms as he went into him. Mr AA said Mr Cole had turned 180 degrees and was facing Mr BB directly at that point, with his back to Mr AA. He said Mr BB did not come into contact with Mr Cole’s head or neck, as his hands were too low. He said Mr BB’s hands were always around about Mr Cole’s forearms and he did not come into any contact at all with Mr Cole’s neck. Mr AA said he was certain Mr BB grabbed Mr Cole around about the biceps area. Mr AA said Mr Cole did not attempt to throw any punches at Mr BB. 256. In his police interview Mr BB said Mr Cole tried to strike Mr AA a second time, so he and two police officers held Mr Cole to try to restrain him and calm him down. Mr BB said he held Mr Cole around the arms in “a kind of bear hug” and Mr Cole

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was facing him, while the police officers tried to put a handcuff on one of Mr Cole’s hands. He said Mr Cole had not calmed down and was struggling, and then Mr BB ended up on the floor and the police officers pulled Mr Cole off of him. He said he was holding Mr Cole’s t-shirt but he let go when he fell. He said he was the only one who went to ground. 257. In his first interview with the IPCC Mr BB said he went in front of the police officers to grab Mr Cole, and the police officers followed behind him. Mr BB said after the contact with Mr AA, Mr Cole had spun around so he was facing the road. He then grabbed Mr Cole in a “bear-hug” at mid-chest level with Mr Cole facing him. He said he held down both of Mr Cole’s arms so he would not punch anybody else. He said his arms were not interlocked behind Mr Cole. He thought he may have said “alright, calm down now”. He said Mr Cole tried to wriggle free and the police officers tried to get Mr Cole off of him. Mr BB said the police officers were still behind him, and were pulling at Mr Cole. Mr BB said he was facing diagonally towards the footpath and the taxi rank, still standing up. 258. In his second interview with the IPCC Mr BB said the police officers were in front of him when Mr Cole went towards Mr AA, but they did not do anything, so Mr BB decided to go over there to restrain him. He said Mr Cole turned round and looked like he wanted to go for Mr AA again, so Mr BB stepped in and took Mr Cole in “a kind of bear-hug” around his arms. He said Mr Cole was swinging punches, so he thought he would hold Mr Cole’s arms down so he could not hit Mr AA or anyone else. He said this was not a technique that he had been trained in, but thought he had used it before. He said he was not trying to take Mr Cole to the ground, and was absolutely sure he did not make contact with Mr Cole’s head, neck or face. 259. Witness 36 said that, after Mr AA pushed Mr Cole, he was caught by a male police officer and Mr BB. He said Mr BB caught Mr Cole under both Mr Cole’s arms and his back was against Mr BB’s chest. The police officer took hold of one of Mr Cole’s arms, he thought his right arm. He said Mr Cole “sort of fell” into Mr BB and Mr BB took a couple of steps back. 260. Witness 39 said Mr BB and three police officers ran over and struggled with Mr Cole, nearly knocking over a girl who was coming out of the club. She said she could not make out who was holding who because everyone was moving and struggling with Mr Cole. 261. Witness 24 said that suddenly Mr Cole ran around several cars and tried to get back in but was stopped by a mixture of door staff and police. He said he did not see exactly where Mr Cole ran but had a side view of him running towards the door staff. 262. Witness 11 said Mr Cole walked towards the door staff and the doorman named [Mr BB] rugby-tackled Mr Cole and took him down to the floor. He said Mr BB made impact with Mr Cole around the top part of his chest and it appeared Mr BB hit him hard on the take down. He said Mr BB was much bigger than Mr Cole and when he took him down Witness 11 could only see Mr Cole’s legs, not his face. 263. Witness 31 said Mr Cole broke away and made a curved run back towards the entrance of the nightclub, then the head doorman, identifiable from his description as Mr AA, grabbed Mr Cole and flipped him onto the ground. He described the movement as Mr Cole and Mr AA momentarily being face-on, with Mr AA lifting Mr Cole up by wrapping his arms around his waist area so their faces were

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almost level, and Mr Cole’s feet were off the ground. He said Mr AA then twisted his body to one side and threw Mr Cole onto the ground, landing on top of him. 264. Witness 20 said Mr Cole ran in a semicircle around the back of the vehicles parked outside the club and ran towards the doorman standing at the front. He said Mr Cole went to punch this doorman and had his hand raised, and this doorman moved backwards. Witness 20 described a male police officer, 6ft, broad with muscle, 30 or older and without a hat. Witness 20 said this police officer rugby-tackled Mr Cole. He said he came from the front of the group of police officers and there was a female police officer standing immediately behind him. He said he believed the police officer came from Mr Cole’s right side and Mr Cole hit the floor left side first. He said the police officer’s arms were either side of Mr Cole’s head or shoulders in a hug or a rugby tackle; it was a downwards movement as the police officer was taller than Mr Cole, causing both Mr Cole and the police officer to hit the floor. He said the police officer reacted to protect the doorman from being hit by Mr Cole. 265. Witness 9 said after Mr AA pushed Mr Cole away all the police officers in the immediate area rushed in and four or five of them took Mr Cole to the ground. 266. In his police notebook PC Oates wrote that after he requested more units he looked back at the nightclub. He wrote “I then looked back over at [the nightclub] and saw that one of the door staff rushed at the male as the male made an effort to get back in the club. As they clashed the male and the door staff fell to the floor.” 267. After the incident PC Oates attended a post incident procedure which was held during the day on 6 May 2013. During this procedure he provided a statement concerning only the force used by the doorman on Mr Cole. PC Oates stated that, after he had put out an emergency call requiring police officers, he then saw Mr Cole running towards a doorman who he could not describe apart from the fact that he was of exceptionally large build and was wearing dark clothes and a green high-visibility jacket. He said Mr Cole ran towards this doorman at speed and he saw the doorman take hold of Mr Cole and throw him to the ground with such force that he was taken aback by it. He said it looked like a professional move by the doorman. He said as Mr Cole went down the doorman fell on top of him. Compared to the doorman Mr Cole was of much smaller build and he went down straight away. 268. In his first IPCC interview PC Oates said he saw Mr Cole run at high speed, looping on the pavement and road. He said the doorman had come away from the entrance of the nightclub. He described him as a lot taller than Mr Cole. He said that, as Mr Cole ran towards him, the doorman saw Mr Cole coming towards him, pre-guessed Mr Cole's direction, lunged and took Cole down with force. He said the doorman slung Mr Cole to the floor and he was taken aback and quite shocked. He said he recalled the door staff taking hold of Mr Cole, throwing him to the floor and the doorman going on top of him. PC Oates said he was sure the door staff did not let go of Mr Cole because he went down with him and was on his upper body. He said the doorman was very large, very tall and wearing a long dark coat and green fluorescent coats. He stated he could not provide any further description of the doorman and did not know his ethnicity. 269. In his second IPCC interview PC Oates was asked for further detail on the doorman’s actions but he declined to answer these questions. After being shown CCTV of the incident PC Oates said he was near the hairdresser shop when he

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looked over and saw Mr Cole taken down by a doorman. He said he only saw the back of the doorman. After being challenged PC Oates said he knew that it was the doorman who took Mr Cole to the ground. He said that the only major fall he saw Mr Cole have was when the doorman took him to the floor, and that was the only time PC Oates saw Mr Cole suffer what could be deemed as a fall to the floor. 270. In her police notebook PC Ross wrote “male one came running down Mill Street towards the bouncer. Officers moved forward. One bouncer put him into a ground pin position. Male one had prior to this had placed his t-shirt over his face. The bouncer put him onto the floor.” 271. After the incident PC Ross also attended the post incident procedure held during the day on 6 May 2013, and she also provided a statement concerning only the force used by the doorman on Mr Cole. She stated she saw Mr Cole run towards one of the doorman outside the nightclub. She said as he approached the doorman, he used his t-shirt to cover his face. She described the doorman as a large male wearing a high-visibility jacket and said as Mr Cole and the doorman met, she saw the doorman grab hold of Mr Cole and drag him to the floor. 272. In her first interview PC Ross said Mr Cole broke free from his friends and did a semi-circle from where he was up the middle of the road then back across the pavement towards the doorman. She said that, as he crossed the road, he pulled his t-shirt up over his head to the front. She said the doorman moved forward towards Mr Cole as he approached. She said the doorman grabbed Mr Cole; he put one arm around him and got his other hand onto him and threw him down into the floor. She said it was “so aggressive” and she had never seen a takedown like it. She said he got his arm around Mr Cole like a hug and used his other arm with sheer weight and force and by being bigger. It was one clean swoop and Mr Cole was down on the floor. She said when Mr Cole hit the floor, the doorman was sort of on top of him. 273. In her second interview PC Ross said she “had no idea” which doorman threw Mr Cole on the floor. She said she could not remember any details about his appearance or ethnicity. In response to all questions regarding this use of force she said she could not remember or did not know. When challenged, PC Ross said she was absolutely sure of the account she had given previously and that Mr Cole was taken to the floor by a doorman. 274. Witness 28 said Mr Cole ran from the smoking area out onto the road around some of the parked cars then cut back in towards the club. He said Mr Cole was running side on towards a doorman identifiable from his description as Mr AA. He said Mr Cole ran towards him with his fists clenched down by his sides. He said before Mr Cole could reach Mr AA, two police officers grabbed him by his arms. He said both police officers were white males, approximately 6ft, wearing black clothing with high-visibility police jackets and police hats. 275. Witness 2 said the male in the blue t-shirt ran away from the police officer and back towards the entrance of the nightclub, where there were two door staff outside the entrance. He said they were both wearing big black coats and he thought one was bald. He said they were standing facing the male and they stepped forward to block him. They were standing in the direction he was running and were ready to stop him once he reached the entrance of the club, but they did not come into contact with him. He said 15–20 police officers then stepped in to stop him.

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276. In his police notebook PC Spicer wrote “male one... ran, very fast onto the area/concourse in front of [the nightclub]. Door staff intercepted him and tackled him to ground... When male one returned he charged through [members of the public] hitting at least two (one male and one female).Both asked if okay.” 277. PC Spicer said he caught sight of Mr Cole running out the corner of his eye. He said Mr Cole ran towards the club, he thought choosing a line that avoided police officers. He said two door staff walked down to intercept Mr Cole. PC Spicer said he started to move towards them because it appeared there was going to be some conflict. He said that, before Mr Cole and the door staff met, there were two members of the public who were knocked over. PC Spicer said he saw that Mr Cole went down on the floor and it would have been at the location where he met with the door staff, however he did not know what happened because people blocked his view. He said his attention at that time was drawn to the two people who had been knocked over and he briefly asked them both if they were alright. 278. In his second interview PC Spicer was shown the CCTV from the nightclub and identified himself as the police officer wearing the helmet. When asked about his actions at that point he said he thought he was further away, could not provide any further detail and maintained that he engaged with a couple who had been knocked over. When it was put to him that it was implausible that he did not see anything PC Spicer said he did not know whether it was a conscious effort, but he did not want to get involved. He said he was scared, and he was ashamed of it.

The first indicated period on the ground 279. Footage from the Local Authority CCTV camera at 01:47:38, showed movement within the crowd outside the nightclub which suggested several people involved in a struggle and at approximately 01:47:40 the movement of the crowd indicated a group going to the ground. At 01:47:42 an individual in a high-visibility vest, believed to be PC Ross, was seen bending at the waist and then moved to crouch down on the forecourt but the view was then blocked again by the crowd. At the same time PS Withey could be seen standing up next to this individual, apparently looking down, but he then almost immediately blocked and pushed away an individual from getting near the location of people on the ground. 280. In his police interview Mr AA said Mr Cole was originally on his feet during the struggle with the police, and they tried to get him to the floor. 281. In his first IPCC interview Mr AA said the police got Mr Cole either completely down or half down. 282. In his second IPCC interview Mr AA said when Mr Cole went to the ground he was not in contact with Mr BB and he said when Mr Cole was on the ground he was not in contact with Mr BB at all. He said that Mr BB did not go to ground at any point. 283. In his police interview Mr BB said he fell back onto his backside. He said he had hold of a bit of Mr Cole’s t-shirt sleeve and Mr AA told him to let go but he had already let go of Mr Cole beforehand. He said the police officers pulled Mr Cole off of him. 284. In his first interview with the IPCC Mr BB said he held Mr Cole in a “bear-hug” and the police officers reached over his shoulder from behind to pull at Mr Cole, instead of moving around the other side of them. He said the police officers took hold of Mr Cole’s lower arms and spun him around. This was when Mr BB fell

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backwards to the floor. Mr BB said he had hold of Mr Cole’s t-shirt around his left shoulder area with his right hand. He said Mr Cole nearly fell on top of him, but not fully because the police officers held Mr Cole. Mr BB said he did not know if Mr Cole touched the floor at that point. He thought probably not because Mr Cole would have landed on top of him. He thought a police officer might have held Mr Cole around the waist at that point. 285. In his second interview with the IPCC Mr BB said he held Mr Cole for a number of seconds while the police officers tried to grab Mr Cole. Mr BB said he then fell backwards onto his back. When questioned about the suggestion he rugby- tackled Mr Cole, Mr BB said he did not take Mr Cole to the ground. When challenged about the position of his arms, Mr BB said he held Mr Cole over his arms around his lower biceps. He said he was certain of this because the reason he did it was to stop Mr Cole from lashing out. He said Mr Cole did not want to be held and was still jumping. The police officers pulled Mr Cole from over his left shoulder, which caused Mr BB to be pulled around and fall backwards. He said he landed on his back and backside, and lost his radio. He said that, as he fell, his hands moved up from Mr Cole’s back and he gripped part of Mr Cole’s t-shirt around the shoulder or collar bone with his right hand. He said he may have held the t-shirt as he fell but he was not sure. He said Mr Cole partially fell forward towards him, but the police held Mr Cole so he did not fall on top of him. He said when the police pulled Mr Cole away, he let go of his t-shirt, so Mr Cole was then an arms length away from him when Mr BB was on the floor. This was when Mr AA told him to let go but he had already done so. 286. Witness 39 said the three police officers and the door staff who were struggling with Mr Cole twisted and fell to the ground; not quickly, but as a gradual process. She said at this stage there may have only been one doorman struggling with Mr Cole and the police officers but she was not sure who. 287. Witness 2 said up to 20 police officers came from all around the area where their vehicles were parked. He said they came to the front of the nightclub around the male, and he then saw the male went to the floor, but he did not see how this happened. 288. In his police notebook PC Oates wrote “I ran over as well as PC Ross in order to assist. The male was resisting and lashing out and PC Ross was also now on the floor, trying to prevent the male from resisting. This male appeared to be very strong.” 289. In his first interview PC Oates said Mr Cole was on the floor, the doorman was on top of him and then PC Ross joined the doorman on the floor to restrain Mr Cole. He said PC Ross also got onto Mr Cole on the floor; he believed PC Ross was to Mr Cole’s right side, trying to pin him down. He said Mr Cole’s friends had returned and PC Oates told them to get back and pushed them away to protect PC Ross, himself and the doorman. 290. In interview PC Ross said she immediately ran over to the doorman and Mr Cole. She said her view of Mr Cole on the floor was obstructed. She said the doorman was quite big and he was on the floor with Mr Cole near a bollard. She said she saw another doorman, who was bald or had short hair, who made his way down from the raised step to assist his colleague. She said she went straight to Mr Cole’s legs and was followed by PC Oates, who was on her right. She said Mr Cole was struggling on the floor and the doorman was almost sitting on top of

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him. She said Mr Cole’s friends were crowded around them and tried to get on top of them to get to Mr Cole. 291. Witness 11 said that, while on the ground, Mr BB had Mr Cole in a neck hold; Mr BB’s arm was around Mr Cole’s head, neck and upper body area and Mr BB also had hold of Mr Cole’s arm. He said Mr Cole could not move. He said Mr Cole did not speak while being held. Witness 11 went over and told Mr BB to get off him. He said Mr BB did not have hold of Mr Cole for long, it was a minute at the most. He said police officers then intervened and Mr BB let go of Mr Cole. He said he did not see what the police officers did as Witness 24 was angry with the door staff and Witness 11 tried to calm him down. 292. Witness 20 said the police officer who rugby-tackled Mr Cole was on top of him and more police rushed forward from the group. He said his vision was then blocked by police officers but he saw Mr Cole and the police officer who rugby- tackled him were wrestling with each other on the floor. 293. Witness 31 said he was angry because he could see Mr AA putting “elbow digs” into Mr Cole’s torso while three policemen restrained Mr Cole on the ground. He said the policemen were saying, “We’ve got him, we’ll handle it”. 294. Witness 39 said that, when the police officers and door staff fell to the ground, she could not really tell their positions but it appeared the police officers were at the top of the bundle when they fell. She said the police officers then backed off and one of the door staff tried to hold Mr Cole’s legs as they tried to handcuff him, but Mr Cole struggled so much every part of his body was moving. She said Mr Cole was shouting but she could not tell what he said. 295. Witness 21 said he was speaking to Witness 35 at the entrance of the nightclub and had his back to the road. When he turned he saw a couple of police officers in high-visibility vests on top of somebody and trying to restrain them on the ground. He could not describe the police officers or see the person under them at that time. He said a couple of minutes later he saw a radio slide across the floor. He walked over to pick it up. He said he assumed the person under the officers was still struggling because the police struggled to restrain them. He said he did not hear the police or the person say anything. He said he thought the police officers were on each arm of the individual. He said he saw Mr BB was involved and then quickly got up from the ground where the police officers were on top of the individual. 296. In his police notebook PC Spicer wrote “Officers assisting and attempting to restrain. Further males also trying to intervene inc [Witness 11] and another IC3 male. Pulled off and away.” 297. In interview PC Spicer said that, when he turned back after he spoke to the two bystanders who had been knocked over, there was a knot of people on the floor. He said this involved door staff, police officers and somewhere in there was Mr Cole. 298. In his police notebook PS Withey wrote “I saw a crowd of persons in a melee. I recognised an IC3 doorman I had spoken to earlier. He was restraining and on top of a male. I saw other door staff, police officers and door staff involved in the incident. Two IC3 males were attempting to intervene. One was a short muscular male wearing a grey t-shirt and the other was a taller male wearing a purply/blue t-shirt.”

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299. In his first interview PS Withey said as he arrived he saw a melee. He said he recognised a black doorman from the nightclub and knew that his colleagues were contained in the melee somewhere. He said he did not see Mr Cole at that time and had no memory of seeing him fall. He said two of Mr Cole’s friends were there, indicated to be Witness 31 and either Witness 24 or Witness 11. He said they were circling around the group and tried to get in the gaps. He said they were being aggressive, were both shouting and there was a lot of noise and confusion. 300. In his second interview PS Withey clarified when he arrived there was a melee and a group of people fell, but he could not distinguish who those people were or where they were. 301. Footage from the Local Authority CCTV camera showed that after PS Withey pushed some individuals away at 01:47:42 he was standing next to where a group appeared to be on the ground. At 01:47:46 he pushed another bystander away before then heading towards Witness 31 who could be seen trying to get to the group. PS Withey tried to take hold of Witness 31 who dodged away from him back towards the pavement. PS Withey went after him, apparently trying to take hold of Witness 31. 302. Footage from the CCTV camera above the front entrance of the nightclub showed Witness 32 left the nightclub at 01:47:46 and then stood outside looking towards the forecourt. 303. Witness 31 said he went in to stop Mr AA continue with his “elbow digs”, but was grabbed by police and put into the back of a police van. He did not see anything further to do with Mr Cole. 304. In his police notebook PS Withey wrote “As officers were restraining the male on the ground who was a black male wearing a white t-shirt. I attempted to assist in handcuffing him and I stood up and pushed the male in the grey t-shirt away and also I pushed the male in the purply blue t-shirt away twice.” 305. In his first interview PS Withey said he moved forwards and saw Mr Cole prone on the floor, being handcuffed by police officers and struggling. He said he thought the black doorman had hold of someone and may have assisted in the restraint of Mr Cole. He said he moved forward and lowered himself but could not recall if he physically held Mr Cole; he said he may have moved Mr Cole’s arm but his attention was drawn to Mr Cole’s two friends, indicated to be Witness 24 and Witness 31, who came in from both sides. He said he pushed one away, indicated to be Witness 24. He said Witness 24 and Witness 31 were both muscular and both aggressive. He said he was concerned for the welfare of his police officers and other people at the scene, so he pushed them away and told them to go. 306. In his second interview PS Withey said he only had a momentary view of Mr Cole. He said he went down and may have touched him, but it was very brief and he did not know for certain. He said he certainly did not kneel on Mr Cole or apply force to him. He said he may have leaned over him or kneeled down behind him, but he did not put any force upon Mr Cole’s body. 307. Inspector Fosbury said he drove up Mill Street in response to the request for assistance but had to stop because of traffic. He said that, as he stopped, PC Kalyan got out but he was still sitting in the car.

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308. Footage from the Local Authority CCTV camera at 01:47:51 showed an individual identified as PC Kalyan pushed through the crowd from the road to reach the location where the group of people were indicated to be on the floor. 309. In his police notebook PC Kalyan wrote “Priority shout from PC 5741 Oates more officers to [the nightclub]. Officers seen struggling with an IC3 male from earlier incident. PC Ross and Oates had approximately five-six males struggling with them trying to obstruct them. Doormen from [the nightclub] trying to assist officers. I have pushed one-two possible males away.” 310. PC Kalyan said Inspector Fosbury was still in the car when he jumped out. He said there was a melee of 30 to 40 people and he saw PC Oates, PC Ross and a doorman struggling with Mr Cole and his friends on the nightclub’s forecourt. He could not describe the doorman, except that he wore a high-visibility vest. He said PC Ross and PC Oates tried to hold Mr Cole’s arms but they could not get hold of him. PC Kalyan said the doorman tried to assist in the arrest, and was around Mr Cole’s waist area. He said they were all standing at that point and facing away from the nightclub. He said PC Oates was on Mr Cole’s right and PC Ross on his left, and the doorman was between Mr Cole and the nightclub. He said they were bent over trying to get Mr Cole’s arms behind his back. He said Mr Cole’s friends pushed and shoved them, and were leaning or hanging over the police officers. He said Mr Cole’s friends tried to get hold of Mr Cole so he would not be arrested. PC Kalyan said that, as he approached, he pushed several of Mr Cole’s friends out of the way, indicated to be Witness 11 and Witness 24. He said he pushed them back several times and shouted at them to get back. 311. Witness 24 said there was a big struggle between Mr Cole, door staff and police officers. He said he ran towards this group and pulled a short, mixed-race police officer off of Mr Cole. He said there were lots of people, but half of them were door staff in high-visibility jackets and half were police officers not wearing black vests but he was not sure about this. He said that, during the struggle, Mr Cole’s shoe came off, so he picked it up. He said Mr Cole was face-down on the floor with a police officer on top of him. 312. Inspector Fosbury said due to traffic he chose to leave the car blocking the road and he left the vehicle. 313. Footage from the Local Authority CCTV camera at 01:47:53 showed a brief gap in the crowd and an individual in a high-visibility vest with black sleeves, believed to be PC Ross due to the position in which she was last seen, appeared to put a hand to the ground and her opposite shoulder rose up, in what appeared to be a precursor to standing up. At 01:47:57 Inspector Fosbury approached from the road and stepped towards the location of the group. He reached forward apparently moving to grab something at waist-height. The view was then blocked by the crowd. Glimpses of high-visibility clothing at shoulder height through the crowd at this point indicated the group was standing up. 314. In his police notebook Inspector Fosbury wrote “Assistance shout o/s [the nightclub]. Same male being detained by door staff and [PC Ross] and [PC Oates].” 315. Inspector Fosbury said he reached the perimeter of the nightclub and saw a melee of people; there were police officers and door staff detaining a male he later knew to be Mr Cole. He said that, while Mr Cole was being detained, he was “flapping about a little bit”. Inspector Fosbury said he walked over and could see other males interjecting from the crowd. He said there was a door staff member

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involved, but he could not say which police officers were involved. Inspector Fosbury said no one had Mr Cole around the head or the neck; they all appeared to be at his arm area on one side. He said there was someone on his back midriff. He said there were probably more than six people involved because Mr Cole’s friends were there as well. 316. In her police notebook PC Ross wrote “Myself and PC Oates struggling with him. Inspector Fosbury and PC Kalyan assisted with the ground pin position. Other males (friends) surrounding us.” 317. PC Ross said she and PC Oates arrived at the same time or within seconds and were followed by Inspector Fosbury and PC Kalyan. She said Inspector Fosbury was on Mr Cole’s right and PC Kalyan was on his left and had Mr Cole’s left hand. She said PC Oates was on Mr Cole’s right at his arm and she was on Mr Cole’s legs. She said the doorman was around Mr Cole’s waist. 318. In his police notebook PC Oates wrote “We was [sic] then joined by other officers DI Fosbury and PC Kalyan as the male was still resisting I managed to place a handcuff on him. At the same time the other IC3 males was [sic] physically interfering with me and PC Ross. PC Kalyan pushed some of these male away and then assisted us in the arrest of this male.” 319. PC Oates said he pushed Mr Cole’s friends away and Mr Cole was on the floor with PC Ross and the doorman, then they were joined by Inspector Fosbury and PC Kalyan. PC Oates said Mr Cole was brought to his feet, but he could not recall whether the doorman had lifted him up or whether Mr Cole had got up himself. He said he did not recall Mr Cole being held by anybody at this point. He said they were still on the forecourt of the nightclub, Inspector Fosbury was in front of Mr Cole, PC Oates was to his left, PC Ross was to his right and PC Kalyan was behind him. PC Oates said the doorman had walked away but not far. 320. Witness 36 said Mr Cole was sitting up and Mr BB had hold of him under the arms with Mr Cole’s back into Mr BB’s chest. He said it looked as though Mr Cole was being restrained but was not sitting down; it was more a case that Mr BB held Mr Cole still to calm him down. He said the police officers seemed to have Mr Cole restrained, so Witness 36 told Mr AA to draw Mr BB out of the situation. He said Mr BB was involved in the restraint of Mr Cole for one or two minutes. He said that, when Mr BB removed himself, it did not seem to impact the way Mr Cole was restrained or the position in which he was held. Witness 36 said that, after Mr Cole was caught by Mr BB and the male police officer, three or four more police officers came running and held Mr Cole. He recalled that one was the initial police officer that helped to catch Mr Cole, and there was a female police officer to the left of Mr Cole. He thought there were two police officers on each of Mr Cole’s arms. He said he thought Mr Cole was sitting up, with his torso upright at that point and was still quite active. He said Mr Cole was still putting up quite a fight and his friends were again trying to pull the police officers off of Mr Cole. He identified Witness 21 on the forecourt so he and Witness 21 then held back Mr Cole’s friends to stop them from getting involved and to allow the police officers to arrest Mr Cole. 321. Witness 21 said that, when Mr BB got up, he did not know if he had been on top or underneath the pile of police officers. He said he noticed another radio on the ground so went to pick this up too. He said Mr BB came over to collect one or both radios and they saw that his earpiece was strewn across the ground and part of it was still underneath the pile of police officers and the male so they

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waited to collect it. He said he and Witness 36 noticed the male’s friends were irate, running around, and one male kept going back to the struggle. His description indicated this to be Witness 31. He said this friend tried to pull a police officer off from the male and another friend tried to get involved too. He said he and Witness 36 pulled the friends away and tried to calm them down. He said they took one friend each and held them back for a couple of minutes or until they calmed down. He said these friends both then walked off towards the pavement and did not return to the struggle. 322. Mr AA said the police officers managed to get Mr Cole to the floor once, then Mr Cole got up again; Mr Cole made contact with the floor but then was back up on his feet and the whole thing started again. Mr AA said some of Mr Cole’s friends were trying to pull the police officers off him. He said he saw Witness 21 holding someone and talking to them. He said the struggle went on for a minute or minute and a half. 323. In his interviews Mr BB said that, when he got up, the male and female police officers were there. He said it looked like Mr Cole tried to strike the female police officer three times, but he did not know if Mr Cole connected. He said Mr Cole was held by one arm and tried to hit the female police officer with his left hand. He said more police officers then came in. Mr Cole seemed angry and the police officers struggled with him. Mr BB said that, after he got up, a work colleague who was not actually working that night handed him his radio. 324. PC Kalyan said he had been pushed back several times, then he looked around at PC Oates and PC Ross and Mr Cole ended up in his arms. He said he grabbed Mr Cole’s left arm and tried to restrain him. He said at that point he noticed Mr Cole’s t-shirt was over his head which made it difficult to hold him. He said Mr Cole’s head bounced off his stomach on his stab vest and he ended up holding Mr Cole’s lower arm, while PC Ross was around Mr Cole’s shoulder area. He said PC Ross was standing beside him, and PC Oates was on the other side of Mr Cole and tried to restrain his other arm. He did not see Inspector Fosbury or any other police officer there at that time. PC Kalyan said he could not see the doorman at that time.

The second indicated period on the ground 325. PC Oates said Mr Cole was facing the club and without warning he lunged as if to get to the doorman or back to the nightclub. PC Oates said Mr Cole was then taken to the floor again and PC Ross, PC Kalyan and Inspector Fosbury fell to the ground with him. 326. Inspector Fosbury said he could not remember if Mr Cole was on the ground or very close to the ground but as he got close Mr Cole’s right arm came out from the melee. He said he took hold of Mr Cole’s arm with his left hand and he intended to handcuff Mr Cole, but as soon as he took hold of him, he tripped, was pushed or was pulled forward. 327. In his police notebook PC Kalyan wrote “Assisted Oates and Ross taking the male to ground. Legs have given way and male has banged his head on the ground.” 328. PC Kalyan said after he had hold of Mr Cole they turned around and all faced away from the nightclub, then after a few seconds they all dropped down to the floor. He said he dropped downwards in a vertical motion while Mr Cole fell

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forward in a sliding motion, so that he dropped horizontally. He said that, as Mr Cole fell, they still had hold of his arms and Mr Cole banged his head on the floor. He said they were close to the bollards but still on the nightclub’s forecourt. 329. In his second interview PC Kalyan was challenged about his account that Mr Cole hit his head on the floor. He said he definitely saw Mr Cole hit his head on the floor. He could not describe the force used to take Mr Cole to the ground, but said he saw Mr Cole bang his head on the floor when he went down. 330. In his police interview Mr AA said the police officers tried to kick Mr Cole’s leg out from underneath him to get him down, and they took several attempts to do that. He said he stood back and watched. 331. In his first interview with the IPCC Mr AA said there were at least four police officers. He said they tried to get Mr Cole’s arms behind his back and tried to sweep his legs to get him on the floor. He said there were too many people trying to do too many things and it was a free for all. He said he heard a male voice shout “Get him down”, while Mr Cole shouted and swore. He thought Mr Cole shouted “Get off”. 332. In his second interview with the IPCC Mr AA said there were about four police officers who took Mr Cole off of Mr BB. He said once the police had hold of Mr Cole, he told Mr BB to come back and let the police deal with him. He said Mr BB came and stood next to him. He said the police officers pulled Mr Cole away and then the struggle started between Mr Cole and the police officers. He said Mr Cole was swinging his arm, which could have been an attempt to get away. Mr AA said the police officers then took several attempts at a technique to sweep Mr Cole’s legs but Mr Cole’s feet were in the wrong position; Mr Cole had a wide stance so the police officers would only kick one leg and Mr Cole was still able to stand on the other leg. Mr AA said the police officers got him to the ground once, then Mr Cole struggled and somehow managed to get up again. He said a couple more police officers joined in and they got Mr Cole to the floor again. Mr AA said it was the sheer weight of numbers that eventually took Mr Cole down instead of a controlled take down. He said he did not see the police officers put any force to Mr Cole’s neck or head to get him on the floor. Mr Cole went down forwards and landed face-down. Mr AA said Mr Cole could not put his hands out to stop his fall because the police officers had hold of his arms, and it would have been Mr Cole’s chest area that impacted with the floor. He said he did not notice Mr Cole’s head hit the floor but could not discount that in the way that Mr Cole went down. 333. In his police interview Mr BB said that, after Mr Cole attempted to hit the female police officer, the police then took him to the ground, and there were three or four police officers on top of him. 334. In his first IPCC interview Mr BB said that between four and six police officers took Mr Cole to the floor, but he did not know how. He said he thought they rolled around on the floor and were then near the front of the forecourt relatively close to the bollards. 335. Witness 28 said Mr Cole tried to wrestle himself free as the police officers tried to take him to the ground. Mr Cole aggressively resisted so another four or five police officers joined in. He said the third police officer to approach Mr Cole tried to pull him to the ground, while the initial two police officers had hold of him by each of his arms. He described the third police officer as white and approximately 6ft tall, but could not provide any further detail. He said this police officer tried to pull Mr Cole’s arm behind his back but Mr Cole tried to get away. Witness 28 was

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unable to describe the other police officers except that one was female. He said the police officers then managed to throw Mr Cole to the ground, although he could not recall how. He said Mr Cole fell face first and shouted as he went down. He thought Mr Cole’s stomach and chest probably hit the ground first. 336. Witness 9 said Mr Cole at first struggled with the police before he went down to the ground. He said Mr Cole went down facing forwards and ended up lying face down with his head to one side on the pavement outside the nightclub. 337. Witness 25 said the male had gone to fight with the door staff, possibly the black doorman, and then about ten police officers and two police vans arrived. She said it appeared that the male’s friends would take him away but the police took over. She said the male was still fighting and six police officers grabbed hold him and took him away, while his friends followed. She said the male fought against the police officers, and then the police took him to the floor, but she did not know how. 338. Footage from the Local Authority CCTV camera at 01:48:04 showed that a second police van arrived and parked outside the taxi rank, which momentarily blocked the view of the nightclub’s forecourt. Once the van had passed, bystanders could be seen looking down in the approximate location of where the restraint was believed to have taken place, indicating that the group may have gone to ground again at that point. PC Spicer was seen standing around the same location, but then he moved away. 339. PC Spicer said some of Mr Cole’s friends had returned and a couple of them tried to pull the police officers off of Mr Cole. PC Spicer said he got hold of one of them by the shoulders and tugged him away. 340. Witness 20 said the female police officer together with a male police officer somehow got Mr Cole back onto the ground. He said both of these police officers were then on top of Mr Cole; the female police officer had her knee in Mr Cole’s lower back on his left side and the male police officer was on Mr Cole’s upper body. He said he could not see Mr Cole’s head. He said the police officer who rugby-tackled Mr Cole was also on top of him, which made a total of three police officers on him. The other police officers rushed to assist and at least five police officers were then on top of Mr Cole. 341. In his first IPCC interview Mr AA said Mr Cole was lying face down with his head sideways and someone’s hand was on the side of his head. He said there was a knee in the small of Mr Cole’s back and the police officers had got his legs together and were also kneeling across his legs. He said Mr Cole’s arms were behind his back and the police officers were putting handcuffs on him. Mr AA said Mr Cole struggled quite violently. He said Mr Cole was on the ground for about ten or fifteen seconds. 342. In his second IPCC interview Mr AA said the police officers were immediately on top of Mr Cole and tried to get his hands behind his back. He said while they handcuffed him the side of his head was pressed into the pavement, due to someone’s forearm across Mr Cole’s neck. He said that, as the struggle became more intense, he thought there were around six police officers involved when Mr Cole was taken down and handcuffed. He said Mr Cole’s legs were together and one police officer knelt on his legs. He said another police officer knelt on his back and another held their forearm in the nape of Mr Cole’s neck to hold him face down on the floor. He did not see any punches or kicks. He said that on the floor the struggle continued for another ten to fifteen seconds, while he and Mr BB

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just stood and watched. When asked, Mr AA categorically said Mr BB did not have any contact with Mr Cole around the head or neck area when he was on the floor. 343. Witness 1 said he responded to a ‘code red’ call on his radio from Mr AA, and when he was outside he saw Mr Cole on the floor with four police officers around him. He said Mr Cole was lying on his front with his head towards the nightclub and his feet towards the pavement. He said the police officers were in a circle around him, and one of the police officers tried to hold his arms to handcuff him. He could not see Mr Cole’s legs and could not see Mr Cole clearly because the police officers were all around him. He said Mr Cole was aggressive and was shouting and being abusive. He said Mr Cole said “What are you doing? Get off me”. He said the police officers told him to calm down. 344. Witness 9 said Mr Cole struggled on the floor for one or two minutes. The police had pinned him to the floor with two police officers knelt on him, and at least one male police officer was knelt on his back of his neck. He said the police handcuffed Mr Cole behind his back, but he was not sure if Mr Cole stopped struggling before or after he was handcuffed. 345. Witness 28 said that, while Mr Cole was on the ground, one police officer had hold of his right leg, one had hold of his left leg, another held his right arm, another police officer held his left arm, and the 6ft tall white male police officer pushed Mr Cole down with his knee placed on Mr Cole’s back. Mr Cole’s head was turned to the side with his left ear on the ground. He said that, as the police officers got on top of Mr Cole, he went quiet. He said Mr Cole was on the ground for approximately two minutes. 346. Witness 25 said that, when Mr Cole was on the floor, he was “straight, like a plank” and was face-down with his hands behind his back. She said the police then jumped on him like a rugby mess. She said that, when he was first taken to the floor, three police officers got on him and the rest took hold of his legs, arms and body. She said there were roughly six police officers and it looked like they tried to hold him down and were huddled over him but not laid across him. She said there were too many police officers on one person. She said his friends were standing watching. She said at that point she could not see Mr Cole or what the police officers were doing because it was a mess of high-visibility clothing. She said the police officers were on top of Mr Cole for no more than one minute. 347. Witness 12 said he saw a police van come up Mill Street and several police officers came out of the back and made their way towards the male. He said that, around 12–15 seconds later, he turned back and saw three or four police officers on top of the male. He said they were positioned on the side of the forecourt by the taxi office. He said all he could see were high-visibility police jackets in what he described as a “rugby scrum” on top of the male. He said he did not see the police officers lay hands on the male and did not see how he initially ended up under the police officers. 348. The footage from the front entrance of the nightclub identified that Witness 18 came out of the nightclub at 01:48:02 and returned inside at 01:48:35. 349. Witness 18 said she returned outside and became aware of four or five police officers struggling with Mr Cole on the pavement outside the nightclub. She said she could not be specific about what the police officers did, but assumed they restrained or tried to handcuff Mr Cole who was lying on the pavement. She said he was lying face down with his legs apart, his left cheek on the floor, and she

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could not see his arms. She said a male police officer held Mr Cole’s legs; he leant onto him and put his weight on Mr Cole’s legs. She said Mr Cole’s right shoe had come off. She said there were a couple of police officers who tried to calm Mr Cole’s friends, who were angry at him being restrained. The remaining three or four police officers were around Mr Cole’s torso and at his head. She said these police officers were crouched down but she did not know if they were touching him. She said there was a lot of noise and she could not hear anything being said. She said during this period she did not see Mr Cole move. She said there were no door staff near to the police officers at that time and she did not recall the door staff being involved in the restraint. 350. PC Oates said he remained standing when Mr Cole went to the ground as it was an ideal opportunity for the police officers on the floor with Mr Cole to place his arms up so that he could apply the handcuffs. 351. In his police notebook Inspector Fosbury wrote “Male struggling on ground. Handcuff placed on his right wrist.” 352. In his first interview Inspector Fosbury said he fell down onto his elbow. He said he then picked up Mr Cole’s hand and handed it across and it was taken by PC Oates, which he knew because he said to PC Oates "have you got him" and PC Oates said he had. Inspector Fosbury said he was on the floor, so he got up and said to Mr Cole "Put your hands behind your back". He said he did not know whether Mr Cole could hear him because it was loud and there were people shouting. He said Mr Cole complied; there was no force used to drag his hand behind him. 353. In his second interview Inspector Fosbury said he did not see Mr Cole taken to the ground but saw that Mr Cole had fallen on the ground. He said he was not aware Mr Cole had been hurt. He said thought his involvement was maybe five seconds before he stood up again to deal with Mr Cole’s friend. He said at this time he did not see Mr Cole’s neck or his head; the only part he saw was Mr Cole’s hand. 354. In his police notebook PC Oates wrote “[Mr Cole] was cuffed but still resisting. PC Ross made the arrest.” 355. In interview PC Oates said Inspector Fosbury managed to raise Mr Cole’s left arm up and PC Oates placed a handcuff on that arm. He said Mr Cole again managed to break free, and he lost his grip. PC Ross then said that she had handcuffed his other arm and between PC Kalyan and PC Ross they managed to apply another handcuff onto Mr Cole’s right arm. He said Mr Cole was then face down with his head facing the nightclub, and was between the bollards and the club. PC Oates said he and Inspector Fosbury were standing to Mr Cole’s left, PC Ross was to his right and he believed PC Kalyan had restrained Mr Cole’s legs. 356. In her police notebook PC Ross wrote “I placed handcuff on left wrist. PC Oates had handcuffed the right wrist. I removed my handcuffs.” 357. In her first interview PC Ross said she handcuffed Mr Cole’s left hand and did not know that PC Oates had handcuffed his right. She said Mr Cole was handcuffed to the rear and she removed her handcuffs as it was not necessary to use two pairs. She said she also contemplated use of leg restraints because he was thrashing about. She said that, before Mr Cole was handcuffed, she was not anywhere near his face.

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358. In her second interview PC Ross was asked whether she knelt on Mr Cole, but she declined to answer the question. 359. In his police notebook PC Kalyan wrote “Arms have been bought [sic] around to the rear and male cuffed by Oates and Ross.” 360. In his first interview PC Kalyan said he and PC Ross were on the left of Mr Cole’s body and PC Oates was on the right. He said Mr Cole was face down on the floor, his arms were out and PC Kalyan took Mr Cole’s left hand. He said he brought it around and PC Ross handcuffed Mr Cole’s left hand. As they brought his other hand around, there was already a handcuff on his right hand too. He said one set of handcuffs was put on properly and one stayed loose and was dangling from his wrist. He said the second set of handcuffs was taken off at some point, possibly back at the van. 361. In his second interview PC Kalyan said at no point did he see anyone kneel on Mr Cole during his arrest. 362. Witness 39 said Mr Cole was lying face down and the police officers tried to handcuff him with his arms behind his back. She said it seemed like it took a long time to handcuff him because he struggled so much. She said that, as soon as they managed to handcuff Mr Cole, the doorman backed off. She said she did not think the police officers were particularly violent with Mr Cole and said she thought they could have been tougher with him. She said she did not see any punches or strikes from the police officers; they only used the palms of their hands on his back and legs as they restrained him on the ground. 363. In his police notebook Inspector Fosbury wrote “Males friends trying to obstruct. One male kicking out detained by me and placed in van”. He identified the male he arrested as Witness 31 and wrote that he was served with a notice to leave. 364. Inspector Fosbury said he got up and the crowd came towards him. He said there was one male, identifiable as Witness 31, who was really aggressive and was either going to hit him or get to the crowd behind. Inspector Fosbury said he pushed him away and said, "Get back”. He said there was another male, identifiable as Witness 24. Inspector Fosbury said he pushed them away two or three times while Mr Cole was behind him. He said one male came towards him again and he grabbed his arm and put him in an arm lock as he believed he was going to commit an offence. He then moved him away towards the road. 365. In his police notebook and in interview PS Withey said that Witness 31 continued to be aggressive and Inspector Fosbury arrested him. Witness 31 was then handcuffed to the rear. 366. The Local Authority CCTV footage showed police officers identified as PC A, PC C and PS G exited the second police van parked outside the taxi rank, and PC E ran towards the nightclub on foot. The footage from the taxi rank showed that PC A ran past at 01:48:12, followed closely by PC E and PC C and then PS G at 01:48:20. 367. PC A said he saw several police officers push members of the public away and a group of people were crowding around and bent over as if looking at something or someone on the floor. He then saw about fifteen people on the floor with a number of police officers around them. He said there were no police officers on the ground, only members of the public. He said the only police officer he could recall was PS Withey, who was telling people to move away. He said they kept coming towards PS Withey so he lightly pushed them away. He said he also saw

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Inspector Fosbury who struggled with a black male he later learned to be Witness 31. He said Inspector Fosbury had Witness 31’s right arm bent behind his back to control him as Witness 31 pushed back and lashed out. He said PS Withey saw this and went to assist. 368. PC E said when he came around the police van he saw PC A and Inspector Fosbury had hold of a male who he later learned was Witness 31. He said the police officers attempted to handcuff Witness 31 by a vehicle but he resisted so he went over, by which time they had managed to apply handcuffs. 369. PC A said Inspector Fosbury pushed Witness 31 up against a vehicle and PC A assisted in placing Witness 31 in handcuffs. He said they were joined by PC E. He said there were a large number of people around, most of them heavily intoxicated and the atmosphere was tense. He said the members of the public in the area all seemed to be hostile. He said he and PC E and escorted Witness 31 to their van. 370. PS G said as he arrived he saw several scuffles directly outside the nightclub. He said he saw people lying on the floor and people wrestling and struggling with each other. He said he did not focus on anyone in particular but there seemed to be general disorder in the area. He said he saw Inspector Fosbury struggling with a black male who was handcuffed to the rear, who he later learned was Witness 31. He said Inspector Fosbury instructed him and PC A to take Witness 31 to the cell of their police van. 371. PS Withey described his actions in handcuffing Witness 31 and said at some point PS G’s van turned up and Witness 31 was escorted to that van. 372. Inspector Fosbury said he put Witness 31 up against the bonnet of a vehicle and was joined by PS Withey, who he had seen managing the crowd. They then handcuffed Witness 31 and Inspector Fosbury arrested him. Inspector Fosbury said he lifted him off the vehicle and was joined by PS G and PC A. He asked them to put Witness 31 in their van. 373. In his police interview Mr BB said that, while the police were putting the handcuffs on Mr Cole, he picked up his earpiece and went back to his position. He said Mr Cole looked like he was underneath a load of police officers, who tried to handcuff him on the floor. He thought they were there for a couple of minutes. He then moved back to the front door. 374. Footage from the forecourt of the nightclub at 01:48:22 showed Mr BB walked towards the centre of the forecourt. He appeared to have something in his hands and he stood next to Witness 36 and Mr AA. They remained in view of the CCTV, separate from the location of the incident. 375. PC H said he parked opposite the nightclub then stood at the kerb by the police carrier. He said he saw three police officers struggling with a male on the floor. It appeared they tried to handcuff him as he was lying face down on the ground parallel to the road. He said the male struggled to free himself and he could see his shoulders and arms moving. He said a white female police officer with short dark hair held the male’s legs, and an Asian male police officer and another male police officer were involved but he could not recall what either did. He said he believed the male was under control so his attention was drawn to two or three black males who appeared to know the male being arrested and were protesting to the police.

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376. Witness 2 said a few police officers had pinned the male to the floor face down but he could not see much because there were so many people around. He described the police officers as on their feet but with their weight on their hands and they were leant on the male. He said the male struggled but he could not see in what way. He then went back inside. 377. Witness 37 said he saw only police officers restraining the male on the ground. His view was obstructed but he could see the male on the ground, laid flat, face down. He said there was one police officer knelt behind the male restraining his legs. Two police officers were on the male’s left side, crouched over him, with one police officer possibly knelt on the male’s left shoulder. He said the male was motionless but did not have much room to move, and was possibly yelling. He said the male was on the ground for about three minutes and was handcuffed to the rear about halfway through. He said he was shaking from side to side a little when he was handcuffed. 378. Witness 14 said the next time he looked the male was on the floor pinned down next to a pillar. He did not see how the male got to the floor, but he was face down looking in his direction with his head tilted. He said there were two male police officers wearing black without high-visibility; one held the male’s hands which were handcuffed, and the other held his legs, with one hand on each calf. 379. Footage from the Local Authority CCTV camera at 01:48:26 identified that Witness 32 was standing next to the approximate location where Mr Cole’s was restrained. 380. Witness 32 said Mr Cole was on the floor on his front with his hands behind his back with two sets of handcuffs; one set fully attached and one set only attached to one wrist. He said there were four or five police officers on top of him, including a female police officer. He said one had their knee on him, one held his face and one held his legs. He said one of Mr Cole’s ‘Air Force’ trainers had come off, which showed his sock. He said he did not see Mr Cole struggle at all. He said Witness 11 tried to pick Mr Cole up but failed to make contact because police officers stopped him. Witness 11 and Witness 24 then tried to stop the police officers but were outnumbered. He said Witness 31 was arrested and taken to a police van. 381. Witness 24 said he saw Mr Cole face down on the floor. Witness 11 was next to him. Witness 11 picked up Mr Cole’s head and said “Julian, are you alright?” Mr Cole did not answer and Witness 24 thought that he was confused. He said the mixed-ethnicity police officer then pulled him away. 382. Witness 36 said that, when Mr Cole was restrained on the ground, Mr Cole’s friends did not need to be held back; they just stood and watched. 383. Footage from the taxi office CCTV between 01:48:26 to 01:48:36 showed Witness 11 and Witness 24 outside the taxi office. Witness 11 was holding Witness 24 around the waist apparently keeping him away from the nightclub, while Witness 24 tried to get free and head back towards the nightclub. 384. The Local Authority CCTV footage at 01:48:28 showed PC C had moved through the crowd and was standing next to the position where the restraint was believed to have taken place. 385. PC C said he got out the van and approached the nightclub. He said that, when he reached the pavement outside, he could see a male on his chest on the floor, with his head on the side facing north to the left of him and his feet to the south.

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He said he was handcuffed to the rear in back to back position. There were three police officers between him and the male, and two door staff to his far side, closer to the nightclub. He identified the police officers as PC Ross and PC Kalyan, and said the third police officer may have been PC Spicer but he was not sure. He said he could not recall if the male moved, struggled or made any noise. He said he did not see any injuries on the male and he was lying on the floor for five or ten seconds before he was taken to his feet. 386. Witness 20 said Mr Cole was on his front and a male police officer and a female police officer handcuffed his hands behind him. 387. In his first IPCC interview Mr AA said it was a big melee and Mr Cole thrashed about, then all of a sudden it stopped, which was what allowed the police officers to handcuff Mr Cole. He said the struggle between the police and Mr Cole on the ground lasted 30 seconds to a minute, and then after they handcuffed Mr Cole it was probably another 30 seconds before they picked him up. 388. In his second IPCC interview Mr AA said it was not for ten to fifteen seconds into the arrest that Mr Cole became compliant. Mr AA said Mr Cole suddenly stopped struggling and was not saying anything. Mr AA said he thought Mr Cole was being compliant because he allowed his hands to be put behind his back and into handcuffs. He said the police officers were shouting to each other, but he could not understand because there was a lot of noise. 389. PC Kalyan said Mr Cole was on the ground between 10 and 20 seconds after he was handcuffed before they lifted him up. 390. PC Oates said Mr Cole was not on the ground long because they handcuffed him and then stood him up almost straight afterwards. He said there was pressure being applied while Mr Cole was being handcuffed to pin his arms down, but nobody was putting any pressure on Mr Cole’s back to keep him still. 391. Witness 21 said two police officers got off the male and they were both in blue uniforms as opposed to high-visibility jackets. He said he could now see the male’s white t-shirt but could not see his head which he found very strange. He said he took a second look to try to see where the male’s head was, and saw it was in a very unnatural position. He said the two police officers pulled the male’s arms and handcuffed him to the rear. He said the male was lying on his right hand side and his head was looking down tucked underneath his body at a funny angle. He said the male’s shoulder was up against a steel bollard and he felt that his head may have hit the bollard on the way down although he did not see that happen. He said there was a third police officer just standing by arriving shortly after the two other police officers got up off the male. He said he did not see the male move, and thought he looked lifeless. 392. In an incident report written by Witness 21 dated 7 May 2013 in reference to Mr Cole he wrote “his head was at a very bad angle and he was not moving, I believed him to be dead at first... [His] head was to the left of the bollard, and his shoulder very near to the bollard.” 393. Witness 35 said the next time she looked Mr Cole was about three feet from the bollards, and the police officers appeared to spread out, before she then saw Mr Cole directly facing her on his knees. She said by the positioning of his shoulders she assumed he was handcuffed. She said Mr Cole was facing her, but with his head hung down, “like the fight had gone out of him” and he was not saying anything.

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Mr Cole’s removal from the ground 394. Footage from the Local Authority CCTV camera at 01:48:35 showed a partial view through the crowd to the forecourt. Movement could be seen which suggested police officers bending down, then in a swift movement the back of Mr Cole's head and his shoulders rose up into view and his head then appeared to drop back down hanging forwards. He then lowers back out of view. 395. Footage from the taxi office CCTV at 01:48:36 showed that Witness 24 managed to get free from Witness 11 and went back towards the nightclub, out of view. However at 01:48:42 Witness 28 and Witness 11 moved Witness 24 back into view away from the nightclub. Witness 24 was holding a black or blue Nike right- foot trainer. Witness 11, Witness 24 and Witness 28 remained in view and did not return to the forecourt of the nightclub.

396. Footage from the Local Authority CCTV camera at 01:48:52 showed a partial view through the crowd which indicated two police officers leant down, bent at the waist, then straightened up and moved together towards the road. 397. Witness 37 said the three police officers who restrained Mr Cole picked him up under his arms on either side, with one helping from either the rear or the front. They then escorted him to the police van. 398. Witness 20 said the original police officer who rugby-tackled Mr Cole and the female police officer lifted Mr Cole up by placing their arms under his armpits, one police officer on either side. He said at that point he suspected there was something wrong with Mr Cole because he could not get up and the police officers struggled to pick him up. 399. Witness 25 said two police officers then dragged the male up and held him by his arms. She said the male’s head was face down towards the floor. She said the rest of the police officers were stood back watching. 400. Witness 28 said three police officers picked Mr Cole up, one holding his right arm and another holding his left arm. He said Mr Cole’s t-shirt was over his face so one of the police officers pulled it off. Witness 28 said he tried to help Mr Cole but the police officers told him to go away. 401. Witness 1 said the police officers lifted Mr Cole off the floor. He said Mr Cole’s hands were behind his back, his head was bent down to his left shoulder, and his legs were bent. He said he did not stand, but he did not know if it was because he could not or because he did not want to stand. He said Mr Cole was not talking as he could see his mouth was not moving. 402. Witness 9 said the police picked the male up from the ground only after he stopped struggling. He said he was lifted off the ground by his armpits, his arms were behind him, and his head was dropping to one side with his eyes closed. He said he thought this was because the male was drunk, or so tired that he was weak as a result. He said he did not see him moving at all.

403. Mr BB said a couple of the police officers moved back and another two picked Mr Cole up. He said the male and female police officers were still involved. He said the police officers carried Mr Cole by an arm each. He said the position of Mr Cole’s arms made him think he was handcuffed but could not recall if it was behind his back or in front of him.

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404. In his second incident report Mr AA wrote that once in handcuffs, four arresting police officers helped Mr Cole to his feet. He said Mr Cole struggled to stand and his head was hanging slightly. 405. In his police interview Mr AA said he could still hear the commotion going on to his left and then, when it went quiet he looked around and saw the police picking Mr Cole up off the floor. 406. In his first IPCC interview Mr AA said Mr Cole was quiet and very compliant, and he thought that Mr Cole must have been winded. He said the police lifted him up by his arms; he had handcuffs on and they lifted him up more by his trunk. Mr AA said once the police lifted Mr Cole up he was struck firstly by the look on Mr Cole’s face, as his eyes were sort of open and from the look on his face Mr AA thought he must be quite winded; and secondly that Mr Cole’s legs were dragging. He said nobody held Mr Cole’s head as he was lifted. He said he could almost see that Mr Cole’s eyes had rolled in the back of his head, and his mouth was open. 407. In his second IPCC interview Mr AA said the police officers did not perform any welfare checks on Mr Cole before they lifted him up. He said once he was handcuffed the police officers who restrained Mr Cole picked him up; two on either side. Mr AA said there were a lot of people observing but no one interfered with the handcuffing or Mr Cole’s removal to the police van. He said there were no risks to the police officers at that point and there was nothing which prevented them from being able to examine Mr Cole on the floor. Mr AA said when they picked him up his head drooped, and he thought Mr Cole was winded, because he had gone from a massive struggle to being very compliant. 408. Witness 21 said he did not see the police officers check Mr Cole in any way before the two police officers who handcuffed him each put an arm under Mr Cole’s shoulders and lifted him up from the ground. He said he felt they should have checked why he was no longer fighting with them before moving him to prevent any further injury, although he did not say anything as it was a police matter and he assumed they would know what they were doing. He said that, as they lifted Mr Cole up, his head was flopping around and his feet were dragging behind him. He said he saw his eyes were closed as they lifted him up, then he saw his eyes open and he briefly thought Mr Cole was okay, however, he then noticed that Mr Cole’s eyes were rolling. 409. In his incident report dated 7 May 2013, Witness 21 wrote “I felt the police would notice his condition and check to see if he was conscious before trying to get him up. However they didn’t and proceeded to pick him up, one police officer either side and try [to] force him to his feet. It was quite clear he was not able to stand and was dragging his legs, also his eyes where [sic] rolling in his head when he opened them after a minute or so“. 410. Witness 39 said two police officers put their arms underneath the male’s armpits and lifted up from the floor quite quickly to a standing position. She said she noticed he only had one shoe and that his t-shirt was up near his shoulders. 411. In his police notebook PC Oates wrote “Once it became clear that he was arrested this male refused to cooperate. This time he would not move.” 412. In interview PC Oates said they asked Mr Cole to get up but he would not engage in conversation. He said this was not out of the ordinary because throughout the incident he did not talk to them. He said he assumed Mr Cole was refusing to co-

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operate with them. PC Oates said Mr Cole’s friends interfered and physically manhandled them again at this point, which prevented them from doing their duty and was an active attempt to assist an offender get away from police custody. He said reasonable force was used to push some of these males away. PC Oates said Mr Cole was stood up on his feet. PC Oates then took Mr Cole’s right arm and PC Ross took his left. 413. In her second interview PC Ross was asked why they did not perform any welfare checks on Mr Cole before he was lifted up. PC Ross said there was a swarm of people over them and she did not think for one second they were in a situation where they could deal with Mr Cole’s welfare before he was lifted from the ground. She said they were not in a situation where they could assess him, because it was dangerous, stressful and they were being fought with. She said there were hundreds of drunken people around and they had taken him out of the situation as soon as appropriate. She said she did not believe lifting Mr Cole without having done any welfare checks could have contributed to a neck injury, and she thought that the injury was not caused from being detained to transportation to the back of the van. 414. In his first interview PC Kalyan said they asked Mr Cole to get up and tried to pick him up, but his body had gone limp. He said he thought Mr Cole was just resisting arrest by being passively resistant and he was not listening to them. He said Mr Cole was handcuffed behind his back, PC Ross was on his left and PC Oates was on his right. PC Kalyan said he had the back of Mr Cole’s jeans while PC Ross and PC Oates held Mr Cole under his armpits on either side and they lifted him together. He said he held Mr Cole’s jeans by the back pockets with two hands and he literally lifted him. He said Mr Cole’s friends were still pushing and shoving them at this point. He said he was worried about the bang on Mr Cole’s head but said they could not assess the situation outside the nightclub because of his friends pushing them. PC Kalyan said they made a decision to get him into the van because it was quite volatile. 415. Footage from the the nightclub’s forecourt camera at 01:48:53 showed Inspector Fosbury approached Mr AA at the entrance of the club and appeared to engage in conversation with him. 416. Inspector Fosbury said that, after Witness 31 was taken away by PS G and PC A, he came back and saw there was still a large crowd but he said he could not see any sort of aggression so he took a few steps back.

Mr Cole's passage to the police van 417. The footage from the Local Authority camera at 01:48:58 showed Mr Cole emerge from between the vehicles parked outside the nightclub and was taken across the road to the police van opposite. This footage was enhanced and showed Mr Cole was held by three police officers, with one on each side holding him by the elbows with his arms behind him, and another police officer behind him. His torso was positioned with his chest to the floor and his shoulder blades could be seen at around the waist height of the police officers. His head was hanging down below the police officers’ waist height and appeared to bounce as the police officers walked to the van. His legs could not be made out distinctly due to lighting and because of the movement of the police officers’ legs around him. A

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fourth police officer followed behind them. Once they reached the rear of the van the view was largely blocked by a people carrier directly behind the van. 418. The footage from the taxi office CCTV at 01:49:01 showed a group of three police officers carried Mr Cole from the direction of the nightclub across the road towards the police van parked opposite. This footage was enhanced and Mr Cole could be identified as the individual being taken across the road. There was a police officer on each side of Mr Cole holding him under his arms, and a third police officer behind Mr Cole holding the back of his jeans. Mr Cole was in a position where he was leant forwards with his arms to his rear and legs out behind him. It appeared that his feet were dragging along the floor. His head could be seen hanging down facing the floor. There was no discernible movement from Mr Cole. In interview PC Kalyan and PC Oates identified themselves as behind and on Mr Cole’s left side respectively, and they both identified PC Ross as the police officer on Mr Cole’s right. PC Ross identified PC Kalyan and PC Oates but stated she could not identify the third police officer. PC C was identified as the police officer who followed several metres behind them. 419. In his first IPCC interview Mr BB said he thought two or three police officers held Mr Cole up while another two followed behind. He said he did not think Mr Cole walked, and the police may have carried him. He said nothing gave him concern for Mr Cole’s welfare; he thought Mr Cole had given up the fight. 420. In his second IPCC interview Mr BB said that, when the police officers took Mr Cole away, he had given up the fight and as he was taken to the police van he was lifeless. He said it was only for a split second that he saw Mr Cole being taken to the van. 421. In his police interview Mr AA said as Mr Cole was carried to the police van he was face down. He said he was handcuffed and as he was carried away his head was drooped and he could just see that Mr Cole’s eyes were half closed. He said he remembered getting a clear view of Mr Cole’s face and saw his mouth was open and his eyes were almost rolling in his head. Mr AA said he thought Mr Cole had obviously been winded while he was on the floor. He thought Mr Cole looked a bit dazed. He said Mr Cole tried to take a few steps but fumbled, like he had lost the use of his legs. Mr AA thought that was because he only had one shoe on. 422. In his first IPCC interview Mr AA said Mr Cole made no attempt to walk. He said his head was almost in his chest and if the police had sat him up his chin would have been in his chest. He said Mr Cole was almost like a dead weight as he was carried towards the van. He said the police did not try to keep Mr Cole upright; he was almost horizontal because his legs were dragging and he was almost bent over like a ‘U’ shape. Mr AA said Mr Cole did not stand at any point unaided and made no attempt to walk to the van. 423. In his second IPCC interview Mr AA said when Mr Cole was taken away his head was down so Mr AA thought he was winded. He said no one seemed concerned. He said as they took Mr Cole to the van he did not vocalise that he was in discomfort. He said Mr Cole’s feet dragged on the floor; he only had one shoe on so Mr AA thought it would have been painful and Mr Cole would have tried to lift his foot off the ground, but he did not do this. Mr AA said it looked like Mr Cole’s eyes had rolled back, but he could almost see the whites of his eyes as well. Mr AA said he made the assumption that Mr Cole was a bit winded, and that once he recovered his breath he would be fine.

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424. In his police notebook PC Oates wrote “[Mr Cole] had to be walked over to the van.” 425. In his first interview PC Oates said Mr Cole was walked over to the van, but was not walking normally. He said Mr Cole was walked slowly and dragged his heels, so that he was “kind of” walking but without any sort of effort. He said they thought he was resisting them and would not follow instructions. He said it was part of Mr Cole’s refusal to co-operate; he was clearly handcuffed and arrested so he thought Mr Cole decided to passively refuse to co-operate or follow instructions. PC Oates said he did not hear Mr Cole say anything but he was alert because his eyes were open and he was looking around. PC Oates said there were no visible injuries to Mr Cole. 426. In his second IPCC interview PC Oates was shown the enhanced CCTV footage of Mr Cole’s passage across the road and asked to describe it. He acknowledged Mr Cole did not walk himself to the van and said it appeared they had to assist Mr Cole to the van. He described Mr Cole’s head hanging in a forward position unsupported. He said there was no indication at the time that there was anything wrong with Mr Cole. 427. In her police notebook PC Ross wrote “[Mr Cole] was then escorted to the van.” 428. In her first interview PC Ross said she thought PC Oates, Inspector Fosbury and PC Kalyan took Mr Cole to the van. She said she arrived at the van after Mr Cole and could not remember how Mr Cole was escorted to the van. She said she did not think they carried him; he was assisted on his legs to the van. 429. In her second interview PC Ross was shown the enhanced CCTV footage of Mr Cole’s passage across the road and asked to describe it. She said he was being carried to the van and was unco-operative on his feet. When pressed as to whether she could see him walk she said no. She identified the three police officers carrying him as PC Oates, PC Kalyan and said it was possibly her, but she was not sure. 430. In his police notebook PC Kalyan wrote “I have lifted male by his jeans and assisted to take male across the road to the van, in order to take him away from the melee.” 431. In his first interview PC Kalyan said Mr Cole walked to the van; PC Oates and PC Ross were pulling him and he was sort of hobbling over, sort of sideways. He was hobbling side to side. PC Kalyan said he did not know if he had literally lifted Mr Cole off the floor but he believed Mr Cole’s feet touched the ground, because he hobbled side to side. He said as he walked to the van Mr Cole was co-operative and listened to what he was told. He said someone asked him “Is your head okay?”, but could not remember who. He said they asked him several times but all he said was “My neck aches” when halfway across the road. PC Kalyan said one of them replied “We’ll get you to the van and we’ll have a look at it for you”. He said he let go of Mr Cole on the corner as they approached the van, and Mr Cole was not limp; he walked. 432. In his second interview PC Kalyan said he was initially behind Mr Cole and could not see if there was any head injury to him. After he was shown the CCTV footage, PC Kalyan said he was obviously wrong that Mr Cole walked to the van. He described Mr Cole as dragging his feet and looking down towards his legs. He said it looked like Mr Cole was dragged, but said Mr Cole was awake and he initially thought Mr Cole was being passively resistant by doing nothing and not

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co-operating. He said there could have been signs of head injury but he did not believe any of the police officers there were suitably trained. 433. Witness 28 said once the police officers had picked Mr Cole up they took him to one of the police vans. He said he was held by two police officers standing either side of him holding one arm each, and there was another police officer walking behind. He said that, as the police officers took Mr Cole to the van, his head was down and his feet dragged along the ground. He said there was no noise from Mr Cole. 434. Witness 20 said when the police officers lifted Mr Cole he did not walk; he appeared to be a “dead weight” and they dragged his feet. He said the police dragged him to the van and sat him on the first step of the van. 435. Witness 32 said that, after the police officers lifted Mr Cole, his body was parallel to the floor with one police officer at each shoulder and one or two at his legs. He said they carried him part way to the van with no communication between them. His legs were then released and he was dragged the rest of the way with his head hanging down. He said Mr Cole had one shoe off and his toes scuffed across the floor as if his legs were not working. 436. Witness 25 said that two police officers dragged the male off. She said they walked towards the taxi office and she thought something was wrong because the male did not walk. She said his head was down and his feet dragged on the floor. She said he did not resist or help the police officers and was “like a rag doll”. She said they took him towards the taxi office where he was out of view. She said when they took him away the male’s hands were behind his back as if handcuffed, although she could not see the handcuffs. 437. Witness 24 said Mr Cole was dragged to the police van by two or three police officers. In his statement provided to Bedfordshire Police, he said Mr Cole was still struggling and was still angry, however in his statement provided to the IPCC he described Mr Cole as being limp and not moving at all, which was contrary to his expectation that Mr Cole would be struggling because he was so angry. 438. Witness 11 said the next time he saw Mr Cole he was held up by three or four police officers and appeared to struggle to walk as if he was a dead weight. Mr Cole appeared totally different and was not aggressive. 439. Witness 12 said he saw the male restrained by two police officers, one on each arm with their arms hooked under his armpits either side of him. He said he was not sure if they carried him or if he walked towards the police van, and said he may even have passed out. He said another police officer walked closely behind the other two but did not touch the male. 440. Witness 21 said as they walked Mr Cole to a police van he was facing forwards, the police officers lifted him up and he thought one may have said “Stand up” to Mr Cole. 441. Witness 9 said when the police took the man away he was limp. 442. Witness 37 said he thought Mr Cole walked to the police van. 443. Witness 39 said two police officers took the male over to the van but because the male still struggled and appeared “quite slouchy” it appeared difficult for them to get him into the van. She said she could not see the rear of the police van which faced away from her.

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444. Witness 14 said he saw six or seven police officers had picked Mr Cole up. He said Mr Cole was not walking; the police held him up and carried him. He said Mr Cole was silent and his head faced towards him. He described Mr Cole as “like jelly” and said his head was flopping. He said his head was down and he “just appeared wrong”. He said there were three police officers on each side of Mr Cole as they took him to the van. 445. PC C said that, after he was lifted to his feet, the male was taken across the road by PC Ross and PC Kalyan to a police van with a cell at the back. He said PC Spicer may have also walked him across, but he was not sure. He said Mr Cole walked of his own volition when he crossed the road to the van. He was bent over to the front and his knees were kinked. He said he did not recall any dialogue between the police officers and the male. He said he followed them across the road and went towards the back of the van. 446. Witness 3 said she had not been looking but turned around again and saw a police officer taking a male in handcuffs towards a police van near to the road. She said the police officer held the handcuffs which were behind the male. She said it was a tall, white male police officer in uniform with a hat on and she did not see any other police officers. She said it looked like the male was able to walk by himself and he struggled a bit as he was led to the van. She said she was not certain it was the same male she saw before. She said there was nothing she saw that suggested the male was injured or hurt. She said there was a police van parked on the opposite side of the road to the nightclub and the male was walked towards the van. She did not see him put into the van.

The events at the rear of the police van 447. Footage from the taxi office CCTV camera showed PC Ross, PC Oates and PC Kalyan reach the back of the van at 01:49:07 and Mr Cole was lowered to the ground. He appeared to be lying slightly on his left hand side, perpendicular across the road with his head nearer to the far pavement and legs towards the camera to the south. PC Kalyan could be seen standing over Mr Cole’s legs, with his feet either side of Mr Cole’s shins. Mr Cole’s right foot moved slightly to the left but it was unclear if this was because PC Kalyan’s leg nudged him. At the same time that Mr Cole was laid down, PC C reached the back of the van and Witness 24 and Witness 11 started to walk to the back of the van from outside the taxi office. 448. Footage from the taxi office CCTV camera at 01:49:10 showed Witness 24 and Witness 11 reach the back of the van. Witness 11 walked around the right side of the police officers and Mr Cole, between them and the rear of the van, and Witness 24 walked around the left of them. PC Kalyan moved to his left to push Witness 24 away when he got close. At the same time, Mr Cole’s legs moved slightly to the left, but it was unclear whether this was of his own volition or due to contact from PC Kalyan’s leg as he moved to his left to push Witness 24. 449. Footage from the Local Authority CCTV camera at 01:49:15 showed that Witness 11 walked around Mr Cole and the police officers to reach the rear left of the van and could then be seen bending down to where Mr Cole’s head would be. Witness 24 stood next to him, looking down in close proximity to Mr Cole and the police officers.

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450. Witness 11 said Mr Cole’s facial expression was blank and he had to hold Mr Cole’s face up to look at him. Witness 11 said he told Mr Cole to co-operate with the police officers but it did not look like Mr Cole understood. 451. Footage from the taxi office at 01:49:15 showed PS G walked along the pavement next to the taxi office, towards where the second police van was parked. At 01:49:16 he was followed by PC A and PC E, who escorted Witness 31 towards the second van. Witness 31 appeared to be handcuffed to the rear. 452. PS G said he and PC A took Witness 31 to the back of their police van, before he left them and returned to the front of the nightclub. He said that by that stage all physical struggling had ceased, however, there was still an atmosphere and tension in the air. 453. Footage from the taxi office at 01:49:19 showed PC Spicer walked from the nightclub to the back of the police van containing Mr Cole. PS Withey followed and reached the rear of the van at 01:49:19. 454. Footage from the Local Authority CCTV and the taxi office showed PC C opened the rear doors of the van at 01:49:23. 455. Footage from the taxi office at 01:49:27 showed what appeared to be PC Ross, PC Oates and PC Kalyan lean down to lift Mr Cole towards the van. Mr Cole could not be seen clearly. At this time PS Withey and PC Spicer moved Witness 24 away from the back of the van and stood between him and the rear of the van. Footage from the Local Authority at the same time showed PC C did the same to Witness 11 by the left rear of the van. Witness 32, Witness 28, Witness 40 and Witness 20 stood and watched from the other side of the road outside the taxi office. 456. PC Spicer said that, by the time he turned around, the van doors were open and Mr Cole was going into the van. He said Mr Cole was handcuffed to the rear, was upright and was not struggling. 457. In her police notebook PC Ross wrote “[Mr Cole] was complaining of neck pain. I asked if he could move his legs to which he did move his legs.” 458. In her first interview PC Ross said the van doors were open and Mr Cole’s head was in the van with his legs behind him. She said he complained his neck hurt. She said she asked him if he could move his legs, and he moved his legs up and down. She said at this time he was not in the van, but the doors were open and he was facing into the van. She said he was not standing; he was sort of laid forward. She said his legs were not restrained so he had full use of his legs. She said this was seconds before he was turned round and put back into the van. 459. In her second interview PC Ross was shown the CCTV of Mr Cole at the rear of the van and asked to explain what happened. When she described Mr Cole’s initial position on the ground, she said Mr Cole was being assisted or supported by police. She said his position did not mean anything because he was not compliant prior to any takedown or arrest so it did not mean that he would be compliant or co-operative at that point. She said Mr Cole was non-compliant throughout the whole incident. PC Ross said she thought Mr Cole had changed his behaviour because the police now had control of the situation and because once somebody was handcuffed, especially to the rear, they were not as mobile. She said Mr Cole was standing leant into the van and she asked him to move his legs, and he then moved them. When asked why she requested he move his

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legs, PC Ross said Mr Cole had complained of a neck injury and she thought the movement would negate a serious injury. She said she did not see any injury. 460. In his police notebook PC Oates wrote “When we got him to the van and tried to get him in he would not get in the van and said his neck was hurting. We sat him on the step of van [sic] to allow him to compose himself. The male just sat down and would not speak.” 461. In his first interview PC Oates said Mr Cole was standing up at the van and they asked him to get in, but Mr Cole refused to do it and did not respond. He said they thought he was refusing to co-operate as he had done all night. 462. In his second interview PC Oates was shown the CCTV of Mr Cole at the rear of the van. He then said he could not remember if Mr Cole was standing at the van at any point, but he recalled Mr Cole sitting on the step of the van. 463. Witness 24 said he retrieved Mr Cole’s shoe when it came off and tried to return it to Mr Cole but he was blocked by the police officers. 464. In his police notebook PC Kalyan wrote “Male was very groggy but speaking to officers. Male has complained of neck ache. Ross has asked what your name only heard ‘Julien’ [sic] possibly. Then asked can you move your legs – which he did”. 465. In his first interview PC Kalyan said the rear doors of the van were opened and Mr Cole sat himself backwards on the edge of the van, so his feet were hanging off the van, and then he stood up. He said one of Mr Cole’s friends brought his trainers over. He said there were several police officers there and Mr Cole’s handcuffs were brought to the front. He said Mr Cole was still complaining of the neck ache, and then Mr Cole put his trainers on. 466. In his second interview PC Kalyan said he initially thought Mr Cole was standing at the back of the van and he did not want to change that position. He maintained that he thought Mr Cole put on his trainers. PC Kalyan said he thought Mr Cole spoke when he was sitting in the back of the van; he stated his name and said his neck hurt. He said a decision was made to take Mr Cole back to custody, and have him looked at while in custody. 467. In his second interview PC Oates said he recalled seeing Mr Cole sitting on the step and a friend wanted to give Mr Cole his trainer. He said they did not allow the friend to give it to Mr Cole himself, but he handed it to PC Oates and they then asked Mr Cole to put his trainer on. PC Oates said he could not remember how, but Mr Cole’s trainer was then put on. He said Mr Cole may have done it on his own but he could not remember. 468. PC C said he stood with his back to the van with his attention on the people near the back of the van so he could keep a sterile area, but he took fleeting glances back to the van periodically. He said he turned around and saw the man had become rigid; he was laid at an angle between the van and the street with his abdomen on the floor at the entrance of the cell van, and his legs together straight out. He said the male’s feet were on the ground and his torso was rigid, so he was in a straight line. He could not remember the position of the male’s head. He said PC Ross, PC Kalyan and a third police officer, maybe PC Spicer, were with the male. He said he then turned around again to continue to keep people away. He said there was a mixture of females and males and some of the

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females were quite irate. He said he spoke to a short black male but did not recall other details about him. 469. PC B said he was responding to a request for assistance at the nightclub and was nearby when there was another message of no more units required. He said as he was so close he continued to the nightclub. 470. Footage from the taxi office CCTV at 01:49:34 showed PS Withey and PC Spicer moved Witness 24 away from the back of the van, where they spoke to him while Witness 24 was very animated and appeared unhappy. At 01:49:45 PS Withey took the trainer from Witness 24, then walked to the left side entrance of the van. Witness 24 followed but was shadowed by PC Spicer who remained between Witness 24 and the rear of the van. Footage from the Local Authority showed PS Withey placed the trainer in the rear passenger section of the van. At the same time PC C moved Witness 11 to a position approximately three metres away from the rear of the van, where Witness 11 then remonstrated with PC C. Witness 28, Witness 40 and Witness 20 walked over the road and stood next to Witness 11 and PC C, also around three metres away from the rear of the van. 471. Witness 28 said he walked to the police van with Witness 11 and Witness 24. He said Witness 11 went closest to the van and spoke to Mr Cole; he could not remember what was said but Witness 11 said Mr Cole did not respond. He said police officers stopped him and Witness 24 from going any closer to the van. He said there were two police officers, separate from those who had dealt with Mr Cole, who told them to go away. He said it took ten minutes for the police van containing Mr Cole to leave the area, and the police told them Mr Cole had been taken to hospital. 472. Footage from the taxi office CCTV at 01:49:48 showed Inspector Fosbury and PC H walked to the back of the van from the direction of the nightclub. 473. PC H said two police officers had taken Mr Cole to the back of the van, but he was not sure how Mr Cole travelled to the van. He said his focus was with the two or three black males as they walked to the van and he stepped in between them and the police officers with his back to the van. He said he told them to move away and said there was nothing they could do as their friend had been arrested. He said he did not have any involvement in Mr Cole’s arrest but monitored the three friends in case they tried to intervene. 474. Footage from the taxi office CCTV at 01:49:57 showed Witness 32 walk over the road to join Mr Cole’s friends at the rear of the police van. Witness 24 was at the rear left of the police van, but at this time moved away to join the other friends approximately three metres away from the back of the van. Witness 24 and Witness 11 remained in that position and remonstrated with PC Spicer and PC C. None of the friends interfered with the police officers dealing with Mr Cole from this point forwards, aside from Witness 32 who briefly moved closer to the rear of the van between 01:50:41 and 01:50:53. 475. In his police notebook PC Spicer wrote “Myself engaged in calming group / getting them away from van. Again spoke to [Witness 11] and second unidentified male.” 476. In interview PC Spicer said he went over to the van, but by the time he arrived Mr Cole had been loaded in and he did not see him before the doors were closed. He said some of Mr Cole’s friends were there so he stood at the corner of the van to block them from the van. He said Mr Cole’s friends were not obstructive but his

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fear was that they might become so. He said one was quite rowdy, and so he asked Witness 11, who he had spoken to earlier, to speak to his friend to diffuse the situation. 477. Witness 11 said there were four police officers standing in front of the van doors. He and Witness 24 spoke to one of them. He said Witness 24 asked the police officer if they were going to investigate the doorman, and they spoke for about three minutes before the police officer became annoyed with Witness 24 and told them to go away. 478. Footage from the taxi office CCTV at 01:50:04 showed PC B walking along the road from the front of van and reaching the rear of the van, where he stood facing away from the doors. At the same time PS Withey returned from the side of the van, and stood at the rear of the van, apparently looking in. 479. Footage from the Local Authority CCTV camera at 01:50:23 showed that Witness 11 moved away from the police officers and started pacing in the middle of the road. Witness 24 was positioned several metres behind the van, apparently still remonstrating with PC Spicer and PC C. 480. PC B said that, as he walked to the rear of the van, he saw Inspector Fosbury and PC H talking to each other, standing on the road. He said PC Ross was outside the van standing closest to the pavement and PC Kalyan was standing inside the van. He said he saw a male at the rear of the van, although he thought his view may have been blocked by PC Oates and he could only see the top half of the male. He said the male’s head was up and he was looking forward and he could see the back of the male’s head. He assumed the male was on his knees or crouching down because he was low down and probably came up to waist height. He said the male had his hands to the rear so he thought he was handcuffed. He said he did not hear the male say anything or any of the police officers speak to him. He said the male was not moving; his demeanour was calm. He said no police officers had hold of the male. He believed the male was conscious because he was holding himself up of his own accord at the time. 481. Footage from the taxi office CCTV at 01:50:41 showed Witness 32 stepped slowly closer to the van while looking towards it, however, there were still several police officers between him and the van. His hands were in his pockets and he did not appear to touch any police officers. 482. PC Ross said one of Mr Cole’s friends was insistent on crowding them and trying to obstruct them. She said one friend shoved his head in front of Mr Cole’s face and told him to relax. She said there was another, whose description indicated Witness 32, who stood nearby and was pushed away. She said that PC B, PS Withey, PC Oates and Witness 32 were at the back of the van. She said PC B pushed Witness 32 away. 483. In his police notebook PC Kalyan wrote “Whilst male was being spoken to at the rear of the van his friends again tried to intervene and again obstruct officers.” 484. PC Kalyan said there was a friend, indicated to be Witness 32, who tried to get to Mr Cole to take him away and he pushed and shoved police officers. PC Kalyan said he had an argument with him and told him to get back and stay back. He said he was taken away by the rest of the friends. 485. In his second interview PC Kalyan said Mr Cole’s friends interfered and they were being harassed to the extent that they could not assess Mr Cole properly at the back of the van. After the CCTV footage was played to PC Kalyan he noted that

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Mr Cole’s friends (Witness 24 and Witness 11) interfered up to approximately 01:50:00. He acknowledged that after this time Mr Cole’s friends did not interfere and he said there was then nothing which prevented them from assessing Mr Cole. 486. PC B said a male walked over to where the police officers were with Mr Cole. He said it was a sterile area and he did not want the male there while the police officers tried to deal with Mr Cole so he put his arms out and told him he could not go in there. He said the male stepped back and walked away. 487. The footage from the taxi office at 01:50:53 showed PC B held his hand on or near to Witness 32’s chest and guided him back away from the van. Witness 32 complied and walked away from the van. Witness 32 then moved back to where Witness 24 and Witness 28 were still standing with PC Spicer. Witness 40, Witness 30 and Witness 11 moved to stand closer to the middle of the road, but still a distance of three metres or more away from the rear of the van. 488. PC B said his attention was then drawn to PC Spicer who was arguing with another male so he walked over to PC Spicer. He said it appeared the male was a friend of Mr Cole. He said PC Spicer tried to explain why Mr Cole had been arrested but was shouted over by the male. He said he stood with his back to the van and watched and observed the actions of the male. 489. The enhanced footage from the taxi office at 01:50:53 showed what appeared to be Mr Cole’s foot briefly visible below the door of the van, hanging above the ground. His foot was pointing outwards, indicating that Mr Cole may have been sitting at back of the van facing outwards at this time. There was no discernible movement of the foot. 490. In his first interview PC Oates said they turned Mr Cole around and sat him on the step of the van to allow him to compose himself. He said they assumed he may have worn himself out, so to give him some breathing space they allowed him to sit on the steps of the van. He said Mr Cole’s friends interfered with them again even though they had been told numerous times to move away from the van. PC Oates said Mr Cole said “My neck, my neck” on a couple of occasions. PC Oates said Mr Cole’s eyes were wide open so he assumed he was alert and conscious. PC Oates said as Mr Cole spoke about his neck he considered whether an ambulance should be called. 491. In his second IPCC interview PC Oates was challenged regarding his description of Mr Cole’s actions. PC Oates said Mr Cole did not follow instructions to get into the van, so they sat him on the step. He reiterated it was assumed that this was all part of his continued refusal to co-operate with them. He said there was nothing obviously showing that there was anything medically wrong with Mr Cole. He said Mr Cole complained about his neck while at the back of the van. PC Oates said he recorded it in his notebook and had mentioned it in his previous interview, and reiterated that Mr Cole was sitting on the step and he said "My neck, my neck". PC Oates confirmed he said it twice. PC Oates said Mr Cole looked at them at the time, so he was alert. When asked to describe Mr Cole’s manner of speech, PC Oates said he spoke normally and was not displaying any signs of pain whatsoever. 492. The footage from the Local Authority CCTV footage at 01:50:35 showed an ambulance driving along Mill Street from the High Street and being blocked by traffic due to the police car in the centre of the road. The ambulance was three vehicles behind the van containing Mr Cole. At 01:50:48 a police officer in a

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custodian helmet, believed to be PC E, spoke to the driver of the ambulance and pointed in the direction of the High Street, then walked back out of view towards the taxi office. The ambulance then performed a three-point turn to drive back towards the High Street. While the ambulance was in frame completing this manoeuvre the view of the rear of the police van was largely obstructed. By 01:51:47 the ambulance had finished the manoeuvre and drove out of view back towards the High Street. 493. In their second IPCC interviews all subject officers were shown footage of the ambulance in close proximity while Mr Cole was at the back of the police van. All of the officers stated they did not see the ambulance and were unaware of its presence. PC Spicer identified himself at the back of the police van at that time speaking to Mr Cole’s friends including Witness 11. He said he was distracted by talking to several people and did not see the ambulance or it did not register. 494. The footage from the taxi office at 01:50:51 showed PS G crossed the road from the direction of the nightclub to the rear of the van and started talking to Inspector Fosbury. 495. PS G said he looked for Inspector Fosbury to get further instructions and noticed him standing with several other police officers at the rear of a police van parked opposite the nightclub. He said he crossed the road and spoke with Inspector Fosbury. PS G said that, as he arrived, he saw a male, identifiable as Mr Cole, in the van sat with his backside on the floor of the cell with his legs dangling over the edge of the van. He said the cell door and van door were both open. His feet were down on the floor. He said he could not see the handcuffs but he believed Mr Cole was handcuffed to the rear based on the otherwise unnatural way he was sitting. He said he did not see any police officers or other members of the public touch him. He said the male seemed calm and was just sitting there, slumped slightly forwards with his eyes open. He had the appearance of someone who was resigned to the fact of their arrest. He said the male was leaning forward slightly, head up but with a slightly glazed expression, not unusual for someone who had drunk alcohol to excess. 496. The footage from the taxi office at 01:51:10 showed PC A outside the taxi office. He crossed the road and spoke to Inspector Fosbury. 497. PC A said that, after he placed Witness 31 in the cell of his van, he walked over to the other van where Inspector Fosbury was standing. He said there were police officers around the cell of the van as if someone had been detained but his view of anyone in the van was obscured. He said he spoke to Inspector Fosbury regarding Witness 31. He said he did not think there were more than four police officers at the rear of the van. He said the only police officer he remembered was PC Ross. He said he tried to look in the van but his line of sight was obstructed by the open rear doors. He said he had the impression there may be members of the public around the back of the van. He said he did not interfere with the police officers but seemed to want to know what was going on. 498. Inspector Fosbury said that, before he moved his car, PC A and PS G approached and told him that the man he had arrested (Witness 31) was now calm and asked to give him a Section 27 notice to leave the area. Inspector Fosbury said he agreed, because Witness 31 had been detained to prevent a breach of the peace; the breach of the peace had been stopped so a Section 27 notice was then proportionate. He said he had a brief glimpse of Mr Cole who he believed was sitting on the rear step of the van. He said he did not see his face at

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any point or any other part. He thought that when he saw Mr Cole at the van, he was handcuffed to the front. He said nothing caused him concern. 499. In his second interview Inspector Fosbury was shown the CCTV footage and he acknowledged he was standing at the back of the van for three minutes. He said there were a couple of people between him and Mr Cole who was sitting on a step, leant forward. He said he did not get a direct view of him. He said PC A and PS G asked him something about Witness 31, and he had his back to the van. He said someone asked him about a prisoner in custody by his earpiece, then he liaised with PC H about the time he was going off-duty. Inspector Fosbury said he was assessing what resources he had and where they were. He said he did not consider Mr Cole’s situation; as far as he was concerned Mr Cole was detained for a public order offence and he had no information that he was hurt. He said Mr Cole did not have a cut to the head or any visible injury. He said Mr Cole had sufficient police officers there to deal with him and none of the police officers spoke to him about Mr Cole’s welfare while at the back of the van. He said that, despite being the highest-ranking police officer there, he would not have responsibility for Mr Cole because each police officer was empowered with their own responsibility. He said that, if he knew Mr Cole was hurt or if it was visibly clear he was hurt, then he would have responsibility for him. He said that, if he had seen that Mr Cole had an injury to his head, then he would have said he needed medical help and would either have called an ambulance or have told them to take him in the van, because if they had called an ambulance they would be waiting around with the large crowds coming out the pub. Inspector Fosbury said that, if he had been told Mr Cole had hit his head but he had seen no visible injury and Mr Cole had acted normally, then he would have sent him to custody. 500. The footage from the taxi office between 01:51:00 and 01:51:43 showed PS Withey was standing at the back of the van and it appeared that during this time he spoke to either PC Oates or PC Kalyan. 501. In his first interview PC Oates said they were joined by PS Withey who was the van supervisor. He said PC Ross asked PS Withey “Should we call an ambulance?” PC Oates said that, after some thought due to the situation on Mill Street with Mr Cole’s friends still actively trying to get to Mr Cole in the van and resisting them, PS Withey decided that Mr Cole would be taken to custody instead of an ambulance being called. This was due to the chaotic situation on Mill Street at the time. PC Oates said this was done for their safety, the safety of the ambulance crew and to get Mr Cole out of that situation as soon as possible. He said they all agreed it was the right decision. PC Oates said nobody checked Mr Cole for injuries because if he had a neck injury then it could be aggravated by prodding about on his neck. He said they were not medically trained to do that. 502. In his second IPCC interview PC Oates said that by that time there were a lot of experienced police officers present, including Inspector Fosbury, PS Withey, PS G and PC B, and he assumed that if there was any indication that something was wrong with Mr Cole somebody would have said something. 503. In her first interview PC Ross said she asked PS Withey whether they should take Mr Cole to hospital or custody, and he told them to take him to custody. She said this happened after Mr Cole was in the van and when she was outside the van. 504. In her second interview PC Ross was asked to explain why she asked PS Withey whether to take Mr Cole to hospital or custody. She said she could not remember her reasons. She said she assumed she asked because PS Withey was a

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custody sergeant and they would frequently go to custody and as soon as they arrived they would be told to go to hospital. She noted Mr Cole had referred to neck pain but said people said it all the time: “my legs hurt/my neck hurts” and they would have to go through the motions. She said physically Mr Cole appeared to be fine and he behaved in the way of a person who was okay. When asked what she meant by ‘okay’ she said “okay to fight”. She said he had no obvious injury or signs of any injury. She said he had not displayed any behaviour indicating he was unwell, and she had no reason to question PS Withey's decision. She said if she could have recognised that Mr Cole had a broken neck at that point he would have gone to hospital. She said there were not any signs at that time that Mr Cole should have gone to hospital. 505. PC Kalyan said PC Ross relayed some information back to PS Withey and they told him Mr Cole had banged his head. He said PC Oates, PC Ross, and PS Withey were there and they tried to make sure of Mr Cole’s wellbeing and see what sort of injury he had. He said he did not see any injuries on Mr Cole’s head. He said Mr Cole’s head was examined when he got back to the van but not by him. 506. In his police notebook PS Withey wrote “I did not see the male in the white T-shirt until he was at the rear of my police van. He was handcuffed to the rear. He complained that his neck was hurting.” 507. PS Withey said Mr Cole was sitting on the bottom step of the police van or inside the van with his feet on the step. He said Mr Cole’s legs were in front of him and he was handcuffed to the rear. PS Withey said Mr Cole mentioned that his neck hurt and PS Withey made a decision that Mr Cole should go to custody. He said PC Oates and PC Ross were with him at the back of the van, and PC Spicer was possibly in the vicinity. PS Withey said Mr Cole was coherent at this point. He said nobody examined him or asked him if he had any other injuries. He said he only heard Mr Cole complain about his neck once. PC Ross asked him “Custody or ambulance?” and he said “Custody”. He said they had numerous occasions where people came into police custody and complained of injuries that were not real. He said he was not hugely convinced at that time that Mr Cole had a serious injury and he considered the options. He said they had a violent incident in Mill Street and he was concerned about the safety of his police officers; there were very few of them on the street at that time which he knew because he was counting them off as they went back to the police station with other detainees, so he realised they were short on people. He said quite often somebody would feign an injury or an illness, or claim they had swallowed medication in order to get to hospital and get themselves de-arrested. He said that was part of his thought process. PS Withey said he decided Mr Cole should be removed from that location so they could properly assess him out of the public highway, away from his friends or other people who were going to cause them problems. He said he was not overly worried about the condition of Mr Cole at that point. 508. In his second interview ,when asked about his assessment of Mr Cole’s condition, PS Withey said that head injuries had similar symptoms to violence and intoxication and it was an incredibly difficult task to clarify which one. He said it was incredibly difficult for police staff, nursing staff or hospital staff to treat anybody who was violent or potentially violent and may have head injuries, or maybe under the intoxication of drink, drugs or a combination of the two. He said he heard Mr Cole say “My neck hurts” once. He said he was at the back of the van for literally three to four seconds, or twenty, maximum. PS Withey said that,

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without absolving himself of his supervisory responsibility, it was a matter for individual police officers to assess the information they had and gauge whether an ambulance should be called. He said had he seen Mr Cole smack his head on the pavement, this would have significantly affected his assessment of the situation. 509. In her first interview PC Ross said Mr Cole had been arrested when the handcuffs were applied but he was not told at that time because it was not appropriate. She said PS Withey asked her who had arrested him and she told him she had. She then told Mr Cole he was under arrest and cautioned him. She said it had calmed down a bit and they had control. 510. In her second interview PC Ross clarified that she informed Mr Cole he was under arrest while at the back of the van, which was the first opportunity that would have been appropriate. She said Mr Cole was fully aware he was under arrest. 511. PS Withey said he spoke to PC Ross just before they pulled Mr Cole into the van, and although he did not hear Mr Cole being cautioned he was happy all the necessary information was there for the arrest. He said it was disorderly conduct, possibly a threatening behaviour, or drunk and disorderly. 512. PC C said he was facing away from the van and looked back, so only saw a snippet of what happened. He said the male was sitting on the cell floor at the entrance of the van and was handcuffed to the rear. His legs came out of the van and he was facing outwards. He could not say whether Mr Cole was conscious or whether he moved. He did not recall seeing his face. He said he heard someone say the male complained about his neck, but he did not see who said it because his back was to the police van when this was said. He said it was a female voice so could have been PC Ross. 513. The footage from the Local Authority and the taxi office showed that at 01:51:41 PC A walked away from the back of the police van towards where the other van was parked. At 01:51:50 Inspector Fosbury walked away from the police van towards the police response car parked in the middle of the road. He got into the driving seat and at 01:52:02 drove away towards the High Street. 514. Inspector Fosbury said he saw that his abandoned car in the road was causing mayhem so he moved his car and parked it at the other side of the taxi office.

Mr Cole’s passage into the cell of the police van 515. The enhanced footage from the Local Authority CCTV camera at 01:52:08 showed PC Ross bend down for a moment, then she appeared to step up into the van. 516. In the enhanced footage from the taxi rank at 01:52:12 a car passed in front of the camera and at the same time PC Ross moved up into the van. After the car passed Mr Cole’s feet were briefly visible, which showed the trainer was missing from his right foot. His feet were hanging below the edge of the van door together, pointing outwards and could not be seen to move. 517. The Local Authority CCTV footage at 01:52:19 showed PC Ross turned around within the cage to face outwards, then she bent at the waist and appeared to reach down. She remained in this position. This was potentially the time when Mr

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Cole was moved into the cage but the view was blocked by the police officers standing at the back of the van. 518. In the enhanced footage from the taxi rank at 01:52:21 another car passed in front of the camera. After the car passed Mr Cole’s feet were no longer visible. 519. In her police notebook PC Ross wrote “[Mr Cole] was then assisted into the cell van.” 520. PC Ross said she got into the back of the van and put her arms underneath him. She said she had her hands on him and they used a sort of shuffling movement to get him back into the van, followed by his legs. She said PC Oates sort of shuffled Mr Cole’s legs in. She said he was compliant. She said they got him in the back of the van without any excessive use of force. She said she stood behind him and he was sitting up. He was leant against the perspex part of the van. She said his airway was not restricted, there was no sign of any obvious injury and he was conscious at that time. 521. In his police notebook PC Oates wrote “It was decided that the male had to go in the cell and he was assisted by myself and PC Ross into the cell. He was asked to pull in his legs so the door could be shut and he obeyed that instruction. As the cell door was shut he was alert and conscious.” 522. In his first interview PC Oates said Mr Cole was lifted up by him and PC Ross and placed in the van gently. He said no force was used and they sat him facing backwards in the cell. He said Mr Cole’s legs were still hanging out so they could not shut the door. He said they asked Mr Cole to pull his legs in which he did, which showed he was alert, conscious, and was aware of what was going on. He said Mr Cole’s eyes were open and he was looking around. PC Oates said Mr Cole followed their instruction, so he could obviously hear and understand what they said to him, and he pulled his legs in when they asked him to do so. PC Oates reiterated there was no indication at all that he was ill in any way. 523. In his second interview PC Oates was challenged about his account that Mr Cole moved his legs himself. PC Oates said Mr Cole was asked to pull his legs in so the doors could be shut and he followed that instruction. He said that Mr Cole pulled his legs in, and there was no doubt he did it on his own. 524. In his police notebook PS Withey wrote “With assistance of [PC Ross] and [PC Oates] he was pulled into the cell of the van. At the time I was not overly concerned about his injuries.” 525. PS Withey said Mr Cole was pulled into the van by PC Oates and PC Ross. He said he thought they had to get him behind and pull him up from under the shoulders. He said he was concerned that Mr Cole should be sitting properly in the van. He said he was sufficiently concerned that Mr Cole should be put in a position where he was upright and monitored when he returned to the police station. He said he thought PC Ross was under Mr Cole's left shoulder and PC Oates was under his right. He said they were almost under his arms to pull him up. He said that he knew PC Ross was just behind Mr Cole and there was not a lot of room in the cell, so he thought PC Oates was side on, but he was not sure. He said he knew Mr Cole was conscious because he could see it in his eyes. He said Mr Cole was not floppy; he was sufficiently upright. He was put into a seated position in the van, so his legs would have been moved around. He said he did not know how Mr Cole’s legs were moved in there.

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526. In his police notebook PC Kalyan wrote “Sat on the floor of the cell van and taken back to GPS [Greyfriars police station].” 527. In interview PC Kalyan said Mr Cole just pushed himself back or was pushed back into the van. He said he did not remember exactly how Mr Cole got there, but he stayed seated on the floor of the cell van. He said there was a seat on each side but Mr Cole stayed in the middle of the cell on the floor. He said Mr Cole was very calm when they got back to the van. 528. Witness 11 said the police officers had to physically put Mr Cole in the back of the van. He said he was worried about Mr Cole getting arrested and did not worry about his health because he was up and breathing, however Mr Cole’s whole demeanour had changed from being able to walk, talk and being generally coherent to being the total opposite. 529. Witness 20 said there were three or four police officers around the rear of the van. The police officers stood behind Mr Cole inside the van and picked Mr Cole up one step at a time, then dragged him across the floor of the van and placed him with his back to the wall and his feet towards the open van doors. He said Mr Cole’s head was bouncing and his eyes were opening and closing slowly, then he just slid down the wall of the van. Witness 20 said he asked Mr Cole if he was okay, but Mr Cole did not acknowledge or answer the question. He said he asked the short police officer at the rear of the van if Mr Cole was okay, and was told by this police officer to go away. He said this was the police officer who had been aggressive with Witness 24 earlier on. This was his last sighting of Mr Cole. 530. Witness 32 said he remembered Mr Cole being put in the van front first, with his legs hanging out. Then after about 5–10 seconds his legs were “swooped” into the van. He said the cage was then shut followed by the van door and he was unable to see Mr Cole sitting properly in the van. Witness 32 said that at that point he was concerned for Mr Cole because he was aware that he was not drunk because he had spoken to Mr Cole when the phones were passed to him. He said he did not see anyone else speak to Mr Cole and he was not sure why Mr Cole was in that state. He said that at that point he looked like a drunken guy, paralytic with no control, and it seemed like the police did not know what happened to him. 531. The taxi office footage at 01:52:27 showed Inspector Fosbury returning to the rear of the police van. 532. A radio transmission at 01:52:54 from 118, allocated to PS G and PC A stated: “Yeah it seems to be under control now. There seems to be at least two if not three in custody. Public disorder [inaudible] died down”. 533. Inspector Fosbury said he walked back across the road towards the van but he never got there because he then spoke to the dog handler, PC H, with regards to his deployment. He said by that stage he had decided that the nightclub had to be closed because the dog handler was off duty at 3am and a dog was a real public order deterrent. He said he had enough staff because there were two crews on until five but not after five, and he was happy in his mind that the staff at the nightclub were not in control of the people inside. He said he had seen people coming out who were drunk and obviously had too much to drink. 534. PC H said he was asked by an attending sergeant to stay in the area to provide high visibility, although not the immediate vicinity of the incident.

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535. The enhanced footage from the taxi office at 01:52:43 showed Mr Cole’s right foot drop into view just below the van door. His foot was still pointed away from the van. At 01:52:49 Mr Cole’s foot rose back up out of view behind the van door. The Local Authority CCTV footage showed that PC Ross was still bent at the waist reaching down at this point. It was not possible to discern from the movement whether Mr Cole lifted his foot himself, or whether it was lifted for him. 536. The enhanced footage from the Local Authority camera showed that at 01:52:57 PC Ross straightened up within the cell and a second police officer, indicated to be PC Oates or PC Kalyan, stepped briefly into the rear of the van at the left-hand side. The second police officer remained crouched down in the cell until they stepped back out of the van at 01:53:01. PC Ross remained standing up in the cell until 01:53:14 when she stepped out of the back of the van. 537. The footage from the taxi office and Local Authority at 01:53:08 showed Inspector Fosbury walking away from the back of the van in the direction of the nightclub. 538. PC C said the next time he looked around the male was sitting on the floor of the van. He had his back against one of the seats in the van and his feet on the floor, with his legs bent and knees in the air. He was on his own in the cell. The cell door and two outside doors were open. He said he did not remember anything else about that moment apart from how he was sitting. 539. The footage of the forecourt of the nightclub showed that at 01:53:21 Inspector Fosbury returned to the entrance and talked to Mr AA. 540. The footage from the Local Authority showed that at 01:53:23 the cage door was shut, then at 01:53:26 the van doors were shut. The CCTV footage also showed that at 01:53:26 PS Withey walked away from the back of the van in the direction of the nightclub. The footage of the forecourt of the nightclub showed that at 01:53:36 PS Withey joined Inspector Fosbury and Mr AA on the forecourt. 541. Inspector Fosbury said he walked back across to the nightclub and spoke to the same doorman that PC Oates had been remonstrating with earlier. He said he explained that he wanted the club to close. He said Mr AA had a bit of an attitude and said he could not make those decisions and then they were joined by an Asian male who introduced himself as the licensee. 542. PS Withey said that after the van left he became involved in a conversation with Inspector Fosbury, who told the club that he was considering closing them down. He said Inspector Fosbury spoke to an Asian man who he assumed was the manager, and there were a couple of door staff as well. PS Withey said he spoke to Inspector Fosbury to ask what he wanted to do with Witness 31, and Inspector Fosbury made a decision to de-arrest him and give him a Section 27 notice, which PS G did. 543. The footage from the taxi office and Local Authority showed that Witness 11, Witness 24, Witness 28, Witness 30, Witness 40 and Witness 32 all walked away from the van at 01:53:37, heading West on Mill Street. PC Ross, PC Spicer, PC Oates, PC Kalyan PC C, PC H, PS G, and PC B were all still present at the back of the vehicle until 01:54:08 when PC Spicer and PC Ross entered the back of the van, and PC Oates got into the driver’s seat. The other police officers then dispersed in various directions. At 01:54:45 the police van moved off heading east on Mill Street with emergency lights on.

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544. PC Spicer said they needed to get Mr Cole out of the area and back to custody, so he got back onto the van to drive back to Greyfriars police station. 545. PC Ross said they got in the back of the van and turned the light on in the cell. She said they “blue-lighted it” back to the police station. 546. Witness 32 said that, once the police van which contained Mr Cole had left, he went towards another police van with Witness 11, Witness 24, Witness 20 and Witness 28. The second police van held Witness 31 and a police officer was taking his details. 547. Witness 31 said he was waiting in the police van when Witness 11 and Witness 24 came over to speak to him and asked, “Are you OK? Because Julian is not.” He said they told him Mr Cole did not reply to them. Witness 31 said he thought about the elbow digs (from the doorman) being the cause of this. He said they told him it looked like four police officers dragged an unconscious body to the van. He said Witness 11 and Witness 24 then went back to check on Mr Cole. 548. Footage from the forecourt of the nightclub at 01:57:56 showed PS Withey left the forecourt. 549. In his notebook Inspector Fosbury wrote “Spoke to licensee/manager and asked location to close. Extremely drunk persons leaving scene. Number of reports from public about bouncers. Licensee refused – discussed notice to close – agreed to close 03:30.” 550. In interview Inspector Fosbury said he had quite a long discussion with Witness 36 and Mr AA about closing the club. 551. Mr AA said that after Mr Cole had been taken away he and Witness 36 had a conversation with an Inspector who wanted to close the club down, but after a long conversation with him he decided to leave. 552. In his notebook Inspector Fosbury wrote “Call from [PC Ross]. Male she has detained is ill in GPS yard.” 553. Inspector Fosbury said that as he was talking to Witness 36 he got a point-to- point call on the radio from PC Ross who told him the male she arrested was at the police station and the ambulance were doing CPR on him. He said he immediately got back in the car. He said PC Kalyan was with him and Inspector Fosbury told him that the person arrested by PC Ross was not very well. They then drove straight back to the police station. 554. The footage from the nightclub at 02:04:23 showed Inspector Fosbury leave the forecourt. 555. Witness 11 said he was aware Witness 31 was arrested and he received a call from him about 25 minutes after the police van left. Witness 31 told Witness 11 he had been dropped of at campus, so Witness 11 took a taxi back with Witness 20, Witness 28, Witness 24 and Witness 32. Witness 11 said when he was back at campus Witness 20 handed him Mr Cole’s iPhone, Blackberry, bank card, gym membership and driving licence and said that Mr Cole had given them to him.

Mr Cole's transport to Greyfriars police station 556. The journey from the scene to Greyfriars police station is shown on Googlemaps as a distance of 0.8 miles and could take four minutes to drive.

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557. PC Oates said he put the light on in the cell so that PC Ross and PC Spicer could observe Mr Cole, and he drove back to Greyfriars police station partially on blue lights. He said the ride back was less than five minutes. 558. In her police notebook PC Ross wrote: “Transported back to GPS. Cell light was switched on. I observed him whilst transporting to GPS. Asked him for his surname, he replied OWENS from what I could make out. Male was moving around in the cell and was cuffed to the rear”. 559. In her first interview PC Ross said she stood up in the back of the van the whole journey. She said she spoke to Mr Cole, asked him his surname, if he had taken anything and if he had been drinking. She said she could not really understand him, but he was conscious and spoke to her throughout the journey. She said she remembered he said what she thought was “Owers” or “Owens”. She said she stood and watched him as a general observation. She said it was a three- or four- minute journey back to the police station. She said Mr Cole moved his legs up on to one of the box seats in the cell, and he was lying on the floor. She said he was not lying flat on his back, but was in a more upright position without sitting upright. She said he moved one of his legs on to the box and then put it back down. 560. In her second interview PC Ross was challenged on whether Mr Cole spoke to her or moved his leg, and PC Ross said she definitely saw his legs move and definitely had a conversation with him. She said she stood by what she had said. She said she spoke to him and he spoke to her, and that happened on several occasions back to the police station. She said there was no indication of any injury to Mr Cole and she did not remember any change during the journey that would account for Mr Cole being unable to support himself when they arrived at custody. She said he did not slur his speech and did not whisper, because she would not have been able to hear him. 561. In his police notebook PC Oates wrote “During the journey back to [Greyfriars police station] I could hear PC Ross and Spicer talking to the male asking for his name, [date of birth]. I could not hear him speak due to the sound of the engine of the van.” 562. In his first interview PC Oates said that while driving back he could hear PC Ross and PC Spicer making conversation with Mr Cole, although he could not hear Mr Cole speaking back, which was down to the sirens and the engine noise. He said he heard PC Ross say “Oh so your name is Owens?” 563. In his second interview PC Oates reiterated that he did not hear Mr Cole speak, but said PC Ross was in the back of the van and he recalled hearing her clearly say, "Oh, so your name is Owens?" 564. In his police notebook PC Spicer wrote he rejoined the van and transported the male to Greyfriars police ptation. He wrote “suspect engaging although incoherent”. 565. In his first interview PC Spicer said he was in the back of the van with PC Ross. PC Ross was standing right up against the cage and she spoke to Mr Cole. He said he could not see Mr Cole. He said PC Ross spoke to him and asked what his surname was to engage him. PC Spicer said Mr Cole responded to the questions at the right times but he was incoherent. He said at one point he thought Mr Cole said “Owen”. PC Spicer said he did not hear Mr Cole say anything else coherent. He said PC Ross engaged with Mr Cole all the way.

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566. In his second interview PC Spicer said Mr Cole responded to conversation during the journey back to the police station; he was not coherent but Mr Cole‘s responses seemed to coincide with the timing of PC Ross’s attempts to talk to him.

Mr Cole’s arrival at Greyfriars police station and removal from the police van 567. A map of the CCTV cameras in the rear yard of Greyfriars police station demonstrated that there were three cameras covering the yard, labelled ‘Custody Entrance’, ‘Rear Gate’ and ‘Vandock Area’. These were all positioned on the same wall relatively close together, which meant that all cameras had a similar vantage point. 568. The CCTV footage from the rear gate camera showed a van approaching at 01:57:21 and PC Spicer exiting the van. PC Spicer opened the gate, the van was driven in and parked in the van bay, facing towards the position of the cameras. The rear of the van could not be seen. 569. PC Oates said that, when they arrived at Greyfriars police station, he drove straight in instead of reversing in. He said he did this for speed to get Mr Cole out of the van. 570. The CCTV footage of the vandock area at 01:58:20 showed that PC Oates exited the van and walked to the back of the van. The footage from the rear gate camera showed that PC Spicer went to the rear of the van and opened the doors at 01:58:26 and PC Ross then walked to the rear of the van. Once behind the van all police officers were out of view. 571. In his police notebook PC Oates wrote “Back at GPS we were told that due to the long wait to be booked into Custody that we had to remain outside until we could be booked in. The cell was opened and the male was not speaking back at us. However his eyes was [sic] open. He would not follow our instructions to come out of the cell. We took hold of his arms and attempted to gently remove him and stand him up. We managed to get him out of the van but he kept dropping to his knees.” PC Oates wrote that they were joined by PC D and the four of them could not stand him up. He wrote “It appeared that the male was just not following instructions. The male who was cuffed to the rear was then cuffed to the front and sat on the step of the van.” 572. PC Oates said that when the cell doors of the van were opened, Mr Cole was still sitting up and his eyes were open, however, PC Oates did not hear him respond to their questions regarding his welfare. He said Mr Cole was sitting on the floor. PC Oates took hold of one arm and PC Ross took hold of the other and they lifted him up gently out the van. PC Oates said that, when they walked him over to custody, PC D came out and said “Oh there’s a queue in custody you’ll have to keep him in the vehicle and wait your turn”. PC Oates said they had only walked Mr Cole a couple of steps from the van and he kept dropping. He said Mr Cole could not stand on his feet and kept dropping his weight. 573. In his police notebook PC Spicer wrote “Upon arrival GPS male unresponsive. Carried from van. Resistant to stand up, sat on ground at rear of van, cuffs moved to front position.”

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574. In his first interview PC Spicer said they got back to the station, parked the van and immediately got out and opened the back. He said Mr Cole was lying on the floor in a sort of curled position. He said it was a very confined space in there, and was not wide enough to lie out straight. PC Spicer said he did not remember which side Mr Cole’s head was, but his head was on one side and his feet the other. PC Spicer said he did not recall it, but logically because he got under Mr Cole’s left armpit, his head was probably on the nearside of the van. PC Spicer said they asked him to get up first and get out, but he did not get up and did not respond verbally. PC Spicer said this was not unusual. He said that Mr Cole did not speak coherently but he was responding to what was said to him in as much as there were sounds coming from his mouth at the time that they spoke to him. PC Spicer said he went in first and took Mr Cole’s arm and moved him to a sitting position. PC Spicer was on the left-hand side and he did not know who was on the other side. He said they brought Mr Cole out “sort of sideways”. He said Mr Cole’s feet were then lifted down. He said the aperture was not as big as the width of the cell, so his feet would have been pulled and manoeuvred round so then he was in a sort of sitting position. PC Spicer said his legs came out first so he came out forward. He said he did not think Mr Cole used his legs, and they had lifted him out essentially. 575. In her police notebook PC Ross wrote “Upon arrival at custody male was removed from cell van, ambulance called. Male sat on floor awaiting arrival of ambulance”. 576. In her first interview PC Ross said she could not remember if she assisted Mr Cole out of the van, but PC Spicer and PC Oates had hold of him and transported him towards custody. She said Mr Cole was not forthcoming on his legs. She said she grabbed his trainer and followed them. She said he was not being co- operative on his legs and she described them as “floppy” and said he was not taking his weight on his legs. She said she did not hear any sounds from Mr Cole. 577. In her second interview PC Ross said she thought she followed behind and said to him “Right come on, you can stop acting like this now, you can take your own weight”. She said every Friday and Saturday night in the town they were faced with people who were very non-compliant so she made a general assumption that he was behaving stereotypically like people do on a Friday or Saturday night in town after being detained by the police; she thought he was being deliberately non-compliant. She said she thought he was intoxicated and possibly on an illegal substance, which gave her greater suspicion that he was unco-operative and non-compliant with them. 578. The CCTV footage from the vandock area at 01:59:02 showed Mr Cole was taken out of the van facing forwards, with PC Spicer on his left and PC Oates on his right. PC Ross was behind them. Mr Cole’s legs dragged behind him. The police officers took a few steps before they stopped. Mr Cole was then face down with his legs flat on the ground, and PC Spicer and PC Oates still held his upper body up. PC Ross then moved around to Mr Cole’s head while the others were stationary. There was no discernible movement from Mr Cole. 579. The CCTV footage from the custody entrance at 01:59:03 showed the door to custody open and a police officer identified as PC D emerging and walking towards the van.

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580. PC D said he was at Greyfriars police station in the early morning and went into the police yard. He said that as he exited he saw three figures struggling around the corner of a police van which was in the parking bay. 581. The CCTV footage from the Vandock area at 01:59:17 showed PC D approach the rear of the van. He stepped over Mr Cole’s legs and moved out of sight behind the van. At 01:59:26 PC Ross, PC Oates and PC Spicer moved Mr Cole back to the rear of the van and out of view of the cameras. 582. PC D said that as he got closer he saw PC Ross and PC Spicer struggling with a male. He said PC Ross and PC Spicer carried him towards the station. The male was passive and was not helping the police officers carry him. He thought the male may have been drunk as he had observed other drunken people exhibit this passive behaviour. He said PC Ross and PC Spicer held him by the shoulders, which were at the height of their waists. He said they held him but tipped to the left and right. He said as he passed he saw the male was handcuffed at the rear. He said the male had his head down to the front, so he could not see his face. He said it was dark so he could not see the male very clearly. He said he did not see the male move at all. PC D said as the male was non-compliant, “It would be easier to have him handcuffed at the front” so they could hold him by the arms to make him easier to carry. He said PC Spicer was to the right of the man, with PC Ross to the left. PC D then offered to move the handcuffs for them and they moved backwards and positioned the man in a seating position on the metal step of the van. He said he did not see the man sit himself on the step. 583. PC Spicer said they knew there was a queue waiting for custody so it was a matter of making Mr Cole comfortable for a wait. He said there was no resistance and no assistance. He said “you often find when you arrest somebody that they continue fighting then once they were in handcuffs they suddenly realise they’re not going anywhere so they go the opposite”. He said that was the impression he had but he could not assume it; it was not an unexpected reaction but you would be on alert. He said Mr Cole was not coo-perating; he was in a daze more than a sleep. 584. PC Ross said PC D came out from custody and told them that there was a queue for custody. She said Mr Cole was sitting on the floor. She said she called for an ambulance at that point. She said he was then taken back to the van and leant up against the back of the van assisted by PC Spicer. She said he was still handcuffed to his rear at this stage. 585. The CCTV footage from the vandock area at 01:59:32 showed PC Spicer and PC Ross at the edge of the van, slightly bent at the waist looking down. PC D moved in front of them and gestured, apparently in conversation with the police officers. At 01:59:55 all three appeared to lift Mr Cole back to the van, and they all moved behind the van door out of view. 586. PC Oates said they walked Mr Cole back to the van and sat him on the steps, then took the handcuffs off him from the rear and applied them to the front. He said this was to make him a little more comfortable and give his arms a bit more manoeuvrability. PC Oates said he was sitting on the step of the van facing them. 587. PC D said PC Spicer and PC Ross were on either side of the male. He said he came around the side of PC Ross on the man’s left and reached behind him to undo the handcuffs. He said he turned on his torch which he held up to see the handcuffs because it was so dark. He said PC Ross and PC Spicer continued to hold the male at the shoulders as he undid the handcuffs. He said the man may

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have been leaning on PC Spicer. The man’s head was down to the front and he did not see him lift it up. He said when the cuffs were removed his arms were moved from the rear to the front. PC D said he did not know if he did that on his own or if PC Spicer or PC Ross did it for him. He said he moved round to the front of the man and fastened the handcuffs in the front stack position. He said his torch was not aimed at the man’s face and he did not see him clearly. He said he did not see if he was conscious but he believed he was. He said he did not see whether he was breathing or not. He said he did not see the man move of his own volition at any point and did not hear him speak. He said he may have sighed but he was not sure. PC D said he then went to collect an item from another van, and when he moved off, PC Ross and PC Spicer began to move the man again, but he advised them the custody suite was too busy and they moved back again. He then went to the other van and returned to the station. He said that while he was in the police yard there were no welfare concerns for the man brought to his attention by PC Ross or PC Spicer and he did not see them perform any first-aid or welfare checks on him. He said there was nothing he saw that made him think there was a welfare concern. He said there was no discussion about an ambulance while he was in the yard and he did not see or hear PC Ross or PC Spicer call for an ambulance. 588. In his police notebook PC Spicer wrote “male supported in sitting position and asked details – non responsive other than put his arm out to apparently break sideways tilt. Ambulance requested – still in rear yard as queue for Custody.” 589. In his first interview PC Spicer said it was pretty much when they got out the van that they moved Mr Cole’s handcuffs from the rear to the front. He said they were immediately aware they were going to be waiting to go into custody and Mr Cole was not “kicking off”’. He said that was expedient to make people comfortable and keep them in a good mood. PC Spicer said Mr Cole must have had both hands free because he put his arm out to stop himself toppling over. PC Spicer said Mr Cole went to the left and then his hands went down to stop him and that was when PC Spicer caught his shoulder and then held him upright. He said that when Mr Cole put his arm out it was quite apparent that he was not asleep or unconscious. PC Spicer said Mr Cole was sitting on the ground when they took the cuffs off, right against the back of the van. He said that after Mr Cole put his arm out, PC Spicer sat on the back of the van because it was the most convenient place to sit and stop Mr Cole from toppling. He said he was behind Mr Cole because the van had a metal step which would have been digging into Mr Cole’s back. He said they continued to talk to him. He could not remember who was on the other side and said possibly PC Oates. He said PC Ross was in front of Mr Cole and she was doing the main talking to him, as she had in the van. PC Ross then decided to call an ambulance because of Mr Cole’s condition. 590. In his second IPCC interview, when presented with the medical expert opinion that Mr Cole could not have moved his arms at that point, PC Spicer said he disagreed. He stated that Mr Cole did not speak while at the police station. He declined to answer why an ambulance was called at that stage. 591. PC Ross said they moved Mr Cole back to the van and he was sitting on the floor outside the van. She said he complained about his neck. She said he was probably leaning against the step with PC Spicer on his left and PC Oates sitting on his right. She said he was sitting upright on the floor and complained about his neck so she called an ambulance. PC Ross said she decided to call an ambulance because Mr Cole was still complaining about his neck, there was a

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queue in custody and she felt it was appropriate. She said he was not talking but his eyes were open and he was leaning against PC Spicer’s leg. She said there was no change to his condition; he was compliant and not saying anything. She said she decided to move his handcuffs from the back to the front because the ambulance was on its way. She said she removed the right handcuff, and then he was handcuffed to the front, but she could not recall who did that. She said that while they were in the process of doing this Mr Cole fell away from her towards PC Spicer and stopped himself from falling with his left hand. She said within seconds Mr Cole started making noises and she believed he was still conscious at that point. She said as time went on he complained about his neck more. She said he was whispering “My neck”. She said in between saying that his neck hurt he was making a noise which she could only describe as “like gargling”. She said it was not a continuous noise; it was intermittent rather than constant. She said he was moving his mouth in a way that made her think of her previous experiences dealing with people who were on drugs; the chewing of their gums. She said she suspected that he had probably taken some sort of substance. She said they asked him what he had taken, and told him they did not understand what he was saying. She said nobody looked to see if there was anything stuck in his throat or examine him at all. She said nobody touched him as she remembered. 592. In her second interview when challenged about Mr Cole speaking or moving, PC Ross said all she remembered was him whispering “my neck”, and making some sort of gargling noise, which raised her suspicions that he had been on something. She said she did not think she had welfare concerns because there were no visible injuries and she was under the impression he had taken something. When asked for further explanation on why she called an ambulance, PC Ross said she did not know. When asked for further explanation on her decision to move the handcuffs, she said they changed the handcuff position to the front to make him more comfortable because he was now compliant and was sitting down at the back of the van. She said Mr Cole definitely put his hand out to stop himself falling of his own accord and she was 100 per cent sure of this. She said he spoke the whole time up until a very short time before the paramedics arrived and he made some sort of gargling noise. 593. In his police notebook PC Oates wrote “It was decided by myself and PC Ross to arrange for an ambulance to attend to check on the male to make sure he was ok as a precautionary measure. Whilst waiting the male started to make some noises that sounded like he was trying to regurgitate something. We all asked the male if he was ok but the male kept making the same noise on and off. We made comment it was a gurgitating [sic] sound. The males [sic] head was straight and he was sitting up. Apart from this sound he was not making any other noises of his body displaying any movements.” 594. PC Oates said that when Mr Cole was sitting on the step of the van, he started making a “regurgitation” sound and they decided to call an ambulance. He said at that time Mr Cole’s head was really limp. He and PC Ross were supporting him, holding him so he would not fall forward. He said Mr Cole was sitting on the step of the van and they were supporting a shoulder each, facing away from the van. He said they tried to speak to him but he could not recall Mr Cole speaking back, only hearing the regurgitation sound. He said he thought PC Spicer was just standing by the side of the van. He said PC Ross called the ambulance. 595. In his second interview PC Oates said Mr Cole was not speaking when they got back to Greyfriars police station but he was making a gurgling sound. He said he

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could not remember whether his eyes were open. He said in relation to movement Mr Cole had to be assisted. He declined to answer why an ambulance was called at that stage.

The request for an ambulance 596. An entry on the Bedfordshire Police Incident Log at 02:02:23 from unit 112, allocated to PC Ross/PS Withey, requested an ambulance to custody and stated “Male that has been arrested complaining of neck injury”. 597. A radio transmission at 02:05:03 from a female police officer stated “Can we have a paramedic to custody please?”, followed by “It’s the lad from Embassy [sic] who came in, about a neck injury”. 598. A call at 02:06:33 from the Control Room to the ambulance service reported “We’ve got a male complaining of a neck injury”. The age of the male was queried and the control room agent tried to speak to the police officer. The ambulance controller asked if he was awake and breathing, and the control replied “Yeah” then said “I think he may... uh... have gone down with... uh... a bit of a lump when we arrested him... I’m guessing. If it’s the guy we saw getting arrested, I think it might be.” The Control Room agent confirmed it was outside the nightclub. She then stated “I think he may have been involved in some sort of scrap, so... I don’t know what sort of extent the neck injury is”. She then confirmed his age as about twenty and the location as Greyfriars police station. 599. The footage from the custody entrance camera at 02:04:38 showed PC D re- enter custody. 600. The East of England Ambulance service (EEAS) Incident Details Log records receipt of a call at 02:02:16 relating to Greyfriars police station, which was passed to ambulance call sign BA116 at 02:03:02 and acknowledged by Paramedic Witness 33 at 02:04:12. The log recorded “identified traumatic injuries. The patient is a male of unknown age, who is conscious and breathing”. Further logs stated “There is a single patient. It’s not known when this happened. It’s not known if there is serious bleeding. It’s not known if he is completely alert (responding). The injury is to the neck. It’s not known if he has difficulty breathing”. 601. Paramedic Winess 7 said at 2.03am she was crewing a double-staffed ambulance with her colleague Witness 33, and received a call to a male, age unknown, suffering from traumatic injury at Greyfriars police station. She said Witness 33 was driving and they were booked en route at 2.04am. 602. Paramedic Witness 33 said that at 2.06am he and Witness 7 were in an East of England Ambulance with call sign BA116, and they received a call through the CAD screen requesting them to attend Greyfriars police station. 603. PC Spicer said that, after the ambulance was called, Mr Cole made a crackling noise. He said it was not like choking; it sounded like a rasping sound, like a really bad sore throat. PC Spicer said he had no reason to believe that Mr Cole did not remain conscious. He said the responses or what he took to be responses to questions were fairly well synchronised up until around just before PC Ross called for the ambulance, but after that he made these raspy noises in his throat.

The arrival of paramedics

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604. The EEAS Incident Details Log recorded the ambulance on scene at 02:08:04. 605. The footage from the rear gate camera at 02:08:52 showed PC Ross walk from the rear of the van towards the gate and an ambulance came into view. The gates opened and the ambulance drove into the yard, parking to the right of the van so that the rear of the ambulance was closest to the rear of the van. PC Oates and PC Ross were visible at the right-hand side of the rear of the van. 606. PC Ross said the ambulance turned up within minutes and she went to the back door and let the ambulance in. She said she gave the paramedics a brief handover. 607. XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXX 608. XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXX 609. The footage from the rear gate camera at 02:10:07 showed a female paramedic, identifiable as Witness 7, approaching the rear of the van. A male paramedic identifiable as Witness 33 followed her. 610. Witness 7 said that as they approached the police van, a female police officer approached them. She said this police officer told them they had picked the male up in town at a nightclub. She said the male had rushed the door staff at the club and had been taken to the ground by door staff. Witness 7 said she asked the female police officer if the male had been knocked out and the police officer said she did not think so. The police officer said the male had been “fine” when he was arrested, he had walked to the van and had not been at all aggressive towards her or the other police officers. She said the police officer informed her that the male had been chatting on the journey to the police station, and as soon as they started to get the male off the police van at the station, he “went all floppy and collapsed”. Witness 7 said one of the police officers said they thought the male was called ‘Justin’ or ‘Julian’. They found that Mr Cole was unconscious and did not respond to pain stimulus. She said she remembered one of his trainers was

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on the edge of the step of the van behind him and Mr Cole was handcuffed in front of him. She said none of the police officers said whether or not they had administered first aid and she did not ask them. She said Mr Cole did not have any visible injuries although it was very difficult to conduct a proper examination as it was very dark. She said she noted Mr Cole’s airway was clear and that his breathing rate was not unusually low for someone who had been drinking. His radial pulse was very weak. The police officers said they were not aware that Mr Cole had injured his head or taken drugs. 611. Witness 33 said when he walked towards the patient, the female police officer said the patient was “fine” in the back of the van but, as he was getting out, he made a funny sound before sitting down. He said the officer told him the patient had been “chatting” but when they arrived at the police station the patient walked towards the back of the van then suddenly sat down and became difficult to rouse. He said the police officer said the patient had previously been removed from a nightclub by the security staff, and shortly after that was arrested for what Witness 33 believed was an anti-social behaviour offence. The police officer also told him the patient was “chatty” while sitting in the police van and had not given them any hassle. He said the police officer then told them briefly what had happened between the patient and the door staff before they arrested him. He said they thought he may be putting on this behaviour at the van. He said Witness 7 then conducted an initial assessment of the patient, checking his pulse and breathing. He said she was trying to get a response from him but there was not much response coming back. Witness 33 said he had a quick look at him but was not getting a good response. He said they tried to get a verbal response by talking to him but he did not respond. They then tried a rub on the sternum to see if he would respond to that, and his eyes flickered slightly. He said the police officer who had been holding the patient with his arm was still sitting in position, but he was not sure if he was still supporting the patient or if he had pulled back a bit. 612. The ambulance patient care record noted that on arrival a history was given. The notes stated “Ptn charged at a bouncer in town centre and was knocked to the floor and ‘bundled’ by several people. As far as police officers aware he was not knocked out. He was arrested and taken in police custody van to Greyfriars police station. He was talking to police officers, however when they tried to remove him from the van he became unresponsive”. The notes of their initial observations stated “Patient sitting against rear of police van unresponsive though showed some eyelid flicker with constricted pupils to pain stimuli”. 613. PC Ross said the paramedics did some pressure points on Mr Cole such as a knuckle into the neck, and they prick-tested his finger for sugar levels. She said then they got a sort of sweep sheet out and they put that around his back and swept it across and he was laid on it. She said they all picked that up to put him onto the stretcher. The female paramedic put her hand on his chest and questioned if he was breathing. She said he was put into the ambulance. 614. In his police notebook PS Withey wrote “[PS F] in custody had requested my assistance in custody so I walked back to GPS. As I arrived back in custody I was informed that the male was not breathing. I went to the rear yard where [PC Ross, PC Oates and PC Spicer] were with an ambulance in the rear yard. All the officers were clearly shocked. I saw little of [PC Spicer] as he was in the rear of the ambulance.”

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615. PS Withey said that at some point PS F called him up ‘point to point’ on the radio. He said she was the only custody sergeant on duty and he was a trained custody officer, so she requested his assistance in custody. He said he agreed and walked back to the police station, which was about five minutes away. He said when he arrived back at the station he went into custody. 616. PS Withey said he had literally logged on to the computer systems when he was made aware that Mr Cole was in the rear yard with police officers and an ambulance and he was no longer breathing. 617. The CCTV footage from the custody entrance camera at 02:11:57 showed PS Withey entered the yard from custody and walked towards the ambulance. 618. The CCTV footage from the Vandock area camera at 02:12:16 showed PS Withey walked to the rear of the van. He was partially visible behind the door of the van, then at 02:13:00 he walked away, back into custody. 619. PS Withey said he went out to the yard. He said he had no involvement with Mr Cole because he was already in the back of the ambulance and PC Spicer was in the back of the ambulance with him. He said PC Oates and PC Ross were in that general area. He said he could see that both these police officers were quite visibly shocked and distressed about what had happened and he could hear the ambulance crew conducting first aid on Mr Cole. 620. The footage from the rear gate camera at 02:12:50 showed Witness 33 went to the rear of the ambulance, released the access ramp and opened the rear doors. The nearside rear door of the ambulance restricted the view from the camera. 621. The CCTV footage from the vandock area camera at 02:13:43 showed Witness 33 brought a stretcher trolley out of the ambulance. 622. The footage from the rear gate camera at 02:14:52 showed PC Oates walked away from the van and entered custody at 02:15:07. 623. Witness 33 said he went over to the ambulance to get the trolley and the carry sheet, and as he did so one of the police officers was assisting Witness 7 by shining a torch on the patient so she could see. He said the lighting in the police station yard was very poor.

The application of cardiopulmonary resuscitation (CPR) to Mr Cole 624. XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXX 625. Witness 33 said the police officers assisted them as they slid the carry sheet under the patient, and once the carry sheet was under the patient they carefully slid him on to the trolley. He said they then took the patient into the ambulance. 626. In his police notebook PC Spicer wrote “male still unresponsive ambulance attended and treated on vehicle. Handcuffs removed by myself to enable unrestricted treatment on ambulance”.

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627. PC Spicer said the paramedics put some sort of barrier underneath Mr Cole between him and ground and then he was lifted away onto a stretcher. He said it was at that point or soon after that the female paramedic said something like she was not getting a pulse. He said Mr Cole was wheeled to the rear of the ambulance and the stretcher was taken up in the lift, and then he was treated in the back of the ambulance by two paramedics. 628. The CCTV footage from the vandock area and rear gate cameras at 02:16:00 showed the paramedics took Mr Cole on the stretcher trolley taken onto the ambulance. Witness 7 was in the rear of the ambulance with Mr Cole. 629. Witness 33 said they noticed Mr Cole had stopped breathing just before they got him into the ambulance. He said they then began CPR. Witness 7 started doing chest compressions and he fixed the bag and mask to the patient, manually holding it onto him. He said advanced CPR protocol was started, which involved putting a tube down through the patient’s throat passing through the vocal cords to help air get into the lungs and preventing any vomit getting into the lungs. He said Mr Cole was handcuffed with his arms in front of him from the time they arrived at the police station to the time they started CPR. He said he did not see which police officer took off the handcuffs. 630. Witness 7 said they got Mr Cole into the vehicle and a police officer removed the handcuffs. She was not sure if it was the same police officer who had been supporting Mr Cole at the back of the van. 631. In his police notebook PC Oates wrote “When the ambulance arrived I was advised that there was concerns about his breathing and I could see that they were performing CPR on him. The male was then taken to hospital and I had no further dealing with him.” 632. PC Oates said the paramedics assessed Mr Cole and took him into the back of the ambulance, and after he was in the back of the ambulance the paramedics said they thought he was not breathing. 633. The CCTV footage from the vandock area and custody entrance cameras at 02:16:28 showed PC Ross was watching the paramedics at the ambulance. She then picked up a medical bag and took it to the rear of the ambulance, before then jogging to the custody entrance and into custody. 634. PC Ross said she went into Custody and notified PS Withey what was happening at that point. She then called Inspector Fosbury on his radio and told him. She said he made his way back to the police station and PS Withey came outside and then two more ambulance cars turned up before Mr Cole went to Bedford South Wing Hospital. 635. PS F was the custody sergeant at Greyfriars police station at that time. She stated PC Ross came into the custody office and she could tell by PC Ross’s demeanour that there was an issue. PS F said she asked if PC Ross was okay and she replied words to the effect “Our prisoner is not very well” She noted PC Ross looked shocked and bewildered. When PS F queried her PC Ross said “the ambulance is there”. PS F said she immediately left the custody office and went to the back yard. 636. The footage from the rear gate camera at 02:17:00 showed Witness 33 and PC Spicer got into the rear of the ambulance.

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637. PC Spicer said the male paramedic had a mask over Mr Cole’s face and was squeezing a bulb and the female paramedic was doing chest compressions. He said he removed the handcuffs to facilitate the paramedics and then stood in the back of the ambulance. 638. The footage from the custody entrance camera at 02:17:42 showed PC Ross, PS F and PC Oates all exiting custody into the yard and heading to the ambulance. 639. The footage from the rear gate camera at 02:17:58 showed PS F getting into the back of the ambulance while PC Ross and PC Oates stood outside. 640. PS F said she walked to the back to the ambulance and saw two paramedics and a male she later knew to be Mr Cole lying on the ambulance stretcher. She said she could see immediately that he was unconscious and unresponsive. She said the male paramedic told her Mr Cole was not at all well. She said the male paramedic listened to Mr Cole’s chest and then shook his head at the female paramedic, who then commenced chest compressions. PS F said she turned to PC Ross who was standing behind her and said words to the effect “Hannah, this is really serious, where is the Inspector?” PS F said she was in complete shock, and as she exited the ambulance she asked how long Mr Cole had been in this state and asked why no one had notified her when he had become unwell. She said all the police officers in the back yard seemed shocked and upset, and she was told the situation had occurred suddenly and the ambulance arrived very shortly after being called. 641. The footage from the rear gate camera at 02:18:55 showed that PC Oates and PC Ross walked away from the ambulance just before PS F got out of the rear. PS F stood by the rear of the ambulance and PC Ross stood nearby. 642. The footage from the custody entrance camera at 02:19:20 showed PS Withey leave custody, walk to the ambulance and speak to PS F. 643. The footage from the rear gate camera at 02:21:07 showed PC Oates returning to the yard and standing next to PC Ross at the rear of the van. PC Spicer then stepped out of the ambulance at 02:21:32 644. Witness 33 said he believed he requested assistance at around 02:20am. 645. XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 646. The EEAS Incident Details Log records paramedic Witness 8 as being assigned to the incident at 02:21:53 and acknowledging at 02:22:13. A subsequent entry at 02:24:50 records “116 requesting car to scene – cardiac arrest”. 647. Paramedic Witness 8 said he was on duty single crewed, driving a rapid response vehicle. At about 2.21am he was on standby at North Wing Hospital, Bedford when he received a call via his mobile data system. He said the information he initially received was just the location of the incident as Greyfriars police station. He said that during the journey he received a call via his radio informing him an ambulance was already on scene with a male in cardiac arrest and they needed assistance.

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648. PS F stated that a couple of minutes after she exited the ambulance, she made a call to Inspector Fosbury and told him an Inspector or Sergeant needed to attend the back yard to deal with the situation as she could not manage it as well as the custody suite. She said she then had to return to the custody unit to attend to another detainee. 649. The CCTV footage from the vandock area and custody entrance cameras at 02:22:03 showed that PS F and PS Withey walked away from the ambulance and back into custody. PC Spicer then got back into the ambulance. 650. The footage from the custody entrance camera at 02:22:35 showed PS Withey exit custody back into the yard. He stood by the entrance for some time before he then walked to the left rear of the van. PC Ross and PC Oates were stood by the right rear of the van. 651. The EEAS Incident Details Log recorded paramedic Witness 8 on scene at 02:24:21. 652. PC Spicer said another paramedic arrived and entered the ambulance. PC Spicer said he exited the ambulance at that point, because it was too overcrowded. 653. The footage from the rear gate camera at 02:25:14 showed Witness 8 entered the yard and went straight to the ambulance. 654. Witness 8 said he arrived at the rear gates at 2.26am. He walked into the yard and there were four or five police officers milling around at the rear of the ambulance. He said he went into the rear of the ambulance where the crew, Witness 33 and Witness 7, were working on a patient. He said he did not speak to any of the police officers at that time. He said when he entered the ambulance Witness 33 was looking after the patient’s airway and Witness 7 was performing chest compressions. He said he then obtained intravenous access to the patient’s left arm and Witness 33 gained access to his left external jugular. At that stage they administered adrenalin and an anti-opiate drug called Naloxone. They then continued CPR and obtained a return of spontaneous circulation, which was felt and seen on the monitor. He said that while that took place he was aware the police officers were still milling around the rear of the ambulance, but at no time did they talk to them or distract them from the treatment they provided. 655. XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXX 656. The CCTV footage from the vandock area camera at 02:29:28 showed PS F, PC Kalyan and PS Withey all approached the ambulance before going back into custody 02:31:03. 657. Paramedic Witness 5 said he could not recall the time but during his shift he received a call from the Control Room asking for his attendance to an incident in Bedford. He said three crew members, Witness 8, Witness 7, and Witness 33

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were already in attendance. He said he was informed that someone was in cardiac arrest at Greyfriars police station. 658. The EEAS Incident Details Log records paramedic Witness 5 as being allocated to the incident at 02:29:39 and his acknowledgement at 02:30:24. He was logged as on scene at 02:32:11. 659. The footage from the rear gate camera at 02:32:56 showed a paramedic identifiable as Witness 5 entering the yard and going straight to the ambulance. 660. Witness 5 said when he got to rear of Greyfriars police station the gates opened and he saw several police officers in the yard, some in uniform and some in plain clothes. He said he went straight to the ambulance, opened the back door and saw the ambulance crew treating the patient. He said at this point either a police officer or crew member told him the male had collapsed as he was getting out of a police van. He said he stood back and observed. He said on seeing the male in the ambulance he could see no visible injuries.

Mr Cole’s removal to Bedford Southwing Hospital by ambulance 661. The footage from the yard cameras showed that at 02:33:26 PC Ross and PC Oates went into custody, and the paramedics then left the rear of the ambulance before the ambulance was then driven out of the yard at 02:36:29. 662. The EEAS Incident Details Log recorded the ambulance leaving the scene at 02:36:13, and at the destination at 02:38:54. 663. Witness 33 said they left the scene at 2.36am. He said he gave the patient another 800mcg Naloxone one minute before leaving. At this stage his heart had started again but he was not breathing for himself. He said they arrived at Bedford South Wing Hospital at around 02:37am. They explained to the hospital staff what had happened, what treatment they had done and gave them basic details. He said the hospital staff seemed confused as to why a young fit male would go into cardiac arrest. He said by the time they left the hospital at 3.52am Mr Cole was virtually breathing for himself. 664. Witness 8 said once they had obtained the spontaneous circulation they left the scene at 2.36am and took the patient to Bedford Hospital, arriving at about 2.40am. He said the details of the patient and his treatment were entered on to a patient record form completed by Witness 7. 665. Witness 7 said Witness 8 arrived at the police station at 2.36am and they drove to the Accident and Emergency at Bedford Hospital, arriving at 2.38am. She said Witness 33 did a verbal handover to the casualty staff. 666. Witness 5 said that when the ambulance left Greyfriars police station he followed. He also noted there was a police officer in the ambulance en route. He said that at Bedford South Wing Hospital they went straight to the ‘resus area’ in Accident and Emergency, the crew gave a handover to hospital staff and his role ended. 667. XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

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Chronological summary of post-incident events 669. Chief Inspector (CI) V was the senior ranking officer on duty overnight, and had supervision over four uniformed inspectors, including Inspector Fosbury. He stated he received a call from Inspector Fosbury at 2.10am regarding the incident at the nightclub. CI V said Inspector Fosbury informed him that a man had been arrested and taken to Greyfriars police station where he had become unwell. An ambulance had attended and the injured person had been given CPR. CI V said Inspector Fosbury asked him to make his way to the Bedford area.

670. CI V said Inspector Fosbury informed him that the crew of the police van who were involved in the arrest were off the road, and the other van crew he had at his disposal was at the nightclub to preserve the scene and close the premises. Inspector Fosbury informed him the condition of the injured person was serious

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and his identity had not been established. CI V informed Inspector Fosbury that he would make his way to Bedford once another police van at Luton police station resumed circulation. CI V decided not to deploy either of the two Luton vans to Bedford, due to resource concerns and noting that there was a separate serious incident in Luton.

671. The audio recording of radio transmissions showed that at 2.37am Inspector Fosbury made radio contact with the Control Room Inspector, Inspector I. Inspector Fosbury summarised the incident at the nightclub to Inspector I, and noted he had been directly involved in the incident, as had PC Ross and PC Oates. Inspector Fosbury said the Professional Standards Department (PSD) needed to be contacted.

672. Inspector I told Inspector Fosbury that he had already logged the incident. Inspector Fosbury informed Inspector I that due to his involvement in the incident he should not deal with the case and noted he had informed CI V who was on his way. Inspector I said that CI V could control things at the scene and noted the need to isolate the cells and other areas at the police station. Inspector I stated he would contact PSD.

673. An entry on the Storm log at 2.37am confirmed that Greyfriars police station had closed due to a person in cardiac arrest.

674. The audio recording of radio transmissions showed that at 2.41am Inspector I spoke with the Duty Inspector, Detective Inspector (DI) K. Inspector I described the incident at the nightclub and explained he was having difficulty contacting PSD. DI K stated that he was dealing with a separate serious incident and would not be able to deal with this incident as well; he suggested Inspector I contacted the Major Crimes Unit if he could not contact PSD.

675. At the same time, Control Room Supervisor Mr Q made enquiries to establish who was ‘on call’ for PSD. He identified that Ms S was the ‘on call’ PSD representative.

676. Ms S explained that she was the PSD ‘on call’ Misconduct Investigator, and that her role on the PSD ‘on call’ rota was to provide an independent oversight on incidents involving death or serious injury following police contact. She explained that before her shift she agreed with Detective Chief Inspector (DCI) U (a senior officer in the PSD) that she could contact him for advice.

677. Ms S stated that Mr Q contacted her in relation to the incident. She said Mr Q advised her that a prisoner at Bedford custody was in possible cardiac arrest, CPR had commenced and it was “not looking good”. Mr Q explained the circumstances of the incident and told her that custody had been shut down. She said Mr Q could not provide any details of the injured person or of the officers involved.

678. The audio recording of radio transmissions showed that at 2.46am CI V spoke to Inspector I. CI V noted he had spoken to Inspector Fosbury, and advised that he would attend if necessary, but that they should also contact PSD and a Post Incident Manager (PIM) if required. Inspector I informed him that they had notified PSD, and CI V suggested the matter should be handed to them. Inspector I notified CI V of his conversation with DI K and that DI K would not be able to deal

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with the incident. CI V said they should see how the next half an hour developed and he asked to be contacted again if the situation appeared to get worse.

679. Inspector Fosbury stated that when he arrived at Greyfriars police station he started to allocate tasks to officers. He said he tasked DC J and DC AD to follow the ambulance taking the injured male to hospital.

680. The audio recording of radio transmissions showed that at 2.50am Ms S contacted Inspector I. Inspector I confirmed that the identity of the injured person was still unknown, and then provided basic details of the incident. Ms S said she would call the Duty Inspector in relation to the incident, and Inspector I informed her that DI K was already occupied on another incident, and that Inspector Fosbury had been involved. He notified her that CI V had been informed and would make his way to Bedford if necessary. Ms S said to leave it with her and she would call him back.

681. Ms S stated she called DCI U to advise him of the information Mr Q had provided. Ms S stated DCI U advised her to ensure that the ‘Golden Hour Principles’ were followed and she should wait to establish the injuries sustained or whether the injured person died. She said DCI U advised her that they would not go to Greyfriars police station unless the injured person died or further details of the incident were known.

682. Ms S’s notes of her call to DCI U included reference to the ‘Golden Hour Principles’ and to secure evidence. She also noted “Officers to one side – make notes”, “Get ready to go out”, “Wait and see if the person dies / injuries”, and “Names of officers involved”.

683. DCI U corroborated the call from Ms S and the information she provided about the incident, including that the injured person had suffered a cardiac arrest after being involved in disorder at the nightclub, but that she had no further information. He said he advised her to make contact with Inspector I and establish more information about the incident, the person’s identity and condition. DCI U stated he advised Ms S of fast-track actions that Inspector I would need to consider, such as the need to identify and secure possible crime scenes, including the rear yard and the police van. He said he advised them to secure the CCTV at Greyfriars police station and obtain a pre-transfusion blood sample, if possible, on the injured person’s arrival at hospital, however he said he emphasised that the focus of those involved should be on the preservation of the injured person’s life. He said he also advised that the officers involved should be asked to make notes of the incident as soon as possible. He said he asked Ms S to be ready to deploy to Greyfriars police station, and asked that she contact him once she had further information so that decisions could be made on referring the matter to the IPCC and further actions considered.

684. PS AE stated that Inspector Fosbury contacted her at 2.50am. She said that he informed her of the incident and asked her to attend the nightclub to preserve the scene and obtain evidence from the location. PC AF, PS G, PC A, PC AG and PC C also stated Inspector Fosbury tasked them to attend the scene at the nightclub to close the club, secure the scene, obtain CCTV, take photographs of the scene and obtain details of staff members and potential witnesses.

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685. Inspector Fosbury stated he had all of the principal officers involved in the report room at Greyfriars police station. He stated he had a debrief immediately afterwards and he told the officers involved to write up their pocket notebooks. He said at the debrief he was informed of the earlier events involving Mr Cole such as altercations within the nightclub and his ejection. He was also informed that Mr Cole had walked to the van, got himself in and put his own trainers on. He could not recall who told him this.

686. A ‘Bed-safe debrief’ report recorded basic details of the incident, including that a male had been involved in disorder and was at hospital in a serious condition. It appears to be a summary report and does not record the timing of the debrief or attribute any information to specific individuals.

687. The notes in PC Oates’s pocket notebook recorded that he started his notes at 3am and finished at 5.25am. PS Withey’s pocket notebook recorded that he wrote his between 3am and 4.16am. The other subject officers’ pocket notebooks did not record the timings.

688. In interview PC Ross, PC Kalyan, PS Withey and Inspector Fosbury confirmed the subject officers were in the same room when they wrote their pocket notebooks, and stated there was no conferring aside from PC Withey confirming the time that he left the van unit before the incident involving Mr Cole occurred.

689. PC Ross and PC Kalyan stated that they did not receive any warning not to confer about the incident, but stated that there was no conferring and no one influenced their accounts of the incidents. The other subject officers declined to respond to these questions in interview.

690. An entry on the Storm log at 3.04am recorded that DC J and DC AD were at the hospital and took steps to obtain blood samples. However they did not have any details of the identity of the injured person.

691. An entry on the Storm log at 3.15am recorded the latest update from the hospital as “He is unconscious but breathing on his own and his heart is working”.

692. Ms S stated that she called Inspector I at 3.15am. He informed her that the injured person was at hospital, still unconscious but stable. Inspector I said he had no details regarding the identity of the injured person, the officers involved or who was in charge of the incident. She stated Inspector I confirmed that some of the fast-track actions they had previously discussed were complete: The CCTV had been seized; the police van and areas of custody had been secured; and a decision to close the nightclub was being considered. Ms S advised Inspector I to adhere to the ‘Golden Hour Principles’ and to treat the scene as a crime scene. He assured her this was being done. Ms S asked Inspector I to call PSD back once he had details of the injured person and a list of the officers involved in the incident, along with any updates regarding the injured person’s condition. She said he agreed to do so.

693. The audio recording of Ms S’s call to Inspector I at 3.15am showed that Ms S asked Inspector I to check who was on the PSD rota to take over from her at around 7am or 8am in the morning. Inspector I identified that PSD officer AH would be on duty in the morning. Inspector I provided Ms S with an update from

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the hospital and stated, “He is unconscious but stable. His heart is working on its own and he’s breathing on his own”. Ms S asked for details of the officers involved, but Inspector I said he did not have those details. He informed her that the CCTV had been seized and that areas of Greyfriars police station had been isolated as well as the van. He informed her that they were looking to close the nightclub and seizing their CCTV. Ms S confirmed that it was being dealt with as a crime scene and that evidence was being secured. Ms S then said that the Control Room or the person in charge should call PSD with details of the injured person and the names of the officers involved. Ms S then said that later in the morning when they were aware of the diagnosis and medical condition of the injured person they should let the PSD officer know. Inspector I asked “We’re going to [PSD officer AH] in the morning are we?” and Ms S replied “[PSD officer AH] in the morning” and said she would give him a handover. She then said, “Obviously unless he dies between now and then”. Inspector I confirmed if the injured party died then she would get a call. Ms S then said, “If he dies then I’ll be coming out. Until that time it sounds like as long as like the golden hour principles are adhered by and everything is secured then we won’t come out at this time. So I’ll either speak to you or someone will speak to [PSD officer AH] in the morning”.

694. An entry on the Storm log at 3.16am recorded that PS AE was attending the nightclub to close it down, seize the CCTV and speak to the door staff. The entry also noted that the Local Authority CCTV would be seized.

695. An entry on the Storm log at 3.18am listed a report from unit BH112 (allocated to PC Ross/PS Withey) which stated “The male is possible Julian Owens or Justin Owens – he was very evasive with officers and would not give details – he then deteriorated”. Subsequent entries on the Storm log showed efforts taken to identify the injured person, based on the possible surname “Owens”.

696. PS AE stated that she arrived at the nightclub at 3.20am. She said she asked for the nightclub to be closed and asked PC AG to secure the scene. She arranged with the nightclub’s staff to secure the CCTV footage from 1am to 2.30am from all cameras and she said PS G assigned an officer to collect it. She then took details from the nightclub’s staff members, door staff and from witnesses with the assistance of PC AG and PC AF.

697. CI V stated he travelled to Bedford after receiving a request from Inspector Fosbury, and called Inspector I. He asked if PSD had been informed and Inspector I stated that he had spoken with the PSD officer who had said “we will only come out if he dies”. CI V stated he was shocked at this remark. He stated he wanted PSD to attend to ensure the utmost transparency around any investigation and so that evidence from officers was produced appropriately. Inspector I informed him that a CID officer was at the hospital and that the injured party’s condition was not as bad as first thought.

698. The audio recording of CI V’s call to Inspector I at 3.21am showed that he asked Inspector I to contact the ‘on call’ Chief Superintendent, Superintendent M, as he would be the ‘Gold’ Commander for a critical incident. Inspector I informed CI V that the injured person was serious but stable, and asked if it was too early to declare a critical incident. They agreed that the next couple of hours would tell them. CI V asked if the next of kin had been identified, and Inspector I confirmed that they still did not know the identity of the injured person. CI V said they

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needed to make next-of-kin enquiries and confirmed with Inspector I that DI K was unable to take on the incident. CI V said he would call DI K anyway. Inspector I informed CI V that he had spoken to Ms S in PSD and that she would brief PSD officer AH, who was on shift at 8am. He said “She’s not coming out yet unless obviously he goes”. He confirmed that Ms S had instructed them to put in place the measures they already had done in respect of securing scenes.

699. CI V said he then called DI K and asked if he could attend Bedford to take charge of the investigation. DI K informed him that he could not because he was dealing with a separate serious incident. CI V stated he then went to the hospital.

700. The audio recording of radio transmissions confirmed that CI V reported arriving in Bedford at 3.29am and was going straight to the hospital.

701. CI V stated that at approximately 3.30am he called Acting Inspector W using his work Blackberry. He stated that Acting Inspector W was the most impartial supervisor he had at his disposal: She had not been on any of the public order van crews, had not been in Bedford and was of senior rank with an experienced background in investigation. He said he contacted Acting Inspector W as PSD were not prepared to attend and nor was the ‘on call’ Detective Inspector. He stated that he did not perform this function himself as he was directly in the chain of command and had responsibility for the rest of the county, so he delegated the task to her and asked her to attend Greyfriars police station.

702. CI V stated there was a female CID officer (DC J) at the hospital with a member of Essex Medical. He tasked her as a priority to find out the identity of the injured person and inform his next of kin. He stated that this was a vital task that needed to be completed as soon as possible. CI V stated he then spoke with a doctor who was taking the injured person for a scan and the doctor informed him a prognosis would not be available for two to three hours. At 3.35am he informed the Control Room of this update from the doctor. He said he then made his way to Greyfriars police station.

703. The audio recording from the Control Room confirmed that at 3.38am Inspector I spoke to Inspector Fosbury and updated him on his call with Ms S. Inspector Fosbury confirmed that they were completing pocket notebooks at that time and would leave copies at custody. Inspector Fosbury also noted that they could not hold the scene at the nightclub all night and he did not think there was any ‘on call’ Scene of Crime Officer (SOCO).

704. Entries on the Storm log confirmed that CI V provided a medical update to the Control Room at 3.35am and arrived at Greyfriars police station at 3.40am.

705. CI V said that at the station he spoke with Inspector Fosbury, who briefed him regarding the incident. He said Inspector Fosbury confirmed that fast-track investigative actions had been completed: The van had been secured, the nightclub had been closed, the scene was preserved and CCTV had been seized. CI V said he spoke briefly with the van crew and described them as being in shock. He stated that PS Withey and PC Spicer were taking the gravity of the situation particularly badly.

706. PC B stated that he entered the report room at Greyfriars police station and that PS Withey, PC Ross, PC Spicer, PC Oates, PC Kalyan and CI V were there. He

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said no one spoke much, but someone informed him that the male from Mill Street had suffered a heart attack. PC B stated that they all seemed to be in shock and CI V said something along the lines of “I think you all need to do a pocket note book entry about what has happened during this incident, your roles in it and once this is done we will get back in the van and go out.” PC B stated that some of the officers were shocked that they might have to go back out and PS Withey said he did not feel like going back out again after the incident.

707. The audio recording from the Control Room showed that immediately after he spoke to Inspector Fosbury at 3.38am, Inspector I contacted Superintendent M. Inspector I informed him of the incident, including that the injured person was serious but stable at the hospital. Superintendent M questioned Inspector I on various details and the actions taken, and noted that there was the potential for it to become a critical incident and so a senior investigating officer (SIO) should be appointed and evidence secured and preserved. Inspector I confirmed it had not been declared a critical incident at that time as they were waiting for an update on the injured party’s condition, but if he deteriorated it would be called a critical incident. Superintendent M noted the most important actions were to secure and preserve the evidence, to identify the injured person and notify the next of kin. Superintendent M then advised on key strategies, but emphasised that it was vital to identify the injured person and notify the next of kin. 708. Inspector I confirmed the priorities of identifying the injured person, and noted that the next stages would be dictated by his medical condition. Inspector I informed Superintendent M that the officers involved were out of circulation, but Inspector Fosbury was involved and had been collating the pocket books. He noted that Acting Inspector W was travelling to Bedford to take the role from DI Fosbury. Superintendent M noted that police actions would be under scrutiny and advised on preserving evidence. The call concluded with Superintendent M advising he could attend if necessary.

709. Acting Inspector W stated that on arrival at Greyfriars police station she was advised by CI V to collate all information regarding the incident so that she could liaise with and update PSD on their arrival. She stated that she prepared a report which detailed all of the information she obtained and made requests to PS G for actions at the scene at the nightclub.

710. Entries on the Storm log at 3.45am noted that Witness 24 and Witness 11 had gone back to the nightclub and were giving witness accounts to PC C and PC AI.

711. The record of radio transmissions showed that, at approximately 4.04am, the Control Room contacted officers at the scene at the nightclub to ask if any of the witnesses could provide the identity of the injured person. PC AI responded that a witness had identified him as ‘Julian Cole’. PC AI placed a further call to the Control Room to provide a possible London district for the home address and said he was possibly born in 1993. The Control Room operator confirmed that an address for a ‘Julian Cole’ in London had been identified.

712. At 4.01am an entry on the Storm Log stated: “The male may be called Mr Cole” At 4.02am a further Storm Log entry was made which stated: “CIB [Central Intelligence Bureau] completing further checks on Mr Cole”. At 4.07am a Storm Log entry was made which stated: “Mr Cole is possibly from London, possibly

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born 1992”. Subsequent entries on the Storm record show that the ‘Julian Cole’ identified in London by CIB was not the correct individual.

713. An untimed pocket notebook entry by DC J stated that she liaised with PS G (who was at the scene at the nightclub) and the details of the injured person were “Julian Cole, 1992, Bedford University Student”. The subsequent entries from DC J between 4.04am and 4.50am concerned the actions taken by her and DC AD to secure medical samples and other evidence from the hospital.

714. At 4.25am an entry on the Storm log identified the telephone number for the ‘out of hours’ staff at Bedford University campus.

715. At 5.40am an update on the Storm Log received from DC AD stated: “Attempts have been made to contact University Staff... message has been left asking them to contact control room or ext 5397.”

716. A pocket notebook entry by DC J timed at 5.50am recorded that she received an update from the hospital which stated: “Bilateral fracture on side of C2, stable vertabre [sic], patient breathing on own, blood pressure is okay. Can’t assess paralysis whilst unconscious. Suspected that injury caused the cardiac arrest. Awaiting confirmation from Addenbrookes Hospital”. DC J recorded that this update was relayed to DS X and PS Withey.

717. A pocket notebook entry by DC J stated that she and DC AD left Bedfordshire Hospital to conduct enquiries at Bedford University at 6.20am.

718. CI R was the Chief Inspector for the day shift. He said that at 7am he received a call from CI V who provided an update regarding the incident at the nightclub. At the conclusion of the call CI V handed command over to Acting CI R before he went off duty.

719. At 7.12am an entry on the Storm Log noted a call from Bedford Hospital to advise that Mr Cole was just leaving to be transferred to Addenbrooke’s Hospital and was due to arrive by 8.30am.

720. Superintendant L commenced on duty at 7.30am and reviewed the Chief Constable briefing document which included details of the incident at the nightclub.

721. The record of radio transmissions showed that at approximately 7.48am DC AD called the Control Room to update the Storm log. DC AD said he had been at Bedford University to obtain contact details for the next of kin and had obtained two numbers but one did not work and the other had no answer. DC AD asked the Control Room to arrange for the Metropolitan Police Service to go urgently to the next of kin’s address to inform them Mr Cole was being taken to Addenbrooke’s Hospital with serious life-threatening injuries, but he was stable at the time. DC AD then provided the address for Mr Cole’s family and emphasised the urgency on the request.

722. At 7.47am an update on the Storm Log, received from DC AD, stated: “Have tried calling NOK [next of kin], no joy, can Met be tasked with attending NOK address urgently to make them aware that Mr Cole is being taken to Addenbrooke’s with life threatening injuries, although he is stable at this time”. The entry included the

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address for Mr Cole’s family. The entry then stated “We are going off duty, I have handed over to ‘earlies’ [early shift] [DS O].”

723. CID Duty Sergeant DS O came on duty shortly after 7am. He stated he became aware of the incident as a result of the ‘overnight log’ so set about reviewing the Storm log to inform himself of the incident, alongside other incidents which had occurred overnight.

724. The record of radio transmissions showed that at approximately 7.54am, the Control Room contacted the Metropolitan Police Service and asked that a visit was made to the next of kin of Mr Cole to inform them of the situation.

725. Ms S stated that she received a call from DCI U at 8am. DCI U stated that he made this call at 7.43am. Ms S informed him that she had received no further updates from the Control Room. They agreed that if she was unable to obtain any further details over the phone then they would attend the station in person. DCI U stated that during this conversation it became apparent that the subject of the incident was male and that he was in hospital with life-changing injuries.

726. Ms S stated that she then made several attempts to contact Inspector I and Mr Q directly and via call handlers in the Control Room but could not get through to them. She also made several attempts to contact CID at Greyfriars police station but there was no answer.

727. At 8.20am Ms S called DCI U and said she would attend Greyfriars police station to establish the facts in person. DCI U agreed to meet her there. DCI U stated that during this conversation Ms S informed him that the male’s condition was stable and that he had a bilateral fracture of his C2 vertebra.

728. At 8.49am an entry on the Storm Log recorded that officers from the Metropolitan Police were at the Mr Cole’s family’s home. The entry included Mr Cole’s father’s details and stated he had been informed that Mr Cole was at Addenbrooke’s Hospital. The entry also noted that Mr Cole’s mother would not be back until approximately 10am, and they would then make their way to the hospital. The entry also stated “The father would like a call from officers please to advise him of what happened to his son”.

729. At 9am Ms S and DCI U arrived at Greyfriars police station. A short time after they arrived they were briefed by Acting Inspector W. She confirmed the identity of the male as Mr Cole and confirmed that she was in the process of informing his family of the incident. She also confirmed that the fast-track actions suggested by DCI U had been carried out. She used her report of the collated evidence to brief them and to update DS O and DI N.

730. DCI U stated that at this stage his decision was that a criminal investigation was ongoing into how Mr Cole sustained his injuries. He stated that his role was to establish what part the police played in this and once he had sufficient information he would refer the matter to the IPCC. Ms S and DCI U also spoke with the officer leading the criminal investigation, DS O, regarding what actions were being taken.

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731. DS O stated that after he received a verbal briefing and the handover paperwork from Acting Inspector W he tasked various officers in respect of the CCTV and other scene evidence.

732. At 9.27am an entry on the Storm Log recorded: “CID aware of comments and will make contact with the father.”

733. At 9.45am Superintendent L chaired the Force Daily Management Meeting and was provided with an update on the management of the incident, including that an investigative team had been created under the management of SIO DI N. He stated that he was also informed that PSD were investigating any issues of criminality or misconduct relating to actions of police and were doing this in conjunction with the IPCC. He requested that he be provided with an update at 1pm.

734. At 10.01am an entry on the Storm Log recorded: “Call from mother [of Mr Cole] asking for an officer to call her – they are on the way to Addenbrooke's now”. The contact number for Mr Cole’s mother was included on the Storm Log. At 10.03am a further Storm Log entry was made which read: “CID aware.”

735. At 10.15am Acting Inspector W sent an email to DCI U, Ms S, DS O and DI N, which provided her report collating the evidence regarding the incident.

736. At around 10.20am DCI U and Ms S went to DI N’s office. DCI U explained that the matter would be a mandatory referral to the IPCC but at that moment he had few facts on which to base the referral. DCI U then met with DS O. DS O relayed the witness, forensic and scene strategies and supplied DCI U with the CCTV from the inside and outside of the nightclub and the CCTV from the rear yard at Greyfriars police station.

737. Ms S and DCI U stated that between 10.35am and 12.20am they were reviewing the CCTV and paperwork.

738. At 10.37am the scene of crime officer (SOCO) spoke with DS O and was informed that DC AJ was attending Addenbrooke’s Hospital to make an assessment of Mr Cole including the viability of making SOCO seizures.

739. DS O stated a key consideration was that Mr Cole was at Addenbrooke’s Hospital and so he dispatched DC AJ to attend the hospital. He noted that DC AJ was not Family Liaison Officer (FLO) trained and ideally he would have liked to send another officer with him, but it was not feasible.

740. At 11.02am an entry from DS O was made in the Storm Log providing an update from a doctor at Addenbrooke’s Hospital “[Mr Cole] could die from his injuries but they are doing all they can and he is still in a coma, he effectively has a broken neck.” At 11.03am a further entry in the Storm Log was made which stated, “With this in mind please can the duty DI be updated and consideration made to FLO deployment to the family.”

741. Ms S and DCI U stated that at approximately 12.20pm–12.25pm DS O informed them that he had received a call from a doctor at the hospital and had been informed that it looked like Mr Cole was going to die.

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742. An entry on the Storm Log at 12.37pm stated DS O had made DCI U aware of the update regarding Mr Cole’s condition.

743. Acting Inspector Z stated she arrived at Greyfriars police station at 1pm and liaised with DS O. At some point DS O stated he needed a FLO and Acting Inspector Z agreed to organise this.

744. Ms S stated that at 1.10pm DCI U told her to call the IPCC having obtained sufficient details to refer the incident. DCI U stated that it was on the basis of the update from the hospital that Mr Cole might die, and the information obtained from Acting Inspector W and DS O that he decided the matter needed to be referred to the IPCC. He confirmed that he asked Ms S to make the referral.

745. Between 1pm and 1.30pm Superintendent L conducted a review of the case. He stated that present at the review were CI R, DI N and a Local Policing inspector. Superintendent L stated he was informed that Mr Cole’s condition was more serious than previously believed; information from Addenbrooke’s hospital indicated that his heart had stopped due to an injury to his neck and he was in a medically-induced coma. Based on this, Superintendent L completed a threat assessment and identified that owing to the serious nature of the injury following police contact, the incident should be declared as a critical incident.

746. CI R stated that while in a ‘Gold’ meeting, i.e. Strategic Command meeting, (which he stated occurred at 11am) with Superintendent L, he received a call from Acting Inspector Z regarding the deterioration in Mr Cole’s condition and that he may not survive. Superintendent L was informed and, after a brief discussion, declared the incident as critical. DI N was assigned as silver commander.

747. An entry on the Storm Log stated that the matter had been declared a critical incident at 1.15pm by Superintendent L.

748. Ms S stated that at 1.30pm she got through to the IPCC call centre who took her details and said someone would return her call. Shortly after, Ms S received a call from IPCC Senior Investigator (SI) Peter Orr, and she provided him with the details. Ms S stated she was advised that if Mr Cole died it would most likely be an independent investigation. SI Orr informed her that the IPCC would not deploy people 12 hours after the incident but would have done so at the time of the incident. SI Orr said he would call DCI U later in the day to advise who would attend from the IPCC the next day. SI Orr stated he was happy for DS O to continue the investigation and that all evidence should be secured and the police van left in situ.

749. The ‘on call’ record completed by IPCC SI Orr confirmed the report to the IPCC at around 2pm and his decision not to deploy at that time, due to more than 12 hours having elapsed since the incident, that the officers involved had gone home, the injured party’s family were engaged at the hospital and the CCTV and vehicle had been secured and preserved. SI Orr recorded that he asked Bedfordshire Police to update him with Mr Cole’s condition, and indicated it would be an independent investigation, but that would be clarified once a clearer picture was obtained the following morning.

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750. At 2.20pm DCI U and Ms S spoke with Acting Inspector Z. She informed them that the incident had been declared a critical incident. DCI U advised Acting Inspector Z regarding the welfare of the officers involved and the need to deploy a FLO. Acting Inspector Z stated that she was already trying to arrange a FLO. DCI U decided at this stage that post-incident procedures should be put in place.

751. Acting Inspector Z stated she spoke to DCI U regarding officers’ welfare needing to be put in place, during which DCI U said that a post-incident manager (PIM) would be appropriate. Acting Inspector Z stated she updated CI R and requested a FLO and a PIM, which were agreed in liaison with DI N.

752. Entries on the Storm log reproduced from an email from Superintendent L at 2.20pm which listed his ‘Gold Strategy’ regarding the incident and noted he briefed the Deputy Chief Constable at 2.45pm.

753. Superintendent L stated that he outlined his strategic objectives which he later wrote up and circulated to members of the command team. These objectives included: To secure and preserve evidence; and to cater for the needs of Mr Cole’s family and provide them with reassurance and confidence in Bedfordshire Police’s response to the incident. 754. Superintendent L stated that he then made contact with Deputy Chief Constable T and appraised him. He stated that DCC T was satisfied that all measures were in place to properly manage the critical incident.

755. Acting Inspector Z stated that from 2.45pm she made phone calls to organise a FLO and PIM, and also contacted the Police Federation.

756. Acting Inspector Z then contacted the six principal officers (i.e. PC Ross, PC Oates, PC Spicer, PC Kalyan, PS Withey and Inspector Fosbury) and asked them to attend post-incident procedures at Greyfriars police station at 5pm. She stated that Inspector Fosbury and PC Spicer were the only officers of the six who were not in a position to attend.

757. Acting Inspector Z stated that at 3.25pm she informed Ms S that there was no longer an ‘on call’ rota for FLOs. She said she had been trying to allocate a FLO but this was difficult due to the Bank Holiday.

758. Acting Inspector Z stated she then liaised with Family Liaison Co-ordinator (FLC) PS AB.

759. At 3.37pm after receiving a voicemail, PS AB spoke to Acting Inspector Z and received details of the incident. PS AB agreed that a FLO was required. PS AB stated she left voicemails and messages for several FLOs, then at 4.04pm contacted Acting Inspector Z to inform her she was unable to deploy a FLO at that time but she would attend Greyfriars police station to receive a briefing and deploy a FLO.

760. Acting Inspector Z stated she also tried to organise a PIM to attend but this was difficult as there was no ‘on call’ rota in place and the individuals she contacted had their phones off or were otherwise committed. She said she eventually spoke with Acting Inspector AC from Hertfordshire Constabulary and he agreed to

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attend as PIM but could not be at Greyfriars police station for 5pm due to the distance from his home.

761. Acting Inspector AC stated that he was off duty on the day but received a call at 3.50pm advising him of the incident and requesting that he act as PIM. A few minutes later he spoke with Acting Inspector Z who provided him with brief details of the incident and requested that he attend Greyfriars police station at 5pm. Acting Inspector AC stated that as he was off duty he had none of the required PIM paperwork at his home, but he then drove the 35 miles to Greyfriars police station.

762. At 4pm Superintendent L conducted a review of the critical incident with DI N, CI R and the Local Policing Inspector. He stated that he was informed that there was no change to Mr Cole’s condition, that DS O was progressing the investigation [into the door staff] and that PSD were progressing their investigation and a referral had been made to the IPCC. He stated that he was informed that due to the Bank Holiday there had been difficulty in finding a FLO but steps were being taken to address this. He stated that he was informed that post-incident procedures had been arranged.

763. PS AB attended Greyfriars police station at 4.30pm. She was able to contact DS P who was available to act as FLO and asked her to attend Greyfriars police station to be briefed.

764. At 5pm PC Ross, PC Oates, PS Withey and PC Kalyan attended Greyfriars police station and met with Police Federation representative DS Y.

765. An entry on the Storm Log at 5.17pm stated that FLC PS AB was at Greyfriars police station, and DS P was attending to be briefed before her deployment as FLO.

766. An entry on the Storm Log at 5.20pm stated that the PIM, Acting Inspector AC, was attending Greyfriars police station and that the Police Federation (DS Y) and PSD (DCI U) were also at Greyfriars police station.

767. PS AB recorded in her rough book that at 5.30pm she and DS P were provided a briefing by DS O, however there are no records of the content of the briefing.

768. Acting Inspector AC stated he arrived at Greyfriars police station at 5.30pm and Acting Inspector Z briefed him. She confirmed that the four principal officers had arrived and were with DS Y, the Police Federation representative. She then visited the officers and explained that she had updated the PIM and that he would be visiting them shortly. Acting Inspector AC stated that he acted as PIM in what he considered to be “a very much reduced capacity due to the process being some 15 hours after the event”.

769. At 6.15pm DS Y introduced Acting Inspector AC to PS Withey, PC Oates, PC Ross and PC Kalyan. Acting Inspector AC gave them an overview of the post- incident procedures. He stated that he did consider the issue of anonymity and giving a conferring warning but given the elapsed timescales, the fact they had already provided personal accounts and the fact that they had gone off duty and

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then returned, he felt (at that time) there was little benefit in covering these issues so he did not.

770. At 6.47pm DCI U spoke with the four officers. DS Y and Acting Inspector AC were also present. DCI U explained what would happen next and advised the officers regarding PSD, the IPCC, their welfare and the PIM process. This concluded at 7pm. Shortly afterwards PC Oates and PC Ross informed DS Y and Acting Inspector AC that they had additional details of the events that they wished to commit to statement. DS Y and Acting Inspector AC relayed this to DS O.

771. At 6.48pm FLC PS AB made a policy decision that if the door staff were arrested then Mr Cole’s family should be informed. She noted that an initial verbal strategy was discussed with DS P. Introductions were to be completed and Mr Cole’s family were to be informed regarding the arrest. PS AB noted that no medical history was to be provided at that stage, and that they had been informed by DS AJ that lots of family and friends were at Addenbrooke’s Hospital and Mr Cole’s uncle was quite hostile.

772. DCI U stated that at 7.30pm, while PC Oates and PC Ross were writing further statements, PS Withey and PC Kalyan left the post-incident procedure suite.

773. At 7.40pm DS P left to attend Addenbrooke’s Hospital.

774. At around 7.45pm PC Oates and PC Ross completed their statements and gave them to DS O before they left the post-incident procedure suite.

775. DS P attended Addenbrooke’s Hospital and met with Mr Cole’s family at around 9pm.

776. DS P made a record of her meeting with Mr Cole’s family in a Family Liaison log book. She said she only spoke to Mr Cole’s mother and uncle in the first instance. She recorded informing them of the following:  Mr Cole had been drinking with a group of friends at the college halls before going to the nightclub.  Mr Cole and a friend had been involved in an altercation within the club and had been ejected by the door staff.  Mr Cole continued returning to the door and was being removed by his friends and told to leave by the door staff on a number of occasions; from information received it appeared Mr Cole was remonstrating about getting his entry money back.  Mr Cole was involved in an altercation outside the club with the same door staff as inside and the police arrested him for public order.  Mr Cole was transferred to Bedford police station in a van during which he was talking but had then gone quiet.  In the rear yard [of the police station] Mr Cole was found to be unconscious and not breathing. An ambulance was called and CPR administered.  Mr Cole was taken to South Wing Hospital and was then transferred to Addenbrooke’s Hospital.

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 That Mr Cole’s family asked her about whether officers had “pinned” Julian Cole on the floor and they provided her with the name and contact details of Witness 20 who they said had witnessed this.  That Mr Cole family were upset that they had received no contact from police other than DC AJ’s attendance at the hospital. They had said that he could not provide them with any information and had only attended for forensic purposes. They had said that this was degrading to Mr Cole as he was being treated as a criminal. 777. Mr Cole’s uncle made notes of his meeting with DS P at Addenbrooke’s Hospital. He noted that DS P informed them of the following:  Mr Cole had some alcohol with friends before going to the club. He continued drinking at the club.  Sometime in the night (time not confirmed) he had an altercation which led to his eviction from the club.  After being evicted Mr Cole went back for a refund of the money he paid to go into the club. [He] had further altercations outside.  As it was a Bank Holiday weekend there were [police] around and it may have been that one of the patrol cars witnessed the altercation and intervened.  Mr Cole was told to leave the area and may have refused which led to his arrest by the officers.  In the police van, he was talking (“chatty”) to the officers; however before getting to the police station or upon arrival at the station car park the officers noticed he was quiet and he went into a suspected cardiac arrest.  The officers on the scene attempted to resuscitate him, an ambulance was called and he was taken to the South Wing hospital in Bedford. Due to the severity of Mr Cole’s injuries he was transferred to Cambridge Hospital.  CID were taking statements and a bouncer from the club had been arrested on suspicion of assault and another was being sought. 778. Mr Cole’s uncle also recorded a series of questions put to DS P which included whether police had ‘pinned’ Mr Cole down as suggested by a witness and why Mr Cole’s family had not received any information before that meeting. His notes also recorded that DC AJ had been at the hospital from 10am, but did not have any information for the family apart from that Mr Cole was evicted from the club at approximately 1.30am, arrested at 2am and taken to Bedford Hospital between 2am and 3am.

779. DS P noted in the FLO log that their meeting concluded at 11.20pm.

780. Mr Cole’s family have subsequently raised criticism of the information received from DS P, in particular regarding the following:  That informing Mr Cole’s family that Mr Cole “had some alcohol with friends before going to the club [and] continued drinking at the club” was intended to convey that he had drunk alcohol to excess. This sought to discredit Mr Cole and raise the possibility that he may have been the author of his own misfortune due to his alcohol consumption.  The comment that Mr Cole was “chatty” in the police van was erroneous and misleading and did not assist with explaining the circumstances of what

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happened to Mr Cole. It was intended to communicate that whatever caused to Mr Cole to suffer injury and enter a coma happened sometime after the period he was restrained by the police. This should also be contrasted with DS P’s decision not to relay information about how many officers used force on Mr Cole or how they restrained him. 781. The family have stated that these comments were intended to deflect criticism away from Bedfordshire Police.

782. At 9.30am on 7 May 2013, the IPCC determined that it would conduct an independent investigation into the incident.

Expert opinion

First medical expert opinion 783. Mr AK was the Consultant Neurosurgeon at Addenbrooke’s Hospital who treated Mr Cole. He provided two reports to the IPCC supplying medical opinion on Mr Cole’s injury. Mr AK was asked to review an earlier draft of this report to ensure that all references to his reports were fair and accurate, and that they had been used appropriately within the findings. Mr AK provided some further comments, which have updated the content of this report.

Description of Mr Cole’s injuries 784. Mr AK stated a CT scan of Mr Cole’s spine showed an angulated and displaced C2 pars fracture (also known as ‘Hangman’s fracture’). 785. He stated the CT scans of Mr Cole’s head were unremarkable, and stated that importantly, there was no soft tissue swelling around the frontal region or any evidence of skull fracture. 786. Mr AK stated Mr Cole had an MRI scan of his brain and spine. The MRI showed high signal within the spinal cord at C2, consistent with the unstable spinal injury at C2 and suggestive of high cervical cord (spinal cord) injury. The MRI scan of the brain was unremarkable. 787. At the time of his first report provided on 25 July 2013, Mr AK reported that Mr Cole was still in a coma and had never shown any purposeful response. He stated the cause of this coma was most likely a hypoxic brain injury secondary to the cardiac arrest which was itself caused by ventilatory failure and hypoxia. Mr AK stated that the brain damage to Mr Cole was likely to be permanent and it was almost certain that Mr Cole would not make any meaningful recovery.

Causal mechanism for the fracture of the vertebra 788. Mr AK described this type of fracture as being “classically associated with restraint where the neck is hyperextended (bent backwards), with a distraction force placed on the head in relation to the body. Typically the forces are large and sudden”. 789. He stated: “This type of fracture is a high energy fracture caused by hyperextension in the context of hanging or sometimes motor vehicle accidents when unrestrained passengers collide with the windscreen and hyperextend the neck during this process. It is unlikely to have been caused directly by either falling to the ground or by being thrown to the ground. It is equally unlikely that it

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was caused by [Mr Cole] being thrown around in the back in a police van by poor driving. It is possible ... that the fracture was caused by forcible restraint with Mr Cole lying prone and his head pulled back, hyperextending the neck.” 790. Mr AK suggested it was unlikely Mr Cole sustained the injury by falling to the ground and banging his forehead as there was no evidence of either soft tissue injury or skull fracture in the frontal area. Mr AK stated: “There is no evidence from clinical examination or from the CT scan that he sustained a significant head injury during this process and therefore a collision with a street bollard on the descent is unlikely.” 791. Mr AK stated that he was sure of this opinion because if someone fell forward and was unable to put out an arm to break their fall, there would be a significant impact on the forehead with evidence of soft tissue injury and/or skull fracture and/or traumatic brain injury. He said this was not the case for Mr Cole. 792. Mr AK stated “this type of fracture requires significant force and I do not believe that Mr Cole could have inflicted this injury on himself by lifting his head off the ground when lying in a prone position.” 793. Mr AK suggested that the most likely course of events was that Mr Cole sustained the unstable C2 fracture between when Mr Cole was last seen to be independently mobile, i.e. when he ran towards the nightclub at approximately 1.47am, and the point when he was seen again being transferred to the police van.

Link between the fracture of the vertebra and injury to spinal cord 794. Mr AK stated that the fracture itself would not cause a spinal cord injury, but by allowing displacement of the C2 vertebral body on C3 this then caused a high spinal cord injury in Mr Cole’s case. 795. Mr AK stated that the fracture would only cause damage to the spinal cord if the spinal alignment was affected as it was in Mr Cole’s case. He said he was sure, beyond reasonable doubt, that Mr Cole suffered a spinal cord injury as a consequence of the spinal fracture.

Causal mechanism for the spinal cord injury 796. Mr AK stated that Mr Cole had an unstable, displaced C2 fracture that subsequently resulted in a high spinal cord injury. He stated this could have occurred at the scene of the restraint or could have occurred when he was lifted and his head fell forward, flexing the C2 vertebra on the C3 vertebra. 797. Mr AK stated that not all fractures of this type were associated with neurological deficit as the spinal canal was relatively wide at this level, giving the spinal cord some room but [based on the CCTV footage] when Mr Cole was carried across the ground, the weight of his head was not supported and it could be seen in extreme flexion. Mr AK stated Mr Cole’s physical state during this transfer strongly suggested neurological deficit had already occurred prior to being placed in the back of the van. 798. Mr AK stated this manoeuvre could therefore have been sufficient to cause his severe upper spinal cord injury in the context of an unstable neck injury, but he could not rule out the possibility that the spinal cord injury had already occurred at the same time that fracture occurred.

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799. Mr AK stated that the most likely scenario was that the spinal cord was damaged either at the time of restraint or during the transfer from the pavement to the police van, following a fracture during restraint and the fact that his head and neck were not supported during the transfer. 800. Mr AK stated that if the spinal fracture was caused by the time Mr Cole was handcuffed on the ground, then lifting him up without head or neck support is very likely to have either caused or exacerbated the spinal cord injury. 801. Mr AK stated that the fracture was unstable, and flexion of the head on the body would carry a very high risk of spinal cord injury. He stated that CT and MRI imaging showed that the fracture resulted in an abnormal degree of flexion at C2 and the high signal (bruising) in the spinal cord was where one would expect to see it from abnormal flexion caused by an unsupported head in the context of this fracture. 802. Mr AK stated that given the absence of spinal precautions visible on CCTV footage, spinal cord damage could have been exacerbated further by Mr Cole’s position in the back of the police van. He stated that if one was attributing any of the injury to Mr Cole to his journey in the police van, the reason would be because of a lack of spinal precautions, not because of poor driving. 803. Mr AK stated that if the fracture [to Mr Cole’s neck] had occurred but he had been restrained on the ground with his neck in a neutral position it is very unlikely he would have sustained a spinal cord injury.

Capabilities of an individual with this type of fracture of the vertebra 804. Mr AK stated that with this type of fracture, prior to displacement and spinal cord compression, somebody could move their arms and legs and possibly even walk, though one would suspect a great deal of neck pain. 805. Mr AK stated it was clear from CCTV footage [of Mr Cole’s run towards the nightclub] that he was moving extremely freely and did not seem to be showing any evidence of pain in the neck. He said Mr Cole ran with no evidence of neck injury. Mr AK stated that, even if Mr Cole had been intoxicated on alcohol or drugs, one would not anticipate somebody moving this freely with such a severe neck injury if it had occurred beforehand. 806. Mr AK stated that the neck injury sustained was highly unstable and, in a conscious individual, would be extremely painful. He said there was nothing in the CCTV footage that suggested the injury occurred before [the period during which Mr Cole was restrained]. 807. When asked to provide his opinion on the likelihood that Mr Cole would have the physical ability to regain his feet and resist three police officers’ attempts to restrain him if Mr Cole had sustained the spinal fracture, but not the spinal cord injury, Mr AK stated he would have expected a change in Mr Cole’s behaviour, as it would likely have caused severe and sudden neck pain. Mr Cole may still have been able to resist arrest, but it was much more likely that he would have been shouting about neck pain and trying to protect his neck than to engage in violence with the police or door staff.

Capabilities of an individual following spinal cord injury 808. Mr AK stated that, once the spinal cord injury had been sustained (consequent to the fracture), then he would expect Mr Cole to have rapidly progressed from a

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combative state to one where he was lying flaccidly and not making any attempts to move. 809. Mr AK stated that, once the spinal cord was compressed, this would cause rapid loss of power below the level of the injury. The arms and legs would become limp and any physical resistance to restraint would disappear. He said he would expect this change in behaviour to be striking, even to someone with no medical training. He stated at this stage, if the individual was asked to follow simple commands with their arms, they would not be able to do so. 810. Mr AK stated that it was implausible that Mr Cole was acting appropriately and engaging with police officers in the police van and en route to Greyfriars police station, “given the dramatic change in Mr Cole’s behaviour before and after the period of restraint, along with the knowledge we now have of the injuries he had sustained and the cardiorespiratory arrest that was imminent.” 811. Mr AK also stated: “If his neurological injury had already occurred prior to his being transferred into the van then it is equally implausible that he could have recovered such that he would be able to move purposefully and respond to conversation appropriately.”

Link between the injury to spinal cord and hypoxia (lack of oxygen to the brain) 812. Mr AK stated that the lack of oxygen to the brain would only happen because Mr Cole was not ventilating properly, the most likely cause of which was that the spinal cord was damaged. He stated the spinal injury resulted in a failure of ventilation as the muscles (diaphragm and chest wall muscles) were paralysed. He said that, in addition, the airway could become obstructed due to poor positioning such that air entry was affected. Thus the lack of oxygen was caused by two problems; airway issues and inadequate breathing.

Causal mechanism for the lack of oxygen to the brain 813. Mr AK stated that Mr Cole’s difficulties breathing (secondary to an obstructed airway) would start as soon as Mr Cole’s head fell forward, but would have continued and been exacerbated in the back of the police van if Mr Cole’s head and neck were not properly positioned. 814. Mr AK stated that once Mr Cole was in the back of the police van, with a spinal cord injury, the most likely course of events was that he was ventilating sub optimally, which progressed to ventilatory failure leading to hypoxia, and over a period of a few minutes this resulted in a permanent hypoxic brain injury and also hypoxic cardiac arrest, as occurred when Mr Cole was in the presence of paramedics. Mr AK stated it was therefore likely that the brain was hypoxic before the cardiac arrest occurred, and it then took a further five minutes to successfully resuscitate Mr Cole. Mr AK stated it was likely that in Mr Cole’s case, his brain will have been hypoxic before the eventual cardiac arrest with a down time of five minutes. Mr AK stated there was no other plausible explanation for the brain injury sustained by Mr Cole. 815. Mr AK stated with regard to the timing of cardiac arrest the heart myocardium was more resistant to hypoxia than the brain and would therefore function for longer. Mr AK stated that the timing of the cardiac arrest was consistent with the hypoxic brain injury occurring at the time or shortly after the restraint, as a complication of progressive respiratory failure.

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816. Mr AK stated it was widely held that the brain could not sustain more than four minutes of hypoxia without resulting in permanent stroke/brain damage.

Specifics of what would be observable to a layperson 817. Mr AK made it clear that there would be no visual signs of the injury itself, but suspicion would have been raised by a very aggressive and combative individual suddenly becoming limp and unresponsive. 818. Mr AK stated that a lack of oxygen to the brain would be suspected due to Mr Cole becoming unresponsive very quickly. He said this could be due to paralysis rather than hypoxic brain injury, but the abnormal noises he was reportedly making from the airway were an indication of upper airway obstruction, which would suggest a serious problem with ventilation.

Recommended immediate medical care 819. Mr AK recommended that, if a neck injury was suspected, the appropriate measures would have been to leave Mr Cole in the same position, maintain in- line immobilisation of the neck and call for an ambulance who would then have been able to place a cervical spine collar (neck brace) and transfer Mr Cole to hospital with full cervical spine precautions. 820. Mr AK explained how immediate medical care could have impacted on the extent of his injuries: “If he had been left in situ on the ground immediately after the restraint and treated by paramedics, it is quite possible that the angulation and displacement of the fracture would not have occurred. I am cautious in this regard as I do not know what manipulation occurred to his neck as this cannot be seen on the CCTV footage, but it is possible that the spinal cord injury was caused by a lack of support to the head and neck during transfer, and on this basis, if he had remained on the ground and treated by paramedics, the cervical cord and resultant hypoxic brain injury may not have occurred.” 821. Mr AK stated “spinal precautions form the first line of management in any trauma patient along with airway, breathing and circulation.” 822. Mr AK described the method of transfer [shown on CCTV footage] as “inappropriate and dangerous in an individual with a suspected spinal injury and falls well below the standard level of care.”

Second medical expert opinion 823. A second medical expert opinion was sought from Professor AL, an independent Consultant Neurosurgeon based at XXXXXXXXXXXXX Hospital. Professor AL was instructed by the IPCC and provided with evidential materials to inform his opinion, but was not provided with the medical expert opinion of Mr AK. 824. Following his initial report, a further instruction was sent to Professor AL with the purpose of clarifying specific aspects of his initial report. Professor AL provided a clarification report addressing these queries.

Description of Mr Cole’s injuries 825. Professor AL stated that in Mr Cole’s case the ring of bone C2 was fractured on either side and this was a completely unstable injury. He agreed that Mr Cole

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“suffered an angulated and displaced C2 pars bilateral fracture and suffered an incomplete high cervical cord injury.” 826. He added that there was no evidence of any other injury and in particular the trauma admission medical notes said “no external sign of injury.” 827. In his clarification report, Professor AL added “My stated opinion remains that Mr Cole suffered a very severe spinal cord injury - for the sake of argument in layman's terms 90%.”

Causal mechanism for the fracture of the vertebra 828. Professor AL stated “In Mr Cole’s case he suffered a ‘Hangman’s fracture’. This is an unfortunate title as the majority of these fractures are caused by extreme force pressing down on the cervical spine and usually backward (extension) – the usual causes are high speed road traffic collisions and contact sports such as American football. This is of course as opposed to the distraction caused by hanging.” 829. “Considerable force is required for this kind of cervical spine fracture affecting Mr Cole to occur – however, a fall to the ground is not necessarily involved. It is likely that his head was extended backwards with force on the head and therefore on the neck causing the fracture.”

Link between the fracture of the vertebra and injury to spinal cord 830. Professor AL stated “It is only when the instability is exacerbated by movement of the head and neck that pressure comes on the spinal cord and therefore it is not possible to be absolutely certain to the timeline between actual injury and paralysis.” 831. He further commented “There was a spinal fracture and subsequently a spinal cord injury and I have stated that it cannot be medically determined that they occurred at the same time or separately.” 832. In his clarification report, Professor AL provided the following additional comments: “A spinal cord injury is an injury to the spinal cord which is contained within the spinal column made up of bone, disc and ligament. A spinal cord injury is in general terms caused when there is disruption, fracture or dislocation on the spinal column. It is perfectly possible to have damage to the spinal column, i.e. traumatic without damage to the spinal cord.” 833. “The time between a spinal column fracture and spinal cord injury is variable.”

Causal mechanism for the spinal cord injury 834. Professor AL stated “It should be noted at C1 and C2 the spinal column internal canal housing the spinal cord is much wider than the rest of the spinal column encasing the spinal cord and therefore there is room for movement of the neck without damage to the spinal cord at all – some patients may have no neurological damager whatsoever. In Mr Cole’s case there was severe spinal cord damage though not complete – he is able to breathe – and this caused respiratory arrest and cerebral anoxia and permanent brain damage as outlined in the medical notes.” 835. “Because of the nature of the anatomy I have described and I believe there may well have occurred in this case a delay between the actual fracture occurring and the onset of neurological symptoms and failure to breath [sic].”

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836. “Having viewed the enhanced CCTV it is my opinion that by [the time of Mr Cole’s removal from the ground and carriage away from the scene] he is limp and therefore it is highly likely, certainly on the balance of probabilities, that he has already suffered the onset of paralysis.” 837. “[At the time Mr Cole was lifted from the ground] the CCTV suggests he was limp, i.e. partially paralysed.”

Capabilities of an individual with this type of fracture of the vertebra 838. Professor AL stated “The neck muscles immediately upon injury try to stabilise the situation and this is associated with pain.” 839. “As far as the symptoms are concerned it is very likely that there would have been neck pain followed by weakness of the limbs although this may well have not been instantaneous but progressive over seconds and minutes followed by difficulty in breathing and then unconsciousness. The timeframe is variable.” 840. Within his initial medical report, Professor AL outlined aspects of witness statements of what appeared to be multiple physical encounters between Mr Cole, his colleagues, doormen and police officers. He noted “This particular kind of fracture occurs in a wide spinal column and it is not unusual to occur with no immediate neurological sequelae (consequences) whatsoever; although the fracture is inherently unstable and in particular I have emphasised that there may be delay between the severe trauma required to cause such a fracture and the onset of neurological symptoms such as paralysis and failure to breathe. I have emphasised [the possible delay of the onset of neurological symptoms] during these multiple ‘encounters’ descriptions of ‘headlocks’, ‘restraints’ and other such physical encounters.” 841. “I have pointed out it is perfectly possible to suffer a spinal fracture of the type sustained by Mr Cole and to be walking around with normal physical effort.” 842. In his clarification report, Professor AL provided the following additional comments: “It is perfectly possible for someone to have sustained a spinal column injury, i.e. a Hangman’s fracture, without neurological sequelae. However … this injury is highly unstable and although the neck muscles will try to stabilise the situation the ‘patient’ will be at very high risk on moving the head of sustaining spinal cord injury within the unstable fractured spinal column.” 843. [With reference to the CCTV evidence, Mr Cole’s] movements at 1:47:33 could have occurred with a cervical spinal column fracture. The degree of neck movement required to cause the spinal cord to be damaged progressively either quickly or slowly after the spinal column facture is very difficult to measure or be certain about.” Professor AL expresses the certainty of this opinion as “beyond reasonable doubt”.

Capabilities of an individual following spinal cord injury 844. Professor AL stated “The spinal cord at the level of C2 works the arms, legs and the nerves controlling the diaphragm and chest muscles of respiration.” 845. “The spinal cord injury was incomplete and probably progressive over a period of time – unknown. It is not possible to definitely answer [the question of whether Mr Cole could remove himself from the ground, stand and resist attempts to restrain him, once the spinal cord injury had occurred].”

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846. In respect of Mr Cole standing at the van, moving his arms to put on a shoe, or moving his legs into the van or onto a seat in the van, Professor AL said he could only comment that “the CCTV suggests he was limp, i.e. partially paralysed.” 847. “[With regards to Mr Cole moving his arm to stop himself falling to the side when sat at the van]; he suffered partial paralysis and movement of his arm was possible.” 848. Professor AL stated “In an incomplete cervical cord lesion it is perfectly possible during the deterioration to speak provided one can breathe. 849. “[Mr Cole saying ‘my neck’ en route to or at the van] was possible as he had not yet suffered a respiratory arrest.” 850. “[Mr Cole engaging in conversation or speaking, even incoherently, during the journey] was possible as he was breathing. 851. “[Mr Cole whispering ‘my neck’ once he was out of the van was] possible as he was breathing.” 852. In his clarification report, Professor AL provided the following additional comments “Partial paralysis is the process whereby the spinal cord has been damaged but not completely. If there is complete damage to the spinal cord there is complete loss of neurological function of the central nervous system, i.e. the spinal cord below the level of the damage.” 853. “The effects of the spinal fracture alone is paralysis - the degree of paralysis being dependent on the degree of spinal cord injury and as above, complete paralysis at the level of C2/3 in this case is a complete injury. Mr Cole in my opinion did not suffer a complete spinal cord injury but very nearly complete. There is no neurological damage, i.e. paralysis unless the spinal cord is damaged. The paralysis caused by an injury at C2/3 affects the upper and lower limbs and breathing. It is possible to speak while one is breathing. The extent of the paralysis will depend on the extent of the spinal cord injury. It is not possible to provide an exact measurement of the degree of paralysis unless a neurological examination occurs.” 854. “In general terms [with] a spinal cord injury that is severe both lower limbs are similarly affected though there may be less paralysis on one side than the other. The same applies to the upper limbs. In general terms the paralysis in upper and lower limbs will again be similar.” 855. [With reference to the CCTV evidence of Mr Cole at 01:47:33], Mr Cole could have sustained a cervical fracture, but not with spinal cord injury and it is highly unlikely if he had injured his spinal cord that he would have been physically capable of moving or even standing.” Professor AL expresses the certainty of this opinion as “beyond reasonable doubt”.

Link between the injury to spinal cord and hypoxia (lack of oxygen to the brain) 856. Professor AL stated “Mr Cole suffered tragically a high cervical cord injury – though incomplete – and this lead to a respiratory arrest leading to a cardiac arrest and cerebral anoxia with permanent severe brain damage but not complete spinal cord paralysis (he would not be able to breathe if this had occurred).” 857. “In this case there is little doubt that Mr Cole’s cardiac arrest was caused by a respiratory arrest which in turn caused lack of oxygen to the brain and brain stem.”

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Causal mechanism for the lack of oxygen to the brain 858. Professor AL stated “[Mr Cole suffered a] high cervical spine fracture with partial paralysis leading to cerebral anoxia.” 859. “The cause of the respiratory arrest was compression of the spinal cord at C2, which caused paralysis of the muscles of breathing.” 860. “In addition my radiological review shows that the right foramen transversarium was shattered and through this hole the right vertebral artery passes and this important blood vessel supplies part of the brain particularly the brain stem. It is possible therefore that an additional insult causing lack of oxygen to the brain stem in particular was caused by dissection (damage) to the right vertebral artery.” 861. “Lack of oxygen to the brain and brain stem can result in damage within a short period of time approximately five minutes.” 862. In his clarification report, Professor AL provided the following additional comments “A spinal cord injury causing a respiratory arrest as occurred in Mr Cole's case will deprive the brain of oxygen and within five, certainly ten minutes, the heart will stop. If the heart is stopped for a period of time in a normal temperature patient for ten minutes or perhaps even five minutes the heart will not start again. Allowing for the time for the paramedics to arrive, I therefore believe that Mr Cole was breathing while being transported in the police van till arrival at the police station. It is not possible to be didactic on the timing of respiratory arrest in relation to the cardiac arrest. On the balance of probabilities the cardiac arrest occurred shortly before the Paramedics arrived (or he would not have been revivable) therefore the respiratory arrest would have occurred a short number of minutes before the cardiac arrest. There is no sliding scale or exact measurement in relation to paralysis, respiratory arrest and subsequent cardiac arrest.” 863. “I must emphasise that time [sic] of a cardiac arrest may be proceeded [sic] for a period of time when the heart is beating perhaps in an irregular manner either fast or more likely slowly perhaps for several minutes before the arrest noted by the Paramedics. it is not possible to give an exact timescale I am afraid in this regard.”

Specifics of what would be observable to a layperson 864. Professor AL stated “[The physical effects are] paralysis followed by breathing difficulties followed by unconsciousness.” 865. “Mr Cole would have been likely to complain of neck pain. [A layperson would observe] complaining of neck pain, progressive weakness of limbs and then difficulty in breathing. Cyanosis would be unlikely.” 866. “The timeline of deterioration cannot be determined in this case but in my opinion is over a period of at least some minutes.” 867. “I have explained in this case that it is possible for a person to have a broken neck and carry on without any change in demeanour.” 868. “It is perfectly possible that Mr Cole sustained a spinal column injury and the early stages of spinal cord injury without any change in demeanour over a period of time.”

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869. “I am not an expert on alcohol intoxication but most reasonable medical opinion would accept that cerebral function may be dulled by alcoholic intoxication. ” 870. In his clarification report, Professor AL provided the following additional comments in relation to the toxicology, noting that alcohol and Midazolam were found in Mr Cole’s blood “I am not an expert on toxicology … emphasising my non-expertise in toxicology but in general clinical practice it is possible or indeed probable that Mr Cole’s combination of alcohol and other drugs could have caused a ‘depressant’ reaction which may have made his reaction to injury slow. I cannot make any further comment in this regard.”2

Recommended immediate medical care 871. Professor AL stated “In theory a neck brace application immediately after the accident, and I do not know when the fracture actually occurred, may have prevented paralysis.” 872. Professor AL also made comment regarding the treatment Mr Cole received from paramedics who attended: “I have been very impressed with the ambulance officers/paramedics ability and expertise in resuscitating Mr Cole, who had an asystolic cardiac arrest by the time they had arrived.” 873. “…on the balance of probabilities I do not believe there was any worsening of Mr Cole’s spinal cord injury caused by any failure of information between the police officers and the ambulance officers/paramedics and this is evidenced by the fact that Mr Cole can breathe spontaneously now.”

Toxicology report 874. Blood samples were taken from Mr Cole on two occasions on 6 May 2013; the earliest at 4.04am and the second at 6.05pm. These were subsequently sent for toxicological analysis. 875. The first sample was found to contain alcohol at a level of 76 mg/dL and no drugs or drug metabolites were detected. The second sample gave an indication of midazolam and laudanosine, and no alcohol, other drugs or drug metabolites were detected. 876. The toxicologist stated that the presence of alcohol demonstrated that Mr Cole had consumed alcohol that night. She stated that based on certain assumptions, calculations showed that Mr Cole’s blood alcohol concentration at 1.30am on 6 May 2013 could have been between 99 and 151 mg/dL with a most likely level of 125 mg/dL based upon an average elimination rate. 877. The toxicologist stated this range of concentrations would be expected to cause mild to moderate intoxication in a normal social drinker, but were lower than would be associated with drunkenness. Associated signs were described as including increased self-confidence and talkativeness, impaired balance, some loss of co-ordination and reduced alertness; however, the exact effects would depend on the person’s experience and tolerance. The toxicologist emphasised that these values were an estimate only. In order to contextualise these values, the toxicologist stated that the drink/drive limit was 80 mg/dL.

2 It is noted that the toxicology report would tend to exclude that Mr Cole had taken any common drugs of abuse or other commonly prescribed medication at the time.

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878. The toxicologist explained that the presence of midazolam and laudanosine indicated the administration of these drugs before sampling. Midazolam is a sedative hypnotic benzodiazepine and atracurium is a muscle relaxant, both of these are commonly administered during medical treatment. 879. The report explained that the length of time a drug could be detected in the body (e.g. blood and urine) depended on many factors, however, as a guide, drugs and/or metabolites may be detected for up to 12 to 24 hours in blood. The absence of any other common drugs of abuse and other commonly prescribed medication would tend to exclude their presence in Mr Cole’s blood at the time of the incident.

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Legislation 880. The aspects of legislation relevant to this incident and in force at the time of the incident are detailed below.

Police and Criminal Evidence Act 1984 (PACE) 881. Section 24(2): If a constable has reasonable grounds for suspecting that an offence has been committed, he may arrest without a warrant anyone whom he has reasonable grounds to suspect of being guilty of it. 882. Section 24(3): If an offence has been committed, a constable may arrest without a warrant: a) anyone who is guilty of the offence; b) anyone whom he has reasonable grounds for suspecting to be guilty of it. 883. Section 24(4): The power of arrest conferred by subsection (1), (2) or (3) is exercisable only if the constable has reasonable grounds for believing that for any of the reasons mentioned in subsection (5) it is necessary to arrest the person in question. 884. Section 24(5): The relevant reason in this case is: e) to allow the prompt and effective investigation of the offence or of the conduct of the person in question. 885. Section 117: Where any provision of [PACE]: a) confers a power on a constable; and b) does not provide that the power may only be exercised with the consent of some person, other than a police officer, the police officer may use reasonable force, if necessary, in the exercise of the power.

Criminal Law Act 1967 886. Section 3(1): A person may use such force as is reasonable in the circumstances in the prevention of crime, or in effecting or assisting in the lawful arrest of offenders or suspected offenders or of persons unlawfully at large.

Public Order Act 1986 887. Section 5(1): A person is guilty of an offence if he: a) uses threatening or abusive words or behaviour, or disorderly behaviour, or b) displays any writing, sign or other visible representation which is threatening or abusive, within the hearing or sight of a person likely to be caused harassment, alarm or distress thereby of the Public Order Act 1986 creates an offence of being threatening or abusive in a way which is likely to cause harassment, alarm or distress.

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Violent Crime Reduction Act 2006 888. Section 27(1): If the test in subsection (2) is satisfied in the case of an individual aged 16 or over who is in a public place, a constable in uniform may give a direction to that individual: a) requiring him to leave the locality of that place; and b) prohibiting the individual from returning to that locality for such period (not exceeding 48 hours) from the giving of the direction as the constable may specify. 889. (2) That test is: a) that the presence of the individual in that locality is likely, in all the circumstances, to cause or to contribute to the occurrence of alcohol related crime or disorder in that locality, or to cause or to contribute to a repetition or continuance there of such crime or disorder; and b) that the giving of a direction under this section to that individual is necessary for the purpose of removing or reducing the likelihood of there being such crime or disorder in that locality during the period for which the direction has effect or of there being a repetition or continuance in that locality during that period of such crime or disorder.

Health and Safety at Work etc Act 1974 890. Section 3(1): It shall be the duty of every employer to conduct his undertaking in such a way as to ensure, so far as is reasonably practicable, that persons not in his employment who may be affected thereby are not thereby exposed to risks to their health or safety. 891. Section 7: It shall be the duty of every employee while at work: a) to take reasonable care for the health and safety of himself and of other persons who may be affected by his acts or omissions at work; and 892. Section 33(1) It is an offence for a person: a) to fail to discharge a duty to which he is subject by virtue of sections [3 and 7].

Police (Conduct) Regulations 2012 893. Schedule 2: Standards of Professional Behaviour. 894. Honesty and Integrity: Police officers are honest, act with integrity and do not compromise or abuse their position. 895. Use of Force: Police officers only use force to the extent that it is necessary, proportionate and reasonable in all the circumstances. 896. Orders and Instructions: Police officers abide by police regulations, force policies and lawful orders. 897. Duties and Responsibilities: Police officers are diligent in the exercise of their duties and responsibilities.

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898. NB: Home Office guidance explains that the Standards of Professional Behaviour reflect the expectations that the police service and the public have of how police officers should behave.

National guidance 899. The aspects of police national guidance relevant to this incident and in force at the time of the incident are detailed below.

ACPO Authorised Professional Practice: Detention and Custody 900. The Association of Chief Police Officers (ACPO) Authorised Professional Practice module on detention and custody replaced the ACPO Guidance on safer detention and handling of persons in police custody, and was in effect at the time of the incident.

Arrest and detention: The decision to arrest 901. Officers are advised… to use risk assessment as appropriate during the contact and arrest phase, see ‘Condition of the detainee’ [below].

Arrest and detention: Hospital 902. A detainee must be transported directly to hospital if they:  Are showing any symptoms of ‘head injuries’ [below]  Are, or have been, unconscious  Have suffered serious injury  Are suffering from any other medical condition requiring urgent attention  Are suffering any condition that the arresting officer or transporting staff believe requires treatment prior to detention in custody.

Pre-custody risk assessment 903. All staff who come across incidents outside the custody suite must make an immediate risk assessment of the situation. The time available to do this will depend on the circumstances.

Risk assessment: Condition of the detainee 904. Wherever possible, detainees must be asked about any current (or recent) mental health or medical conditions. 905. The presence of a health condition and its severity will affect decisions about how and where a person should be treated. 906. Detainees requiring urgent medical attention should not be taken to a police station. 907. If a detainee exhibits any of the following symptoms or behaviours [below] and those symptoms cannot be easily explained, custody officers [or arresting officers] should consider immediate transfer of the detainee to hospital. Or as a minimum the detainee should be examined by a healthcare professional.

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908. Detailed guidance on ACPO approved first-aid procedure and practices in response to a wide range of medical conditions can be found in the ACPO Police First Aid Learning Programme.

Symptoms or behaviours  Unconsciousness or lack of full consciousness (e.g. problems keeping their eyes open)  Any problems understanding or speaking  Any loss of balance or problems walking  Any weakness in one or more arms and legs  Abnormal breathing

Head injuries 909. Detainees who have suffered a head injury should be immediately transported to hospital for medical assessment and monitoring. 910. A blow to the head can result in bruising or bleeding inside the skull or inside the brain; not all head injuries are visible. Complications may occur at any time after the event. Staff must be aware of the risks associated with head injuries, particularly when dealing with detainees who may have been involved in a fight or a road traffic collision; a head injury may result in a rapid deterioration in the health of the detainee.

Custody, restraint and searches 911. Police officers are frequently required to deal with potentially violent situations and may need to use control and restraint techniques. Officers must be aware of the potential risks the use of such techniques place on the suspect or detainee. 912. Staff must be trained in the use of restraints in accordance with ACPO Personal Safety Manual of Guidance and ACPO Guidance on Personal Safety Training.

Supervising detainees 913. Close supervision of detainee health and welfare must be maintained during periods of prolonged restraint and during Rapid Initial Restraint [below] (see also Method of Prolonged Restraint [below]). Individuals may react differently to restraint, especially if restrained in the prone position. 914. When taking charge of an incident, the supervisor must ensure that the health of the detainee is monitored and that the degree of restraint being applied is reasonable. Monitoring should include assessing the detainee’s breathing and heart rate following the incident. The supervisor should ensure that details of the restraint are recorded.

Rapid initial restraint 915. The safest way of dealing with a violent person is by rapid initial restraint by those who have had proper training. A violent or restrained detainee must not be placed in a police vehicle unsupervised. Detainees who have struggled violently should not be placed in a vehicle unrestrained. In order to ensure appropriate control during any journey, the detainee should be seated upright where possible.

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Method of prolonged restraint 916. When a detainee is restrained in a prone position for any length of time, one team member should be responsible for protecting and supporting the head and neck. That person should lead the team through the physical intervention process and ensure that the airway and breathing are not compromised and that vital signs are monitored. Prolonged restraint and struggling can, particularly when the lungs are being squeezed while empty, result in exhaustion. This can be without the detainee being aware of it and can lead to sudden death. 917. Positional asphixia: There is a risk of positional asphyxia when restraining a person. The prone position should be avoided if at all possible, or the period for which it is used minimised. 918. Body weight should not be used on the upper body to hold down the detainee.

Detainee transportation: placement of detainee 919. When placing a detainee in a vehicle, care should be taken with individuals who are restrained with handcuffs or leg restraints, as this can increase the risk of injury.

Detainee transportation: condition of the detainee 920. Staff may consider it is not appropriate to transport the detainee, and should consider calling medical assistance to the scene. 921. An ambulance must be called for any detainee who appears to be unconscious.

Supervision and escort 922. Every detainee must be supervised and monitored while in transit.

ACPO Guidance on Personal Safety Training

Adherence 923. Forces must ensure that only techniques contained within the ACPO Personal Safety Manual are taught to force personnel. They should also ensure that staff receive appropriate and regular training in the techniques relevant to the individual’s role and force policy.

Refresher training 924. Forces must ensure that personal safety training is delivered with such frequency as to maintain competence and develop skills and knowledge. As a minimum, forces must ensure that staff receive assessed refresher and development training on an annual basis, unless an auditable risk assessment clearly identifies why this frequency is not necessary for a particular role.

Accountability 925. Forces must ensure they have a nominated ACPO lead with responsibility for personal safety training. Forces must also have a personal safety policy in place which includes details of: Which staff are affected by it; what arrangements apply to those police officers who refuse, or who are unable to undertake training due to injury, ill health or to other factors and what restrictions on operational duty, if any,

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apply to those who are not trained or whose time limit for refresher training has expired.

Monitoring and recording training 926. Forces must ensure that robust systems are in place to monitor the scheduling of training, to ensure that it complies with minimum standards. This should include identifying staff who have failed to attend their allotted training so that they can be re-rostered as quickly as possible.

NPIA Personal Safety Training Programme version 1.0 927. The National Policing Improvement Agency (NPIA) Personal Safety Training Programme handbook describes all the management processes required to centrally manage and co-ordinate the ongoing delivery of the Personal Safety Training Programme, which was in effect on 6 May 2013.

Monitoring and recording training 928. The ACPO Guidance on Personal Safety Training requires forces to have an auditable process in place to monitor and record Personal Safety Training. 929. The monitoring and recording procedures should include:  The content of training sessions – (mapped to the module learning outcomes)  Details of learners – attendance including re-rostering non attendees  Details of assessment processes

The Personal Safety Training Practitioner Programme 930. The Personal Safety Training Practitioner Programme meets the learning requirements of all police officers and staff whose role may require them to manage conflict situations when encountering the public. 931. It is a modular programme designed to be delivered locally by force trainers. This allows the Personal Safety Training provision to be contextualised to cater for the specific force locality and their individual staff training requirements. 932. The programme comprises: 933. Module 1: Managing Conflict 934. Module 2: Personal Protection: Knowledge and Skills 935. Module 3: Equipment and Restraints 936. Module 4: Role Specific Skills 937. Module 5: Refresher/Development Training.

Refresher training 938. The ACPO Guidance on Personal Safety Training states that: “Forces must ensure that staff receive assessed refresher and developmental training on an annual basis, unless an auditable risk assessment clearly identifies why this frequency is not necessary for a particular role.” 939. Module 5 of the Personal Safety Training Practitioner Programme provides the learning descriptors for refresher training relevant to specific roles.

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Module 5: Refresher/Development Training Learning Descriptor

Module summary 940. Module 5 refreshes and develops skills acquired by learners from their previous personal safety training, in order to improve the safety of themselves and others, thereby reducing the risk of injury.

Learning outcomes 941. Please note: all learning outcomes are linked to tactics and techniques contained in the ACPO Personal Safety Manual 942. Demonstrate personal safety skills:  Approaching individuals and vehicles safely  Possible medical implications following the use of personal safety techniques, including positional asphyxia and acute behavioural disorder  Personal protection skills including flinch response, nerve point stimulation, touch pressure and strikes  Blocks and parries  Releases  Ground work 943. Demonstrate the use of restraints:  Physical restraints  Multi-officer tactics, including removing and inserting an individual from/to a vehicle, removing an individual from a room (including a cell) and inserting an individual into a cell. 944. Demonstrate the use of current authorised work equipment relating to personal safety:  Handcuffing skills  Possible medical implications following the use of equipment

ACPO Personal Safety Manual of Guidance

Medical implications: positional asphyxia 945. Risk factors are stated as including:  where restraints are used  where the subject is prone  where the subject is intoxicated  exhaustion following strenuous muscular activity (such as fighting) 946. Positional asphyxia is likely to occur when an individual is prone causing their stomach to press up to the ribs. Police officers should pay close attention when they recognise the following symptoms, taking immediate action to remedy them, and treat as a medical emergency (relevant items only):  Body position restricted to prone, face down

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 Behaviour changes – an active prisoner suddenly becomes passive or a loud violent prisoner becomes quiet/tranquil 947. Transporting an individual: The condition of the individual must be checked and monitored prior to, during and at the conclusion of the journey.

Medical implications: head injuries 948. An alteration in conscious level, including complete loss of consciousness is the hallmark of significant brain injury and warrants urgent medical attention. 949. Do not assume a change in conscious level is due to alcohol or drugs. The slightest suspicion of injury demands urgent medical attention.

Medical implications: spine and spinal cord injuries 950. As with head injuries many of the techniques described may result in injury to the bony spine with or without involvement of the spinal cord. Particular care must be exercised in dealing with subjects with an alteration in conscious level. Even in a fully conscious patient spinal injury cannot be excluded. 951. The neck is particularly prone to injury. Forceful neck movement in any direction following a fall or blow to the head or neck may result in serious injury. 952. If neck injury is suspected because of a complaint of neck pain or loss of limb function or because of the injury mechanism, the subject should be managed lying on their back with the head in the neutral position and manual immobilisation technique applied. 953. It is also possible to injure the lower spine when applying these techniques. Be alert to complaints of back pain or loss of limb function. In such an even keep the subject lying still and seek urgent medical help. 954. With only rare exceptions, neck restraints are not taught within the police officer safety training programme. Police officers need to understand the lethal potential of neck restraints. Any form of pressure to the neck area can be highly dangerous.

Unarmed skills: ground pin 955. The principle of ground pinning is to apply body weight to a subject’s wrist, arm and/or shoulder, whilst the subject is on the ground. This position will assist police officers to immobilise the subject in preparation for further tactical options. 956. Safety point: No weight is applied to the subject’s head, neck or spine. The subject must be repositioned from the prone position at the earliest opportunity (for example, ground-pin handcuff and reposition the subject on their side). Any delay to this process will need to be justified. Rolling a subject onto their side or into a seated, kneeling or standing position, so that their chest and abdomen are upright and unobstructed, are the optimum positions to facilitate the breathing of a restrained subject. 957. The police officer must always maintain full awareness of their surroundings and maintain a position of advantage. The police officer must continually evaluate all the impact factors associated with the situation. From an effective ground pin position the police officer should be able to maintain tactical awareness and be able to engage or disengage effectively throughout the process giving consideration to any further tactical options.

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958. A ground pin is utilised to control a subject who is on the ground. The subject may have been verbally instructed to the ground and then ground pinned or may have been physically taken down to the ground by the police officer and then ground pinned. The police officer needs to ensure that control of the subject is maintained throughout, for example during the transition from an unarmed takedown into a ground pin. 959. Safety point: All police officers must continually assess the situation and the response of the subject and be aware of positional asphyxia

Unarmed skills: Multiple police officer techniques 960. In some circumstances the restraint of a subject by one police officer may prove to be difficult. Multiple police officers may therefore be required to secure a subject in preparation for further control and tactical options. 961. Communication between police officers is essential. This may be verbal or non verbal communication. In some cases the police officers may have a chosen signal, phrase or code word which initiates an action. 962. The multi police officer restraints may be converted into a variety of different tactical options depending on the circumstances. For example, the police officers may consider the most appropriate tactical option is to keep the subject standing, kneeling or to take them down to the ground. Police officers may also consider it appropriate to utilise further control measures such as handcuffs or limb restraints. As with all force the subject’s welfare and physical well being is of paramount importance, consideration should be given to positional asphyxia, acute behavioural disturbance or any other physiological condition. 963. As part of a multiple police officer tactic there may be a requirement to secure a subject’s head. This may be to assist the police officers to move the subject, to provide additional safety for the police officers or to protect the subject from causing themselves any injury. 964. Police officers may be required to secure both arms of a subject in a ground pin position. This may be as a result of an unarmed multiple police officer takedown or handcuffing techniques. 965. Handcuffing: Introduction. The application of handcuffs is clearly based on the police officer’s perception of the person to be handcuffed at the time, in the circumstances, whilst taking into account all the facts. It must be proportionate and lawful where each officer is accountable, both in law and procedure.

ACPO Guidelines: use of handcuffs 966. Any intentional application of force to the person of another is an assault. The use of handcuffs amounts to such an assault and is unlawful unless it can be justified. Justification is achieved through establishing not only a legal right to use handcuffs, but also good objective grounds for doing so in order to show that what the officer did was a reasonable, necessary and proportionate use of force. 967. Officers should be familiar and comfortable with the circumstances in which handcuffs may be used. Moreover, they should be able to justify the use to supervisory officers, and appropriate Authorities including the Courts. In the same way officers should be prepared to justify the period of time the handcuffs were applied before their eventual removal.

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968. In considering what action is reasonable, an officer should apply the principles of the Conflict Management Model (now replaced by the National Decision Model), especially the Impact Factors. Factors such as age and gender, respective size and apparent strength and fitness may or may not support the justification of using handcuffs, taking into account all the accompanying circumstances at the time. There must always be an objective basis for the decision to apply handcuffs. 969. The physical condition of a person is another consideration in deciding whether or not handcuffs should be applied or their application continued. For example, where a person has a condition that may be aggravated when handcuffed, this might make their use unreasonable. When handcuffs are used, the condition of the person should be monitored to ensure that there is no particular risk of injury or death. 970. The following advice and guidance is provided to help clarify these guidelines:  In establishing an objective basis for believing that a person may escape or attempt to escape, an officer may react to whatever the person says or does, but need not wait for a physical act. The officer should take into account the seriousness of the offence for which the person has been detained. Depending on the circumstances, this can induce a level of desperation so that an attempt to escape could reasonably be expected. Previous indications of the person’s likelihood to escape can also be considered to establish reasonable grounds to handcuff.  In establishing an objective basis for believing that a person should be handcuffed because violence is likely to be used against the officer or a member of the public, the officer need not wait for a physical act from the person. The officer should take into account the actions of the person prior to detention. If violence had already been displayed in the circumstances that led to the detention, regardless of whether or not the detention was for an offence involving violence this could constitute adequate objective grounds for handcuffing. Verbal and non-verbal indications from a person of a possible likelihood of violence can provide grounds for making an objective decision. When a person is known or is believed to be likely to use violence, based on previous experiences of such (perhaps particularly at the point of detention or while in custody), this would also assist an officer to develop an objective basis for a decision to use handcuffs.

NPIA First Aid Learning Programme version 1.0 971. The College of Policing have confirmed that the NPIA First Aid Learning Programme (FALP) version 1.0 was in place on 6 May 2013. The relevant content is listed below.

HSE: legal requirements 972. The Health and Safety (First Aid) Regulations 1981 require employers to provide suitable first aid equipment, facilities and personnel to enable first aid to be given to employees if they are injured or become ill at work. 973. The Management of Work Health and Safety 1999 recommend that employers should consider members of the public when undertaking an assessment of needs for first-aid provision. This recommendation of ‘considering the public’ can be interpreted as those affected by the policing role and functions.

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974. To fully comply with the 1981 Regulations this training must be delivered by a HSE licensed training provider. Forces should therefore train personnel to the recognised HSE standards of Emergency First Aider at Work (EFAW) and First Aider at Work (FAW) based on a local risk assessment. Forces can become a HSE licensed provider, work in collaboration with another force who is a licensed provider or use an external licensed provider. 975. ACPO Cabinet has endorsed the HSE recommendations in respect of the arrangements for the delivery and annual refresher training for First Aid at Work in Policing. It also recommends the Emergency First Aider standard for basic first aid training. 976. The National First Aid Curriculum is defined by the learning outcomes in the Learning Descriptors. 977. Forces can deliver the curriculum using their own materials, materials recommended by the ACPO First Aid Forum or a mixture to meet the required outcomes in the learning descriptor. 978. Irrespective of the method used, forces must demonstrate coverage of the national curriculum as defined in the relevant learning descriptor.

Management of the FALP in forces 979. Forces are responsible for managing and co-ordinating the local delivery of this programme, either within their own force or in collaboration with neighbouring/other forces.

Module 2: First Aid Skills Police (Emergency First Aider at Work) 980. The minimum level of first aid required by police officers and operational support staff with direct contact with the public. This module is equivalent to the HSE EFAW standard. 981. Annual refresher training is required as defined in “Module 2; Refresher Training”.

Module 4: First Aid at Work Police; Initial and Re-qualification 982. For officers or police staff working in medium to high risk areas (e.g. Firearms officers, PSU medics) and where the operational plan requires a higher level of first aid than the emergency first aider. This module is the HSE FAW standard.

Module 2: First Aid Skills Police Refresher Training (4 hours) 983. This module addresses the requirements for refresher training for:  police officers and operational support staff that have direct contact with the public (module 2)  police personnel who work in medium to high risk areas (module 4) 984. The HSE state that, for personnel who are qualified to EFAW attendance, an annual refresher is sufficient to keep this qualification valid and current; no re- qualification is required. 985. Where there is a lapse of more than one year between refresher training then re- qualification of the original EFAW is required. 986. The HSE state that, for personnel who are qualified to FAW attendance, an annual refresher is sufficient for years 2 and 3. However, re-qualification of the

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original training is needed in year 4 to ensure this qualification is valid and current. The cycle then repeats.

Quality assurance of delivery 987. Forces should have procedures for managing the quality assurance of delivery; they should include processes for:  monitoring delivery  for ongoing achievement of learning outcomes  for staff development  identification and dissemination of good practice  gathering feedback from trainers and learners (the data gathered here will inform the evaluation process)

National Policing Curriculum: First Aid Skills Police 988. The College of Policing confirmed that an updated curriculum for ‘Module 2: First Aid Skills Police (EFAW)’ of the FALP was in place on 6 May 2013. The relevant content is listed below.

Overview 989. This module is the EFAW standard as defined by the HSE. 990. The learning addresses basic principles of first aid and deals with a wide range of medical situations that personnel may be expected to deal with. Including the management of a first-aid scene and dealing with the casualty.

Learning outcomes 991. Manage a first aid scene:  Undertake an initial scene assessment  Communicate this information to control  Summon appropriate help  Identify and prioritise tasks  Prioritise casualties for treatment  Make appropriate use of others at the scene 992. Assess a casualty:  Recognise dangers to own and casualty’s safety and take appropriate action  Undertake a basic primary survey  Check airway, breathing  Take appropriate life saving action  Observe casualty for signs of injury  Obtain a history from casualty and note any symptoms (conscious casualty)  Undertake a secondary survey as required  Prioritise injuries for treatment  Monitor casualty continually and reassess them frequently

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993. Perform basic life support:  Recognise dangers to own and casualty’s safety and take appropriate action  Monitor casualty’s condition and react appropriately to any change 994. Report casualty information  Gather information pertinent to casualty  Promptly and accurately inform appropriate specialist of information relating to a casualty  Complete accident records legibly, accurately and in a timely fashion  Record details of first aid given legibly, accurately and in a timely fashion  Submit reports to appropriate authority in a timely fashion 995. Manage a casualty with spinal injury  Immobilise casualty with spinal injury  Co-ordinate log rolling of a spinal injury casualty

National Policing Curriculum: First Aid at Work Police 996. The College of Policing confirmed that an updated curriculum for ‘Module 4: First Aid at Work Police; Initial and Re-qualification’ of the FALP was in place on 6 May 2013. The relevant content is listed below.

Overview 997. This module is the FAW standard as defined by the HSE. It focuses on the level of first aid identified by the HSE as the acceptable level for medium to high risk work environments and operational duties. 998. The learning addresses basic principles of first aid and deals with a wide range of medical situations that personnel may be expected to deal with. It addresses the same content as Module 2 but develops this further by adding more complex medical and trauma skills.

Learning outcomes 999. Manage a first aid scene:  Undertake an initial scene assessment  Communicate this information to control  Summon appropriate help  Identify and prioritise tasks  Prioritise casualties for treatment  Make appropriate use of others at the scene 1000. Assess a casualty:  Recognise dangers to own and casualty’s safety and take appropriate action  Undertake a basic primary survey  Check airway, rbeathing  Take appropriate life saving action  Observe casualty for signs of injury

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 Obtain a history from casualty and note any symptoms (conscious casualty)  Undertake a secondary survey as required  Prioritise injuries for treatment  Monitor casualty continually and reassess them frequently 1001. Manage a casualty with minor injuries  Recognise dangers to own and casualty’s safety and take appropriate action  Undertake a basic primary survey  Treat any minor injury present  Record any treatment given 1002. Perform basic life support:  Recognise dangers to own and casualty’s safety and take appropriate action  Monitor casualty’s condition and react appropriately to any change 1003. Place a casualty in the recovery position  Ensure casualty is in a safe location (do not move unless absolutely necessary)  Assess casualty’s level of responsiveness  Ensure airway is clear and the casualty is breathing  Place casualty in the recovery position  Monitor casualty  Respond to a casualty’s condition changes 1004. Report casualty information  Gather information pertinent to casualty  Promptly and accurately inform appropriate specialist of information relating to a casualty  Complete accident records legibly, accurately and in a timely fashion  Record details of first aid given legibly, accurately and in a timely fashion  Submit reports to appropriate authority in a timely fashion 1005. Manage a casualty with a broken bone (fracture) or dislocation  Immobilise fractures and dislocations  Remove constricting objects from injured limbs  Use dressings and bandages to cover wounds, where appropriate, at fracture sites  Reassure casualty  Treat for shock  Monitor casualty’s condition and react appropriately to any changes  Transfer to hospital 1006. Manage a casualty with a head injury  Recognise dangers to own and casualty’s safety and take appropriate action  Recognise the signs and symptoms relating to head injuries

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 Demonstrate how to examine a head injured casualty  Treat any obvious injury  Position casualty correctly and keep warm  Recognise importance of obtaining prompt medical help  Recognise changes in levels of consciousness and react appropriately  Monitor casualty’s vital signs at 10 minute intervals and react appropriately to any changes 1007. Manage a casualty with spinal injury  Immobilise casualty with spinal injury  Co-ordinate log rolling of a spinal injury casualty

FALP Modules 2 and 4 First Aid Refresher Training 1008. The College of Policing confirmed that the NPIA FALP was the only national guidance in place for the refresher training of Modules 2 and 4 on 6 May 2013. The relevant content is listed below. 1009. The learning is made up of core content that must be completed annually, plus content delivered on a three-year rolling basis.

Learning outcomes: core (must be completed annually) 1010. Assess a casualty 1011. Perform adult basic life support 1012. Report casualty information

Learning outcomes: rolling (delivered over a three-year rolling basis) 1013. Manage a first aid scene 1014. Manage a casualty with spinal injury

Bedfordshire Police training 1015. The aspects of Bedfordshire Police training relevant to this incident and in force at the time of the incident are detailed below.

Personal Safety Training

Delivery policy 1016. Confirmation was received from Bedfordshire Police Organisational Development that police officers were required to re-classify their Personal Safety Training annually. However, due to issues such as operational demand, injury, sickness and annual leave, police officers would occasionally not be booked for training sessions strictly within the 12-month period and training would take place within an 18-month period.

Content 1017. Bedfordshire Police Specialist Training Unit confirmed that there were no lesson plans for the Personal Safety Refresher training attended by the ‘in date’ police

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officers, and the sessions would not have included any classroom content; each session was “a straightforward reclass”, which involved the instructor asking to see the skill and the student demonstrating it. 1018. A sample of Bedfordshire Police Personal Safety Training reclassification assessment sheet indicated the areas on which police officers were assessed at this training. These areas included Control and Restraint and 100 per cent was required to achieve reclassification. Within ‘Control and Restraint’ the following skills were assessed: escort position; front thumb lock; arm entangle; transport wrist lock; takedown (using a choice of the restraints previously listed) into a ground pin.

Subject officer Personal Safety Training histories 1019. Bedfordshire Police confirmed that all police officers were ‘in date’ with their Personal Safety Training, with the exception of PC Oates, who had his previous training on 25 April 2012 and was therefore ‘out of date’ with regards to his Personal Safety Training, i.e. more than a year had passed since his previous refresher at the time the incident took place.

First Aid Training

Delivery policy 1020. Bedfordshire Police Organisational Development confirmed that there was no written policy regarding first-aid refresher training, but Bedfordshire Police followed the HSE guidelines which stated that refresher training should take place annually and should be appropriate to a police officer’s individual role.

Content (EFA) 1021. Bedfordshire Police Specialist Training Unit confirmed that the EFA training package in effect on 6 May 2013 was a two-day training programme with the aim stated as: “To train officers in First Aid to comply with the requirements of HSE Emergency First Aid at Work (EFAW) and the College of Policing guidelines set out in Module 2 of First Aid Skills for Police (FASP).” 1022. The content detailed on the EFA training plan included inputs regarding head injuries and spinal injuries. 1023. For head injuries the EFA training plan listed the content as: “Recognising signs and how to manage. Essentially, as per any other wound. Consider laying down with head/shoulders slightly raised and supported. Key point to emphasise is the likely changes in consciousness and the fact that EVERY head injury needs to be assessed by medical professionals.” 1024. For spinal injuries the EFA training plan listed the content as: “When to suspect spinal injury and the importance of immobilising the casualty (ABCs still take priority).Demonstrate log roll and discuss when this would be appropriate to use. Learners to split into groups of 4-6 and practice log roll. Demonstrate and practice spinal recovery position.”

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Content (Custody FAW) 1025. Bedfordshire Police Specialist Training Unit confirmed that the Custody First Aid at Work (FAW) training package in effect on 6 May 2013 was a four-day training programme; three days were delivered by Bedfordshire Police and the fourth day of training was delivered by Trident Medical. 1026. The aim was stated as: “To train custody officers/staff in First Aid in accordance with the requirements of HSE First Aid at Work (FAW) and the NPIA guidelines set out Module 4 of First Aid Skills for Police (FASP)”. 1027. The content detailed on the Custody FAW training plan included inputs regarding head injuries and spinal injuries. 1028. For head injuries the Custody FAW training plan listed the content as: “Discuss fractures, concussion and compression. Signs, symptoms and treatment as per powerpoint slides. Keep referring back to previous learning by tying into monitoring for shock, changes in level of response”. 1029. For spinal injuries the Custody FAW training plan listed the content as: “When to suspect spinal injury and the importance of immobilising the casualty (ABCs still take priority).Demonstrate log roll and discuss when this would be appropriate to use. Learners to split into groups of 4-6 and practice log roll. Demonstrate and practice spinal recovery position.”

Content (Refresher training) 1030. Bedfordshire Police confirmed that the First Aid Refresher training package in effect on 6 May 2013 was a three-hour training programme with the aim stated as “To refresh officers and staff in basic first aid training to the guidelines set out by HSE”. 1031. When questioned on the inclusion of ‘rolling programme’ content, Bedfordshire Police stated that the annual refresher training was all the same format without any enhanced input. 1032. The content detailed on the First Aid Refresher training plan included inputs regarding head injuries, but did not have any input regarding spinal injuries. 1033. For head injuries, the First Aid Refresher training plan listed the content as: “Discuss head injuries. Recognising signs and how to manage. Essentially as per any other wound. Consider laying down with head/shoulders slightly raised and supported. Key point to emphasise is the likely changes in consciousness and the fact that EVERY head injury needs to be assessed by medical professionals.

Subject officers first-aid training histories 1034. Individual training records for the subject officers were obtained and established the following first-aid training histories.

PC Ross 1035. The training history for PC Ross listed the following first-aid courses:  ‘Beds – First Aid Refresher 1 Year’ on 13 February 2013 (three hours).  ‘Patrol First Aid Refresher’ on 6 April 2009.

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 ‘Patrol First Aid Refresher’ on 29 November 2005. 1036. Bedfordshire Police has been unable to provide any record that PC Ross completed any training to EFAW or FAW standard.

PC Oates 1037. The training history for PC Oates listed the following first-aid courses:  ‘Patrol First Aid Refresher’ on 17 February 2010.  ‘Patrol First Aid Refresher’ on 29 March 2007. 1038. Bedfordshire Police has been unable to provide any record that PC Oates completed any training to EFAW or FAW standard.

PC Kalyan 1039. The training history for PC Kalyan listed the following first-aid courses:  ‘Beds – First Aid Refresher 1 Year’ on 13 February 2013 (three hours).  ‘Patrol First Aid Refresher’ on 29 November 2011.  ‘Patrol First Aid Basic’ between 8 December 2007 and 9 December 2007. 1040. Bedfordshire Police has been unable to provide any record that PC Kalyan completed training to EFAW or FAW standard since December 2007.

PC Spicer 1041. The training history for PC Spicer listed the following first-aid courses:  ‘Beds – First Aid Refresher 1 Year’ on 13 February 2013 (three hours).  ‘Patrol First Aid Refresher’ on 9 August 2010.  ‘Patrol First Aid Refresher’ on 10 October 2007.  ‘Patrol First Aid Refresher’ on 26 May 2004.  ‘Training (1 day) first aid’ on 12 November 1999. 1042. Bedfordshire Police has been unable to provide any record that PC Spicer completed any training to EFAW or FAW standard since November 1999.

PS Withey 1043. The training history for PS Withey listed the following first-aid courses:  ‘Refresher Training for Custody’ on 31 October 2012.  ‘Refresher Training for Custody’ on 20 January 2011.  ‘Refresher Training for Custody’ on 11 May 2010.  ‘Refresher Training for Custody’ on 6 May 2009.  ‘Refresher Training for Custody’ on 14 November 2008.  ‘Refresher Training for Custody’ on 9 May 2008.  ‘Refresher Training for Custody’ on 26 October 2007.  ‘Refresher Training for Custody’ on 10 July 2006.  ‘Training (1 day) first aid’ on 5 February 2003.  ‘Training (1 day) first aid’ on 12 January 2000.

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1044. Bedfordshire Police has been unable to provide any record that PS Withey completed any training to EFAW or FAW standard since February 2003.

Inspector Fosbury 1045. The training history for Inspector Fosbury listed the following first-aid course:  ‘Patrol First Aid Refresher’ training course on 1 November 2005. 1046. Bedfordshire Police has been unable to provide any record that Inspector Fosbury completed any training to EFAW or FAW standard.

Subject officers’ comments regarding policies, procedures and training 1047. Within their interviews the subject officers were questioned on their understanding of aspects of Bedfordshire Police policies, procedures and training which were relevant to the incident. Their responses are set out below.

PC Ross 1048. PC Ross said she would base her decisions on restraint around the National Decision Model. She would make decisions based on what was necessary and reasonable at the time of dealing with an incident. 1049. PC Ross discussed techniques to take an individual to the ground and restrain them. She noted that the ‘ground pin’ was her preferred method to restrain someone on the ground. 1050. PC Ross said they were not really taught multiple police officer techniques; most of their training was one on one. She said she did not recall being trained on multiple police officer takedowns. 1051. PC Ross said she had received training on multiple police officer restraint on the ground, and that the different police officers would have different positions around the person. She stated someone would take control of the head as a monitoring role. 1052. PC Ross said that, once an individual was restrained on the ground, the training and guidance would be to then check them for injuries, search them, and then get them back to their feet at quick as possible. 1053. PC Ross said if someone had a head injury the police responsibility would be to apply first aid, call for assistance from paramedics or take the individual to hospital herself. She said the same applied for a neck or spinal injury. 1054. When asked about recognising a neck injury, PC Ross said she did not think she had received training on it. She stated she thought her first-aid training was inadequate. She said unless the injury was obvious she would not know how to recognise it. 1055. PC Ross stated that they are not trained to identify whether a detainee had broken any bones. She stated “Our first aid training, make of it what you want, but it’s not great.” She also stated that the training did not cover neck injuries. She also referred to the first-aid training as being “abysmal.” She did not appear to be aware of specific situations in which someone must be taken to hospital.

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1056. PC Ross said that she had not been trained to identify spinal injuries, but if she attended a road traffic incident she may be more alert to the possibility of a spinal injury.

PC Oates 1057. PC Oates declined to answer any questions regarding training, policies or procedures, aside from stating that he was not medically trained and had no knowledge of neck injuries.

PC Kalyan 1058. PC Kalyan said that, when conducting a multiple police officer restraint, if possible one police officer would look out for their safety and the safety of the person they were detaining. 1059. PC Kalyan said that when someone was restrained on the floor, their welfare was paramount and their breathing and positional asphyxiation should be taken into consideration. He said that if it was a controlled ‘takedown’ of a person, then watching out for the position of their head and neck would be relevant factors. He elaborated on this and said that considerations would include making sure their head was not being squeezed down and that they were breathing correctly. He said every police officer involved should be aware of that. 1060. PC Kalyan said that if multiple police officers were involved then police officers would take on different roles. He said this would depend on the situation but, if possible, one police officer would apply the handcuffs and another would look out for their safety and the safety of the person being detained. He elaborated on this and said that police officers would normally take on different roles once the person was in a restrained position. It would be at this stage that a police officer would take on the specific role of looking after the person’s welfare and another police officer would have the role of handcuffing the person. He confirmed that this formed part of his training. 1061. PC Kalyan stated that the police responsibilities when dealing with someone with a head injury would depend on the nature of the head injury. He confirmed that an assessment of the person would include issues such as whether the person was conscious, breathing, had slurred speech or was suffering from dizziness. He confirmed that if any of these factors were identified a paramedic would be called. He then qualified this by stating that another option would be to take the person back to custody if they were fit enough and a paramedic could be called to attend custody. 1062. PC Kalyan said he had not received any training on neck or spinal injuries, but, if he was in a situation where he suspected a neck or spinal injury, he would call a paramedic.

PC Spicer 1063. PC Spicer declined to answer any questions regarding training, policies or procedures.

PS Withey 1064. When asked what signs and symptoms would indicate a head injury, PS Withey stated that head injury symptoms were similar symptoms to violence and intoxication, and said it was an incredibly difficult task to clarify which one it was.

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He said if a head injury was suspected then the individual should see a healthcare practitioner or they would go to hospital. 1065. PS Withey stated that there was nothing in Bedfordshire first-aid training about neck injuries and that was the situation up to Custody level. PS Withey confirmed that the first-aid training he had received did not cover neck injuries or spinal injuries and he had raised this with his Deputy Chief Constable.

Inspector Fosbury 1066. Inspector Fosbury said that if a detainee had presented with a loss of normal physical functions he would expect medical assistance to be requested. 1067. Inspector Fosbury said the police received no training on neck or spinal injuries. At the time of interview Inspector Fosbury said he had completed a first-aid refresher three weeks beforehand, and it contained nothing about neck or spinal injuries. 1068. Inspector Fosbury said in the case of a visible head injury he would apply first aid and get the person to hospital. He said he had not received any training on recognising a non-visible head injury. 1069. Inspector Fosbury said the first-aid training was totally inadequate for dealing with an injury of the type that Mr Cole had; either recognising it or having the equipment, knowledge and ability to deal with it. 1070. Inspector Fosbury said there were lessons to learn from the incident and that he was unhappy that police officers were not trained to recognise such injuries. 1071. Inspector Fosbury confirmed that they do not have access to spinal boards or neck braces.

Legislation and guidance relating to post-incident events 1072. The aspects of policies and procedures relevant to post-incident procedures and in force at the time are detailed below.

Police Reform Act 2002 1073. There is an obligation under the Police Reform Act 2002 for a Chief Officer to take all such steps appropriate to obtain and preserve evidence relating to a complaint, conduct matter or death or serious injury as soon as practicable.

IPCC Statutory Guidance 1074. The following is from Section 8 of the IPCC Statutory Guidance to the police service on the handling of complaints, which was in effect at the time of the incident.

Section 8: Referrals 1075. A mandatory referral must be made without delay and in any case not later than the end of the day after the day it first becomes clear that it is a matter which must be referred.

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1076. The process of referral must not delay any initial action by an appropriate authority to secure or preserve evidence especially in relation to incident scene management. 1077. In any case, when referring a matter, an appropriate authority must provide to the IPCC as much relevant information as possible to ensure it makes informed decisions. 1078. The need to provide information should be balanced against the timeliness of making the referral, but the following list gives some examples of information which, where available and relevant, will help the decision maker:  A copy of the complaint.  Use of force forms where there is an allegation of excessive force or an injury.  Medical records relating to any injuries allegedly sustained.  The custody record, where the referral relates to an issue that occurred in custody.  Officer notes relating to the incident.

ACPO Authorised Professional Practice: Detention and Custody 1079. The following is from the ACPO Authorised Professional Practice modules on detention and custody and on operations, which provided guidance on successful interventions, referrals to the IPCC and post-incident management.

Successful interventions 1080. For the purposes of this guidance the terms “successful intervention” and/or “adverse incident2 mean any incident which, if allowed to continue to its ultimate conclusion, would have resulted in the death, serious injury or harm to any person.

Steps that should be taken 1081. Actions to be taken following a successful intervention when it occurs in a place that is not a police station (incident following police contact). 1082. The initial aspects relate to medical and first-aid issues which have been addressed in the main report. 1083. Immediate next steps:  Inform the duty inspector.  Identify all potential scenes and secure as appropriate. 1084. Next steps:  Inform PSD.  Inform the relevant Police Federation representative. They can advise the officers involved and secure legal representation if required.  Arrange debrief. This should be carried out only after the officers involved have provided an account and the needs of the investigation have been met. It may be that such a debrief only takes place at the conclusion of the investigation. These considerations do not, however, preclude speaking to relevant staff on issues of welfare and the next stages of any PSD and IPCC actions.

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Investigation of a death or serious injury in custody 1085. Following a death or serious injury in custody an investigation may be carried out by the IPCC, by the police or by both.

Statutory duty to refer to the IPCC 1086. There is a statutory duty to refer incidents to the IPCC where:  Persons have died or been seriously injured following some form of direct or indirect contact with the police; and  There is reason to believe that the contact may have (directly or indirectly) caused or contributed to the death or serious injury.

Post-incident procedures 1087. Post-incident procedures involve the formal, independent review of police operations by a relevant investigative authority. Post-incident procedures should commence when an operation or critical incident:  Has the potential to cause serious damage to confidence in policing.  Has resulted in death or serious injury.  Has revealed failings in command; and/or  Where police actions may have caused danger to the officers or the public. 1088. A PIM should facilitate the investigation and keep the parties involved up to date with the progress of the inquiry.

Post-Incident Manager 1089. Where the criteria for commencement of post-incident procedures are applicable, a PIM should be appointed to facilitate the investigation and ensure integrity of process. 1090. The PIM also ensures the needs of the principal officer are addressed in a manner which does not compromise the investigative process. 1091. The PIM should be a police manager who has not been involved in the incident, but is trained in post-incident management procedures.

Post-operation debrief 1092. A post-operation debrief should be arranged, where practicable. This will enable all information relating to the incident to be recorded and learnt from. When officers have been involved in an incident or critical operation and are required to provide an account of the event, they should avoid conferring with other officers.

Debriefing procedure 1093. Where practicable, a post-operation debrief to gather and record all the information available is a crucial element in the gathering of information and intelligence, and in the identification of good practice and lessons to be learned. Regrouping of officers also provides the opportunity to provide medical aid if required.

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1094. Only in exceptional circumstances should debriefing take place when the criteria for post-incident procedures have been met, and prior agreement of any investigative authority involved must be obtained.

Staff welfare 1095. Incidents involving [death or serious injury] may well incur public and media interest, and can be highly emotive and stressful for all involved. As a consequence, both the investigative function and the chief officer’s duty of care to officers and police support staff involved must be afforded a high priority. 1096. Duty of Care: The duty of care to officers and police staff extends to welfare, physical, psychological and medical support. In addition, the police staff associations have arrangements for providing advice and support to officers. In facilitating the provision of these services, investigating officers, PIMs and staff association representatives have distinct roles. It is, however, essential that all officers, PIMs and those involved in any debriefing process are able to demonstrate integrity of purpose in all communications between each other and in record making and debrief procedures.

Securing evidence 1097. The responsibility for securing evidence and taking appropriate action in a [death or serious injury] investigation remains with the Police Service until such times as the IPCC has taken over the investigation. 1098. It is the responsibility of the police force being investigated to facilitate that investigation through, for example:  Identification and preservation of the scene and exhibits;  Identification of immediately available witnesses;  Securing of physical evidence;  The availability of experienced family or Victim and Witness Support. 1099. If a [death or serious injury] has occurred outside the police custody suite, for example, at the scene of an incident following arrest, the scene must been secured as soon as is practicable. Officers involved in the incident should return to a police station or other suitable location where post-incident procedures will take place. This will assist in securing the integrity of the scene, defuse any tensions at the scene and enable post-incident issues, including those of evidence and welfare, to be attended to.

Providing accounts: initial accounts 1100. Where an initial account is made by officers they should, subject to any legal advice that they are given, be made as soon as practicable. Accounts should be recorded in writing, timed, dated and signed. 1101. Each officer’s initial account should only consist of their individual recollection of events and should, among other things, state what they believed to be the facts. This account should also provide information on any use of restraint or force (eg, CS or Taser Conductive Energy Device) and why it was necessary. 1102. Officer responsibility: It is the responsibility of each individual police officer involved in the incident to ensure that any information that may be relevant to the investigation is disclosed, recorded and retained. This information should include

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an officer’s own observations relating to the incident and any accounts received from witnesses (eg, custody staff, other officers, escort staff, court staff, members of the public and other detainees).

Providing accounts: detailed accounts 1103. Detailed accounts should not normally be made immediately, but can be left until the officers involved are better able to articulate their experience in a coherent format, normally after at least 48 hours. 1104. As a matter of general practice, officers should not confer with others before making their accounts (whether initial or subsequent accounts). The important issue is to individually record what their honestly held belief of the situation was at the [death or serious injury]. If, however, in a particular case a need to confer on other issues does arise, then, in order to ensure transparency and maintain public confidence, where some discussion has taken place, officers must document the fact that this has taken place, highlighting:  the time, date and place where conferring took place  the issues discussed  with whom  the reasons for such discussion 1105. There is a positive obligation on officers involved to ensure that all activity relating to the recording of accounts is transparent and capable of withstanding scrutiny. 1106. Where an officer has any concerns that the integrity of the process is not being maintained, they must immediately draw this to the attention of the person in charge of the post-incident process and ensure that this is documented.

Authorised Professional Practice on Armed Policing 1107. The following is from Chapter 7 of the Authorised Professional Practice on Armed Policing, which concerns post-incident management.

Principal officers 1108. During a post-incident investigation, the independent investigative authority will, at an early stage, wish to identify the principal officers directly related to the decision to use force. 1109. In the initial stages all actions taken by, and in respect of, principal officers in relation to securing evidence, discussion undertaken and notes made must be documented. 1110. Prior to officers providing accounts of what happened, the following issues should be addressed:  Welfare, including medical and legal advice considerations.

The role of the PIM 1111. PIMs facilitate, manage and ensure the integrity of the postincident procedure. Chief officers must ensure that arrangements exist whereby appropriately selected, trained, assessed and accredited PIMs are available to manage post- incident procedures.

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Nomination of a PIM following an incident 1112. A PIM will usually be nominated by the force to which the principal officer(s) belong.

Bedfordshire Police post-incident investigation policy 1113. Bedfordshire Police confirmed that they did not have their own policy on post- incident investigation and relied on the ACPO guidance.

Conclusions 1114. In respect of each subject officer the investigator is limited to reaching a finding on whether in his opinion any of the subjects of the investigation have a case to answer for misconduct or gross misconduct, or no case to answer. However to reach those opinions, it is necessary for the investigator to evaluate the evidence to determine the facts of what may have occurred. Where it is necessary to make conclusions or findings about the facts, then the investigator has done so by applying a standard of proof which is the ‘balance of probabilities’ i.e. whether something is more likely to be true than not. 1115. A finding that there is a ‘case to answer’ means that the investigator is of the opinion there is sufficient evidence that a reasonable misconduct hearing or meeting could find, on the balance of probabilities, gross misconduct or misconduct. It is not for the investigator to determine that a subject has acted in a manner which constitutes gross misconduct or misconduct, as this would be properly determined within any misconduct hearing or meeting. 1116. Furthermore it is not for the investigator to make a determination in respect of any criminality, as this is ultimately a matter for a court, having heard all the evidence, including potentially cross-examination of witnesses. It is for the investigator to present the report to the Commissioner, who would then make a decision whether to make a referral to the Crown Prosecution Service. The Crown Prosecution Service would then consider whether any criminal charges should be pursued. 1117. For ease of understanding the conclusions have been set out in order of the chronology of the incident, highlighting what are, in the investigator’s opinion, significant findings in respect of the events which occurred, reached on the balance of probabilities. 1118. These subsidiary findings are then followed by the conclusions regarding whether a case to answer exists for each police subject. 1119. The investigator has also included his findings in respect of the actions of the two door staff who were subject to criminal investigation by the IPCC. 1120. The Commissioner may make a referral to the Crown Prosecution Service if they consider that the door staff may have committed a criminal offence and that it is appropriate to do so. However, the IPCC has no role in relation to the licensing or conduct of door staff. It will be for the Commissioner to determine whether the report should be shared in whole or in part with the licensing authorities.

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Chronology of events

The events prior to Mr Cole’s ejection from the nightclub 1121. It is relevant to note that there is evidence Mr Cole had been drinking prior to his ejection from the club, which may have affected his judgement and behaviour over the course of events. Based on the toxicology report, Mr Cole’s blood alcohol concentration, calculated to 1.30am, was estimated at a most likely level of 125 mg/dL. The drink/drive limit is 80 mg/dL. The report stated this level could be expected to cause mild to moderate intoxication in a normal social drinker, but was lower than would be associated with drunkenness. 1122. It is also relevant to note that the toxicology report concluded Mr Cole was not under the influence of any common drugs of abuse or other medication. 1123. Finding 1: The evidence supports that Mr Cole was not forcibly removed from the stage within the nightclub. 1124. The earliest indication of any use of force on Mr Cole was his ejection from the nightclub. The CCTV evidence and witness evidence demonstrated that Mr Cole held onto a barrier at the edge of the stage during a performance, which then engaged the attention of Mr AA, who instructed him to get down. There was no conflict in either the CCTV or witness evidence that this occurred, and whether Mr Cole became abusive, deliberately ignored Mr AA or did not notice him, it is clear that Mr AA felt it necessary to engage further with Mr Cole. 1125. Witness 11 and Witness 31 stated that the member of door staff, indicated to be Mr AA, then ran to Mr Cole, and Witness 31 said Mr Cole was pulled from the stage. However Mr AA’s account conflicted with this and the CCTV evidence demonstrated that Mr Cole left the stage before Mr AA reached him. This, together with the evidence from Witness 30, Witness 17 and Witness 19, supports that Mr Cole stepped down from the stage of his own accord.

Mr Cole’s ejection from the nightclub 1126. Finding 2: The evidence suggests that that the nightclub’s door staff used no more than minimal force to eject Mr Cole from the nightclub. 1127. There was evidence from all parties that Mr Cole and Mr AA then entered into a disagreement which led Mr AA to decide to eject him from the club. Mr AA would have a common-law entitlement on behalf of the owner to ask Mr Cole to leave and to use reasonable force to require him to do so. The accounts from door staff, Mr Cole’s friends and the majority of bystanders indicated Mr AA removed Mr Cole with minimal force and Mr Cole allowed himself to be ejected. 1128. Although the CCTV inside the club was relatively poor quality time-lapse footage, it showed a male believed to be Mr Cole being taken through the corridor by a doorman believed to be Mr AA. Mr Cole was then clearly seen on CCTV outside the nightclub before the subsequent CCTV footage showed what appeared to be several door staff in a struggle with several other males, one of whom could be traced through CCTV footage to clearly identify him as Witness 24. The evidence from door staff, Mr Cole’s friends, bystanders and CCTV footage is sufficient to conclude that, although there was some resistance to being ejected, resulting in a ‘code red’, the parties involved were Witness 11, Witness 31 and Witness 24.

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1129. One witness, Witness 22, said that a male potentially matching Mr Cole’s description was carried out of the club by his arms and possibly his legs, and was moving as if trying to punch the door staff. This was not supported by any other evidence and was contradicted by the CCTV evidence. It is therefore considered likely that Witness 22 was mistaken in this regard.

The initial events after Mr Cole’s ejection from the nightclub 1130. Finding 3: The evidence supports that the nightclub’s door staff used no more than minimal force to prevent Mr Cole from re-entering the nightclub in the initial period after his ejection. 1131. Finding 4: There is evidence that force was applied to Mr Cole by Witness 24, Witness 11 and Witness 31 to attempt to restrain him in the initial period after his ejection. 1132. The CCTV and witness evidence of Mr Cole’s initial behaviour outside the nightclub indicated he was calm and, although by all accounts he complained about his ejection and requested his money back, he did so without being aggressive or indicating violence. 1133. From the point where Witness 24, Witness 11 and Witness 31 were ejected, there was a period of approximately five minutes between 1.28am and 1.33am where the evidence from the CCTV, door staff, Mr Cole’s friends and independent witnesses demonstrated that Mr Cole grew increasingly angry and confrontational with the door staff and continued to request a refund of his entrance fee. The CCTV and witness evidence also demonstrated Witness 24, Witness 11 and Witness 31 took action individually or collectively to physically intervene, which included pulling Mr Cole away from the entrance and at times holding him against the metal barriers on the forecourt. There was also evidence from the CCTV and Witness 19 of a brief physical intervention by a white male bystander who has not been identified by enquiries, but the CCTV and Witness 19’s statement sufficiently indicated there was minimal contact from this male. 1134. The CCTV footage and a statement from independent witness Witness 25 indicated that the door staff used minimal or no force on Mr Cole during this period. Witness 13 stated that door staff pushed a black male in a black shirt, and Witness 38 stated that two door staff picked up a black male in a black t-shirt and walked him away from the nightclub. It is noted that the one-second time lapse recording from the CCTV would not necessarily capture all movements, however the actions described by Witness 38 are considered likely to have taken more than a second and there are no frames captured which suggest this type of motion. 1135. The descriptions from Witness 13 and Witness 38 suggest they were not referring to Mr Cole at this time, but it should also be noted that no other witnesses suggested the door staff used force against anyone at this time and, significantly, Witness 24, Witness 11 and Witness 31 did not describe any use of force by the door staff. For these reasons it is considered that there is insufficient evidence for a tribunal to conclude there was any significant use of force by the door staff at this time and, under common law, the door staff would be entitled to use reasonable force to prevent Mr Cole re-entering the premises.

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1136. Finding 5: The evidence supports that there was some form of provocation of Mr Cole from Mr AA, and some form of threat or aggression from Mr Cole. 1137. Mr BB, Mr AA, Witness 1 and Witness 12 all stated that during the initial period when Mr Cole was joined by Witness 24, Witness 11 and Witness 31 outside the nightclub, there was some form of threat of violence from Mr Cole. These were described as ranging from general statements of “someone is going to get hurt” (described by Mr BB and Witness 1) or more direct threats against Mr AA (described by Mr AA and Witness 12). The evidence from Mr BB, Witness 12, Witness 25, and Witness 27 all indicated Mr Cole also became physically aggressive at this time and attempted to fight with his friends or door staff, punched the metal detector, or kicked at barriers. 1138. Witness 25 and Witness 11 both stated Mr AA encouraged Mr Cole to fight him during this period, by gesturing or adopting a fight stance. While this could not be isolated on the time-lapse CCTV and was not mentioned otherwise, the similarity of this description from an independent witness and Witness 11 support that Mr AA did act in a manner to provoke Mr Cole during this period. 1139. Finding 6: The evidence supports that police assistance and CCTV monitoring was requested by the nightclub’s door staff due to the actions of Mr Cole and his friends. 1140. There was clear evidence that Mr Cole was not the only person to become verbally or physically aggressive; the evidence sufficiently demonstrated there was a general escalation of anger and aggression from Mr Cole and some of his friends during this time. Although the ‘Bedsafe’ radio system was not recorded, Mr BB and Mr AA stated that they requested police assistance over the ‘Bedsafe’ system at this time due to the actions of Mr Cole and his friends, which was corroborated by the Bedfordshire Police Incident Log of an anti-social behaviour incident reported by a third party. Although this log was at 01:34:07, the Local Authority CCTV camera was repositioned to cover the nightclub at 01:33:38, which indicates that their first call for police assistance was placed slightly earlier. 1141. Finding 7: The evidence supports that Mr Cole approached door staff at the entrance of the nightclub with an empty glass bottle held in a manner which was perceived as a threat. 1142. The next significant event was when Mr Cole walked away from the nightclub and collected a glass bottle. The accounts from independent witness Witness 14 and from door staff Mr BB, Mr AA, Witness 35 and Witness 12 are supported by clear Local Authority CCTV footage of Mr Cole returning to the entrance of the nightclub with a clear glass bottle held by the neck in his right hand. The time- lapse footage from the nightclub accords with the witnesses’ descriptions that Mr Cole went straight to the front entrance before Witness 35 saw the bottle and stood between Mr Cole and Mr AA, and that Witness 24 then intervened before Mr Cole was again seen on the Local Authority CCTV footage, still holding the bottle. 1143. Witness 35 and Mr AA both stated Mr Cole said he was not going to use the bottle, however they both identified his actions as threatening, as did Witness 14. 1144. Finding 8: The evidence supports that Mr Cole was moved away from the entrance and the bottle was taken from him by his friends, without physical contact from the door staff.

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1145. The Local Authority CCTV footage then captured Mr Cole, Witness 24, Witness 11 and Witness 31 being ushered away by door staff, which corroborated the accounts from Witness 35, Witness 12, Witness 14, Mr BB and Mr AA that the bottle was smashed in the road as the police arrived at 01:34:25. The CCTV evidence and witness accounts do not suggest that any force was used by the door staff at this time.

The initial police attendance at the nightclub 1146. Finding 9: The evidence supports that police officers PC Ross, PC Oates and PC Spicer first attended the incident at approximately 1.34am. 1147. Mr Cole then remained in view of the Local Authority CCTV camera until approximately 1.36am. During this time the CCTV footage showed that PC Oates, PC Ross and PC Spicer arrived at the scene. Their initial accounts in their police notebooks all stated a first impression that Mr Cole was aggressive. 1148. It should be noted that Witness 31 described a female police officer being outside the club at an earlier stage. However, he described her as similar in appearance to the female door staff. There is sufficient evidence to demonstrate that PC Ross was not at the nightclub at this stage and that no other police officers were in attendance, so it is considered more likely that Witness 31 has mistakenly identified door staff Witness 35 as a police officer. 1149. Finding 10: The evidence supports that Mr Cole was non-compliant and combative on first contact with police officers. 1150. The Local Authority CCTV footage showed that after the police officers got out of the vehicle, PC Spicer made contact with Mr Cole before Mr Cole pushed him off, and there was a brief moment where they were in contact with each other around the arms before Mr Cole’s friends intervened. This ‘push’ on a police officer was also described in witness accounts by independent witnesses Witness 14 and Witness 34, bar staff Witness 23 and door staff Witness 10, Witness 12 and Mr BB. 1151. Although this physical interaction is brief, it is notable, as it demonstrated Mr Cole’s behaviour was not moderated by the involvement of police officers; he was prepared at that stage to be non-compliant and combative with the police officers. 1152. Finding 11: The evidence supports that PC Spicer’s initial contact with Mr Cole was momentary and minimal. 1153. PC Spicer does not make any mention of his physical contact with Mr Cole at this stage and in his interview he said he initially thought Mr Cole was in a fight, then realised the group were trying to grab hold of Mr Cole, who was avoiding them. He said he approached to within a yard but the only people in contact with Mr Cole were his friends. In his second interview he still did not discuss this contact, but did refer to this specific moment by stating that when he first saw Mr Cole and the anger in his face, he was scared and he stood back. He said that he “bottled out” and had since thought if he had arrested Mr Cole then the subsequent events would not have happened. He noted that he did not think that Mr Cole would have passed the threshold test for custody or breach of the peace as his friends were trying to take him away. 1154. Although PC Spicer stated a breach of the peace had not occurred, police officers are entitled to use reasonable force in an intervention to prevent a breach of the peace before it occurs. All witnesses described his contact as a brief attempt to

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take hold of Mr Cole, and the CCTV corroborated that this use of force by PC Spicer was momentary and minimal. 1155. The officers were not compelled to arrest Mr Cole, as it would be at their discretion based on the options available to most appropriately deal with the situation. PC Spicer’s discussion of whether the custody threshold test was met or a breach of the peace made out are noted as considerations for whether an arrest would be appropriate, however his ultimate explanation for his decision not to take action at that point was that he became scared and stood back. 1156. Finding 12: The evidence shows PC Spicer had no further interaction with Mr Cole until Mr Cole ran towards Mr AA at 1.47am. 1157. The evidence of PC Spicer’s involvement in the subsequent events demonstrated that he had then had minimal contact with Mr Cole until Mr Cole ran towards Mr AA at 1.47am. 1158. Finding 13: The evidence supports that the initial response from PC Ross and PC Oates was to instruct Mr Cole’s friends to remove Mr Cole from the area. 1159. The evidence demonstrated that Witness 24 and Witness 11 intervened in the contact between Mr Cole and PC Spicer, then took Mr Cole away, heading east on Mill Street, before Witness 31 caught up with them. 1160. PC Ross and PC Oates both provided evidence that they noted the potential for a breach of the peace based on their first appraisal of the situation, and confirmed that they initially asked Mr Cole’s friends to remove him, which was supported by evidence from Witness 24 and Witness 11.

Mr Cole’s temporary removal from the nightclub 1161. Finding 14: The evidence supports that Mr Cole was forcibly taken away from the nightclub by Witness 24, Witness 11 and Witness 31, and it cannot be excluded that some of their use of force was around Mr Cole’s neck area. 1162. The Local Authority CCTV footage confirmed that PC Kalyan and Inspector Fosbury were crewed together in a response vehicle, and their arrival at the scene coincided with Mr Cole being taken away from the nightclub by Witness 24, Witness 11, and Witness 31. 1163. In the police notebook accounts provided by the five police officers who were present at this stage, none of them recorded any suggestion that Mr Cole's friends had used any force around his neck, however in their first account interviews, Inspector Fosbury, PC Kalyan, PC Spicer and PC Oates all said words to the effect that Mr Cole's friends had him in a necklock or headlock when they were trying to remove him from the scene. 1164. It is noted that despite the consistent account that force was used by Mr Cole’s friends around Mr Cole’s neck, the fine detail of how that force was applied is inconsistent across all police officers. It is also noted that this evidence was provided after the officers were aware of the full extent of Mr Cole’s injuries. 1165. The CCTV evidence showed that Mr Cole’s friends had to move him away by force. The detail of the force cannot be observed on the CCTV footage, but some actions may be interpreted as involving force around Mr Cole’s neck. Considering the CCTV evidence of the methods employed by Mr Cole’s friends when they attempted to restrain him on the forecourt of the nightclub at an earlier stage, it is

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plausible that Mr Cole’s friends may have taken hold of Mr Cole around the neck area. 1166. Finding 15: A tribunal could find that PC Oates took proactive, appropriate action in response to complaints against the nightclub’s door staff from Mr Cole’s friends, and notified a senior officer of his concerns. 1167. PC Ross, PC Oates and PC Spicer all provided evidence that they spoke to one of Mr Cole’s friends, confirmed to be Witness 11 by the CCTV and the account from Witness 11. These police officers all referenced that Mr Cole’s friend complained about the actions of the door staff of the nightclub. 1168. The CCTV evidence showed that this happened as Mr Cole, Witness 24 and Witness 31 moved away down a side road and it is apparent from the police officers’ accounts that they were of the impression that Mr Cole may have left the area. 1169. The evidence demonstrated that PC Oates then spoke to Mr AA regarding the complaints from Mr Cole’s friends and informed Mr AA that he was going to be in touch with the licensing officer. PC Oates then spoke to Inspector Fosbury about the same topic. 1170. There is sufficient evidence that PC Oates took an interest in the cause of Mr Cole’s behaviour, gathered information regarding their ejection from the nightclub, and then took action to take this up with Mr AA as the head doorman. In the investigator’s opinion a tribunal could find this to be a proactive and balanced approach to dealing with what PC Oates perceived to be a recurring cause of disorder. The evidence indicates that PC Oates took the complaints about the treatment of Mr Cole and his friends seriously and did not prejudge the validity of the complaints based on their behaviour. PC Oates also described his intention to take it up with the licensing officer, which was supported by the account from Mr AA. 1171. PC Oates stated he informed Inspector Fosbury of the situation, which was corroborated by Inspector Fosbury. A tribunal may also find this to be an appropriate course of action and demonstration that PC Oates had genuine concerns regarding the actions of door staff at the local venues and so he took action to remedy the situation. 1172. Finding 16: A tribunal could find that PC Kalyan took appropriate action to request CCTV monitoring of Mr Cole and his friends. 1173. PC Kalyan made a radio request for the Local Authority CCTV operators to monitor Mr Cole and his friends. In the investigator’s opinion a tribunal could find that this action by PC Kalyan was a well-considered precaution to take based on his description of the incident as he perceived it. 1174. Finding 17: The evidence shows that PC Kalyan and Inspector Fosbury did not have any direct involvement with Mr Cole on their initial attendance. 1175. The Local Authority CCTV footage confirms that Inspector Fosbury and PC Kalyan did not have any contact with Mr Cole or his friends before they left the immediate area. The evidence shows Inspector Fosbury and PC Kalyan then returned to their vehicle and left the scene.

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Mr Cole’s return to the nightclub 1176. Finding 18: The evidence shows that Mr Cole, Witness 24, Witness 11 and Witness 31 returned to the nightclub at approximately 1.41am, with the intention to speak to Witness 18 to obtain a refund. 1177. The CCTV evidence and all accounts then demonstrated that Mr Cole was absent from the immediate vicinity of the nightclub for a period of time. Witness 24, Witness 11 and Witness 31 all gave evidence that they were a short distance away, that Mr Cole had calmed down and they collectively decided to try to speak to Witness 18 in respect of obtaining a refund. 1178. They were seen on the CCTV footage from the XXXXXXXXXX pub at 01:41:02 returning in the direction of the nightclub. The subsequent CCTV footage from the nightclub’s forecourt and the taxi office demonstrated that Witness 31 and Witness 24 spoke to Mr BB, which was consistent with their accounts that they asked to speak to Witness 18. During this time Mr Cole was seen on the phone outside the taxi office and there was no sign of aggression evident from the footage. 1179. Finding 19: At approximately 1.45am Mr Cole, Witness 24 and Witness 31 spoke to Witness 18, but she did not agree to refund their entrance fees. 1180. The CCTV and witness evidence then demonstrated that Witness 18 spoke with Mr Cole, Witness 24 and Witness 31. In Witness 18’s account of this interaction she described Mr Cole as still angry, and she was not prepared to speak to him. This was supported by Witness 24. 1181. Finding 20: The evidence supports that PC Oates and PC Ross approached Mr Cole shortly after his return to the front of the nightclub, but Mr Cole would not engage with them. PC Oates attempted to take hold of Mr Cole but Mr Cole evaded detention. There is no evidence of excessive force being used. 1182. The CCTV footage then showed PC Ross and PC Oates moved towards Mr Cole. From the footage it appeared that they then moved Mr Cole, Witness 24 and Witness 31 away from the forecourt towards the smoking area, and did not appear to go after them. 1183. PC Ross and PC Oates have provided evidence that they saw Mr Cole had returned to the nightclub and he became angry and aggressive. PC Oates stated that they decided there was going to be a breach of the peace. They stated they approached Mr Cole and attempted to detain him and speak to him, but they were unable to do so. PC Oates stated that he attempted to grab Mr Cole’s arm, but Mr Cole was able to dodge him, which was supported by evidence from Witness 37. PC Oates also stated that Mr Cole would not listen to him, which was supported by the evidence from Witness 35. The witness evidence from Witness 37 and Witness 35 suggested that the physical contact from PC Oates and PC Ross was minimal at this stage. 1184. Finding 21: The evidence supports that at approximately 1.46am Mr Cole gave his belongings to Witness 32 and Witness 20, which included his mobile phones and identification. 1185. After PC Ross and PC Oates approached Mr Cole, he was then out of view of all CCTV for a period. The subsequent events are therefore evidenced only by the police officers, door staff and other witnesses, and there are conflicts over the

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exact sequence, however, the significant events within this sequence can be established. 1186. Mr Cole was evidenced to have gone over to the edge of the smoking area where he met Witness 32, to whom he passed his phones. The CCTV demonstrated Witness 28, Witness 40 and Witness 20 left the nightclub at approximately 1.46am and their accounts confirmed Mr Cole gave his phones to Witness 32. It was also witnessed by doorman Witness 12, and independent witnesses Witness 37 and Witness 2. Witness 20 stated he then received a necklace and ID card from Mr Cole, who said “I wanna fuck them up”. The transfer of belongings was supported by Witness 11’s account that Witness 20 later gave him Mr Cole’s two phones, bank card, gym membership and driving licence. 1187. Although Mr Cole’s statement to Witness 20 was not corroborated, it is plausible given the evidence of Mr Cole’s behaviour up to that point, and his subsequent run towards Mr AA. The evidence therefore supports that Mr Cole had decided upon his subsequent course of action, and shedding his belongings was a preparatory step. 1188. Finding 22: The evidence supports that PC Ross decided to arrest Mr Cole for a Section 5 Public Order Act 1986 offence; there is also evidence which supports that she had a reasonable belief that the offence had been committed and that it was necessary to arrest. 1189. PC Ross and PC Oates both gave evidence that after Mr Cole returned to the forecourt of the nightclub, PC Ross decided he needed to be arrested for an offence contrary to Section 5 of the Public Order Act 1986. There is evidence that his behaviour was disorderly and may have caused harassment, alarm and distress in a volatile situation. The evidence of Mr Cole’s actions up to this point provides support for PC Ross to have reasonable suspicion of the offence and for it to be necessary to arrest. 1190. PC Ross confirmed she could have issued a Section 27 notice for Mr Cole to leave the area, but did not recall whether she considered its application at the time. PC Ross stated that she did not think Mr Cole would have responded to a Section 27 notice, and it is accepted that the evidence sufficiently indicated Mr Cole was not worried about being arrested, therefore PC Ross’s suggestion that he would not have complied with a Section 27 notice to leave is considered a reasonable belief, although there is no evidence she considered this at the time. 1191. Finding 23: The evidence supports that PC Oates and PC Ross attempted to arrest Mr Cole between 1.46am and 1.47am. 1192. The various accounts then described an attempt by police officers to arrest Mr Cole near the hairdressers on the east side of the nightclub’s forecourt. PC Oates and PC Ross described their attempt to arrest Mr Cole at this location immediately before Mr Cole ran towards the front of the nightclub, which is supported by the witness evidence. 1193. Their accounts also correspond with the timing and position of Mr Cole as indicated by the presence of Witness 28, Witness 20 and Witness 40 at the edge of the smoking area at 01:46:51 and the position of Mr Cole at 01:47:27, as evidenced by the CCTV footage.

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1194. Finding 24: The evidence supports that the force used by PC Ross and PC Oates to try to effect Mr Cole’s arrest amounted to attempts to take hold of his arms. There is no evidence of excessive force being used. 1195. PC Ross would be entitled to use reasonable force to effect Mr Cole’s arrest and PC Oates would have been able to use reasonable force to assist in the arrest. The evidence from PC Ross and PC Oates and witnesses indicates that the force used was no more than an attempt to take hold of Mr Cole around his arms; there is no evidence of excessive force being used at this time and this use of force could not have caused the injury to Mr Cole’s neck. 1196. Finding 25: The evidence supports that PC Ross and PC Oates were prevented from arresting Mr Cole at this time due to his resistance and the intervention of his friends. 1197. PC Ross and PC Oates gave evidence that they were prevented from arresting Mr Cole due to Mr Cole’s movements and the intervention of his friends, which was also supported by evidence from Witness 2, Witness 35, Witness 36, Mr AA, Mr BB and Witness 39. Witness 3 stated two or three door staff were in contact with Mr Cole at this location, however, her description suggests that she has mistakenly identified PC Ross and PC Oates as door staff. Witness 3 also stated Mr Cole’s friends attempted to intervene. 1198. The evidence therefore supports the accounts of PC Ross and PC Oates. Given the conditions it is accepted that their failure to make the arrest was not due to any fault on their part. 1199. Finding 26: There is no evidence of any grounds on which to criticise PC Oates’s request for assistance. 1200. PC Oates stated that, after being unable to complete the arrest, he called for assistance, which was supported by PC Ross and evidenced by the radio transmissions. 1201. PC Oates explained he decided to call for assistance because he felt that he, PC Ross and PC Spicer were outnumbered and that the actions of Mr Cole’s friends were starting to escalate. 1202. There is no evidence of any grounds to find that the tactical option to request support to overcome the barriers to Mr Cole’s arrest was unreasonable or could otherwise be criticised.

Consideration of Mr Cole’s injuries being caused before 1.47am 1203. Finding 27: The evidence supports that Mr Cole had not sustained the spinal fracture or spinal cord injuries by the time he ran towards the nightclub at approximately 1.47am. 1204. As explained in Mr AK’s report, there were two aspects to the spinal injuries sustained by Mr Cole which subsequently led to the lack of oxygen to his brain: The fracture of the C2 vertebra, and the high spinal cord injury. 1205. Mr AK stated that the spinal fracture sustained by Mr Cole on its own would not prevent Mr Cole from moving his arms and legs or possibly even walking, but it was a highly unstable fracture and would be extremely painful. 1206. Professor AL’s description of Mr Cole’s injuries agreed with Mr AK’s, including that he sustained a spinal fracture and “subsequently” a spinal cord injury, and it

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could not be medically determined whether they occurred at the same time or separately. 1207. Professor AL also provided a similar opinion that a spinal fracture as sustained by Mr Cole may occur with no immediate neurological effects, and that it would be perfectly possible to suffer a spinal fracture of this type and to be walking around with normal physical effort, but it was a “completely unstable injury” and he noted the neck muscles would immediately try to stabilise the situation which was associated with pain. 1208. He added in his clarification report that “this injury is highly unstable and although the neck muscles will try to stabilise the situation ‘the patient’ will be at very high risk on moving the head of sustaining spinal cord injury within the unstable fractured spinal column.” 1209. However, in commenting on the CCTV footage which showed Mr Cole run towards the nightclub at 01:47:33, Mr AK provided expert opinion that Mr Cole was moving extremely freely and did not seem to be showing any evidence of pain in the neck; he ran with no evidence of neck injury. Mr AK stated that, even if Mr Cole had been intoxicated on alcohol or drugs, he would not anticipate him moving that freely with such a severe neck injury. 1210. Conversely, Professor AL provided expert opinion that Mr Cole could have performed the movements seen on the CCTV footage at 01:47:33 having already suffered the spinal fracture, and qualified this by stating that the degree of neck movement required to cause the spinal cord to be damaged progressively either quickly or slowly after the spinal column facture was very difficult to measure or be certain about. 1211. Professor AL also provided comment that the effects of alcohol and other drugs could have caused a ‘depressant’ reaction which may have made Mr Cole’s reaction to injury slower. He noted this with a caveat emphasising he was not an expert on toxicology. 1212. In respect of spinal cord injury, Mr AK stated this would cause a “rapid loss of power below the level of the injury” and stated it was implausible for Mr Cole to have recovered from this to a degree where he could move purposefully. 1213. Professor AL also described a loss of function after damage to the spinal cord, with the degree of paralysis dependent on the degree of spinal cord injury, including complete paralysis below the level of the C2/3 vertebrae if it was a complete spinal cord injury (although in Mr Cole’s case he has emphasised that it was not a complete spinal cord injury). 1214. Significantly, Professor AL provided expert medical opinion, based on Mr Cole’s movements as seen on the CCTV footage at 01:47:33, that Mr Cole could not have sustained the spinal cord injury. He added “it is highly unlikely if [Mr Cole] had injured his spinal cord that he would have been physically capable of moving or even standing.” 1215. It is clear from the CCTV evidence, police officers’ accounts and witnesses’ accounts that the loss of function resulting from spinal cord injury had not occurred by the time Mr Cole ran towards the nightclub at 01:47:33, and therefore the evidence supports that Mr Cole had not sustained injury to his spinal cord at this time.

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1216. In consideration of the expert medical opinions, the disparity is whether Mr Cole had already sustained the spinal fracture when he ran towards the nightclub at 01:47:33. 1217. Mr AK provided expert opinion positively stating that Mr Cole showed no evidence of the extreme pain associated with a spinal fracture, and he would not expect him to move so freely with such a severe neck injury. Professor AL provided expert opinion that is possible Mr Cole may have had a spinal fracture at this time, but he emphasised this opinion was provided due to the uncertainties involved in the immediacy or totality of the effects of the fracture, rather than any positive identification either way. 1218. On balance, while the possibility cannot be excluded, the weight of the medical opinion supports that Mr Cole did not have a highly unstable and painful spinal fracture (which had not been displaced and therefore had not caused spinal cord damage or neurological deficit) at the time he ran towards the nightclub at 01:47:33. 1219. It should also be noted that there is no witness evidence that Mr Cole exhibited any indication of being in pain or physical discomfort at any point before 01:47:33. 1220. The evidence therefore supports that Mr Cole’s injuries were not sustained through contact with the door staff during his ejection from the nightclub or through the contact with any individuals before his run towards Mr AA at 01:47:33, including any headlock applied by Witness 24, Witness 11 or Witness 31 as described by the subject police officers, or through any force applied by police officers in attempting his arrest before this time.

The restraint and arrest of Mr Cole 1221. It should be noted at this point that broadly across their accounts, the witnesses were unable to describe individual police officers in much greater detail than stating that they were in dark police uniform with some high-visibility coats or vests. This was with the exceptions of PC Kalyan, who was more identifiable as the only Asian police officer present, and PC Ross, who was more identifiable as the only female police officer present. 1222. In interview PC Ross suggested her appearance was such that her gender was not easily discernible, however, as multiple witnesses have described the actions of a female police officer, and she was the only female police officer present, it is considered more likely than not that they are correctly referring to her as the female police officer rather than any of the male police officers. 1223. Similarly, witnesses were unable to describe some of the door staff in much greater detail than stating that they were in dark clothing with high-visibility vests, even despite the difference in ethnicity between Mr BB (who is white) and Mr AA (who is black), who were the only door staff involved at the material time. 1224. Gender, ethnicity, height and build have assisted in identifying specific individuals. However the similarity in the clothing worn by police officers and door staff, combined with the difficulties for a witness that can be presented by the duration of their observations, their distance from the scene, visibility at the time, obstructions to their view and length of time between the event and provision of their account, clearly provide scope for police officers to have been mistakenly identified as door staff, and vice versa.

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The initial physical contact with Mr Cole 1225. Finding 28: The evidence supports that Mr Cole ran towards Mr AA at approximately 1.47am with the apparent intention to assault him. 1226. The Local Authority CCTV footage clearly showed Mr Cole ran down Mill Street and towards the entrance of the nightclub, immediately followed by Mr BB, PC Spicer, PC Ross, PC Oates and then PS Withey. 1227. Mr Cole’s run towards the nightclub was described by multiple witnesses. Witness 11 described it as a walk towards door staff; Witness 24 stated Mr Cole ran in an attempt to get back inside; and Witness 31 stated Mr Cole ran towards the entrance. None of these witnesses indicated Mr Cole had any violent intent, however Witness 11’s description is contradicted by CCTV; Witness 24 went on to state he did not see where Mr Cole went; and Witness 31’s description provided no indication of Mr Cole’s intent either way. 1228. The other witnesses stated Mr Cole ran at door staff. Setting aside the evidence from door staff or nightclub staff, it is significant that Mr Cole’s friend Witness 28 described Mr Cole as having his fists clenched and Witness 20 stated Mr Cole went to punch a doorman indicated to be Mr AA. Although the time lapse footage from the nightclub does not assist in establishing if Mr Cole attempted to punch Mr AA, the evidence, in particular that of Witness 20 who can be considered to have no motive to introduce a punch if it did not occur, supports that Mr Cole ran towards Mr AA with the apparent intention to assault him. 1229. Finding 29: The evidence supports that Mr AA made brief contact with Mr Cole around his chest or bicep area, which amounted to a ‘push’ or part of a technique to deflect Mr Cole’s forward momentum and move him away. Mr AA was entitled to use reasonable force to defend himself and there is insufficient evidence to find that the force used was excessive. Mr Cole did not go to ground as a result of this contact and Mr AA did not have any further contact with Mr Cole. 1230. Across his accounts Mr AA consistently stated he saw Mr Cole running towards him and from his appearance and actions Mr AA anticipated Mr Cole intended to attack him. There is no evidence that this was not a genuine belief and under common law Mr AA would have been entitled to use reasonable force to defend himself from an assault. 1231. In his earliest account provided in his first incident report, Mr AA wrote that he “body-rolled” Mr Cole to the ground, but he later contradicted this in a second incident report and in his interviews with the police and the IPCC. 1232. After his first incident report, Mr AA consistently described his contact as around Mr Cole’s chest or bicep area as a “push” or part of a technique to deflect Mr Cole’s forward momentum, and Mr Cole remained on his feet. He said he did not grab Mr Cole, go to ground with him or make any contact with his head or neck. 1233. There was evidence from PC Oates, PC Ross and PC Spicer that “a doorman” threw or tackled Mr Cole to the ground and landed on top of him, however, for reasons explained below it is believed the doorman they referred to at this time was Mr BB. 1234. Witness 31 stated that Mr AA (identified by reference to the head doorman), wrapped his arms around Mr Cole, flipped him to the ground and landed on top of

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Mr Cole. Witness 39 said Mr Cole made contact with a doorman who was not Mr BB, who had Mr Cole in a “bear hug” for a few seconds. 1235. There was witness evidence which suggested that police officers intercepted Mr Cole before he reached any door staff, however, the CCTV evidence and the accounts of Mr AA and Mr BB, who both stated they made contact before any police officers, are considered to have greater weight. 1236. There is evidence from the other door staff and Witness 36 which supported Mr AA’s interview accounts that he did not take Mr Cole to the ground, but the main evidence which negated the suggestion that Mr AA took Mr Cole to the ground was the CCTV footage from the nightclub’s forecourt. 1237. This time-lapse footage is problematic because any action which could be performed in less than a second may not be captured, or it can provide a misleading sense of motion between frames. However, the accounts from the police officers and from Witness 31 which indicated Mr AA took Mr Cole to the ground all stated that the doorman who went to ground with Mr Cole also struggled with him on the floor for a period of time. The single frame of Mr Cole and Mr AA showed that they were in contact for a maximum of two seconds, and even with the time lapse footage it is considered implausible that the actions described by these witnesses could have happened between frames with no suggestion of it on the footage. Similarly Witness 39’s account, which indicated Mr AA had Mr Cole in a “bear hug” for a number of seconds is not borne out on the CCTV, which is considered more reliable despite the time-lapse issues. 1238. There is clear suspicion created by Mr AA’s change in account from his first incident report and his explanation that this was a mistake. However, Mr AA’s first account description that he “body-rolled” Mr Cole to the ground is also contradicted by the CCTV for the same reasons as above. 1239. The best evidence of the force used is therefore provided by the CCTV footage, which is supported by the accounts of Mr BB, Witness 9 and Witness 36. This evidence is consistent with Mr AA’s description of contact around Mr Cole’s chest or bicep area as a push, or part of a technique to deflect Mr Cole’s forward momentum. 1240. It is noted that the objectivity of the witness evidence provided by Mr AA’s colleagues could be questioned. It could also be suggested that these witnesses conferred with Mr AA and/or viewed the CCTV footage held by the nightclub before they provided their accounts. However, in the absence of reliable evidence to contradict these accounts or indicate a greater use of force by Mr AA at this time, and given the factual evidence of the CCTV footage, overall the evidence supports that this is an accurate description of Mr AA’s contact with Mr Cole. There is insufficient evidence to find that the force used by Mr AA to defend himself was excessive. 1241. Mr AA then remained in view of the CCTV footage, which demonstrated he was uninvolved in the subsequent events that involved Mr Cole. Although Witness 31 stated Mr AA was on the floor with Mr Cole and put “elbow digs” into his torso, the CCTV footage is sufficient to demonstrate that Mr AA did not do so.

Consideration of Mr Cole’s injuries being caused by his contact with Mr AA 1242. Finding 30: The evidence supports that Mr Cole’s injuries were not caused by his contact with Mr AA.

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1243. The evidence of Mr Cole’s run towards Mr AA would suggest that he reached Mr AA with a degree of forward momentum, and therefore if Mr AA had applied a sufficient amount of force to Mr Cole’s face or head in the opposite direction, then this would be sufficient to cause a “large and sudden” force which could hyperextend Mr Cole’s neck, as described by Mr AK as the mechanism for the spinal fracture. A similar opinion is provided by Professor AL, who described the mechanism as an “extreme” or “considerable” force pressing down on the cervical spine; most likely being his head extended backwards with force on his head and therefore on the neck causing the fracture. 1244. While this is clearly a plausible scenario, finding 29 concluded that Mr AA did not apply this type of force to Mr Cole’s face or head, and the force that he used, i.e. a push or deflection at the chest or biceps, would not provide the mechanism of injury described by Mr AK and Professor AL. 1245. Also as discussed below in findings 36, 50 and 53, following his contact with Mr AA, Mr Cole was able to return to his feet, could speak, was physically active and continued to resist arrest by several police officers, which suggests that he had not suffered the spinal fracture or spinal cord injury at that time, even though the expert opinions may not rule it out altogether.

The first occasion Mr Cole went to the ground 1246. Finding 31: The evidence supports that after Mr Cole’s initial contact with Mr AA, the next individual who made physical contact with him was Mr BB. 1247. The next stage in events was the contact Mr Cole had with Mr BB. This is on the basis of Mr BB’s own account, which is supported by the CCTV evidence that he made contact or was in close proximity to Mr Cole immediately after the contact with Mr AA. 1248. Finding 32: The evidence supports that Mr Cole first went to the ground between 01:47:34 and 01:47:42. 1249. The nature of Mr BB’s contact with Mr Cole and its effects were not in view of the CCTV operated by the nightclub, and could not be seen in the footage from the Local Authority CCTV due to the building line and crowd obstructions. Therefore the sequence of events has been considered largely from the accounts of witnesses and those involved. 1250. However, the Local Authority CCTV footage does evidence that Mr BB and police officers PC Spicer, PC Ross, PC Oates and PS Withey were in the vicinity of Mr Cole at that time. 1251. The CCTV footage also demonstrated that Mr Cole was on his feet prior to his contact with Mr BB at 01:47:34; one or more people went to ground at 01:47:40; and PC Ross moved to crouch down on the forecourt at 01:47:42 at the same time that PS Withey appeared to reach the location. 1252. In consideration of these timings and the evidence from all witnesses that Mr Cole went to ground immediately after his run towards the nightclub, and the accounts from PC Ross and PS Withey that Mr Cole was on the floor when they reached him, the evidence supports that Mr Cole was on the ground by 01:47:42.

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1253. Finding 33: The evidence supports that, immediately after Mr AA pushed or deflected Mr Cole away, Mr BB wrapped his arms around Mr Cole’s waist, upper body or head/shoulder area. Due to this contact or during this contact, Mr BB and Mr Cole both went to the ground. 1254. Mr BB provided a consistent account across all his interviews that he witnessed Mr Cole attempt to strike Mr AA. He said Mr Cole was still on his feet after Mr AA pushed him away, and he then saw Mr Cole was about to attempt to strike Mr AA again. Mr BB said he intervened to attempt to restrain Mr Cole so he could not hit Mr AA or anyone else, and there is no evidence that this was not a genuine belief. Under common law Mr BB would have been entitled to use reasonable force to defend others. 1255. Mr BB said he took hold of Mr Cole face-to-face with his arms over Mr Cole’s arms at mid-chest or below Mr Cole’s biceps in “a kind of bear hug”. He said that, while this happened, police officers pulled at Mr Cole and tried to put handcuffs on him. He said he fell backwards onto the ground but by that point he had let go of Mr Cole apart from a grip on his t-shirt. He said Mr Cole did not fall on him and did not go to the ground. 1256. Mr AA’s incident reports made no mention of Mr BB being in contact with Mr Cole, but said that the police were immediately in contact. In his police interview he said the same, then acknowledged Mr BB was there but came away as soon as the police tried to arrest Mr Cole. 1257. In his IPCC interviews, Mr AA said that Mr BB caught Mr Cole before two police officers tried to arrest him, and he described a ‘hug’ action over Mr Cole’s arms similar to Mr BB’s account. He said Mr Cole did not go to the ground while in contact with Mr BB, and Mr BB did not go to ground at any point. 1258. It could be suggested that Mr AA’s lack of inclusion of Mr BB’s involvement with Mr Cole in his early accounts was to avoid incriminating his colleague, and it is noted that Mr AA’s statement that Mr BB did not go to ground at all was in conflict with Mr BB’s own account. This casts doubt on the reliability of Mr AA’s evidence of Mr BB’s involvement. 1259. Witness 9 did not describe any contact by Mr BB either and stated police officers took Mr Cole to ground. However, as this conflicts with Mr BB’s admission of contact and Witness 9 was unable to provide any detail, this description is considered unreliable. 1260. Witness 39 stated that Mr BB, who she identified by name, and three police officers ran over, struggled with Mr Cole and they fell to the ground together. Witness 36 stated that Mr BB and a police officer made contact with Mr Cole, before more police attended and he later described Mr BB holding Mr Cole who was being restrained. 1261. Witness 28 described two police officers in high-visibility and police hats holding Mr Cole, which could indicate PC Spicer and PS Withey. However he also stated Mr Cole remained on his feet until another four or five police officers arrived, and did not see any door staff involved at all, which is contrary to other evidence and casts doubt on the reliability of this identification. 1262. Witness 11 identified Mr BB by name and described him as performing a “high rugby-tackle”, at the top of Mr Cole’s chest and said Mr BB “hit him hard on the take down”, before he then held Mr Cole on the floor.

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1263. Witness 31 identified Mr AA as making contact, but described the contact in very similar terms as Mr BB’s account of his own contact, i.e. they were face on and he wrapped his arms around his Mr Cole’s waist. He stated that this individual then threw Mr Cole to the floor and landed on top of him. 1264. Witness 20 described a police officer in front of a group of police officers who performed a similar action of a “hug” or “rugby-tackle” with both arms on the sides of Mr Cole’s head or shoulders. He said this action took Mr Cole to the ground, and this police officer then wrestled with Mr Cole on the ground. Given his description of this individual and the positioning he described, alongside the similarity of the actions attributed to Mr BB and considering the issues over identification discussed above, it is considered likely that Witness 20 was referring to Mr BB, but mistook him for a police officer at this time. 1265. In their police notebooks PC Ross and PC Oates noted brief descriptions of the door staff action which took Mr Cole to the ground; PC Ross wrote “the doorman put him to the floor” and PC Oates wrote “the door staff pushed at Mr Cole” and “as they clashed Mr Cole and the door staff fell to the floor”. 1266. These descriptions are relatively moderate compared to their statements provided in the afternoon the same day at the post-incident procedure. PC Ross stated the doorman grabbed hold of Mr Cole and dragged him to the floor, whereas PC Oates stated the doorman took hold of Mr Cole and threw him to the ground with such force that he was taken aback by it. Both identify this doorman as the one Mr Cole was running towards, but do not provide description other than that he was large and wearing a high-visibility jacket. 1267. In his first IPCC interview PC Oates reiterated the same as his statement, but noted that the doorman went to ground with Mr Cole. He also stated the doorman waited in anticipation of Mr Cole’s approach, but said he could not provide any further description of the doorman and did not know his ethnicity. In his second interview PC Oates would not answer further questions on the doorman’s actions, however, after he was shown the CCTV he said he only saw the back of the doorman. 1268. The variance in PC Oates’s accounts of this moment undermines his credibility. His first account of a push and fall written immediately after the event is at odds with his subsequent statement describing a takedown so violent that he was taken aback by it, and it cannot be ignored that this was provided after the gravity of Mr Cole’s injuries were known. He has also contradicted himself by describing the doorman as waiting for Mr Cole to reach him, but later claiming he could not identify the doorman because he only saw him from behind. Considering that PC Oates said he was in close proximity to the doorman during restraint, it is suspicious that he is only able to provide a generic description which could fit Mr AA or Mr BB. It is also significant that he implicated the doorman that Mr Cole was running towards as responsible, however, the evidence sufficiently demonstrates that Mr AA did not perform any action which could be described in the terms PC Oates used. 1269. PC Ross provided more detail of the force used than PC Oates in her first interview by explaining the movements of his arms and stating it was “like a hug” and the doorman landed on top of Mr Cole. She also emphasised the aggression of the move and said she had never seen a takedown like it. In her second interview PC Ross stated she did not know or could not remember what happened at that time.

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1270. It is noted that PC Ross’s accounts are less conflicting than PC Oates, but contain the same escalating description of the violence of the takedown, which she did not record in her pocket notebook immediately after the event. The credibility of her account of this event is also undermined by her inability to provide more than a generic description of a doorman, her implication of the doorman Mr Cole was running towards in the same way as PC Oates and, by her claims, in second interview, that she could not answer any questions about the use of force at that stage, despite the uniqueness she emphasised in her previous interview. 1271. In his police notebook PC Spicer wrote that a member of door staff tackled Mr Cole to the ground, and he was seen on CCTV as the closest police officer to Mr Cole and Mr BB at this stage of events. However, in his subsequent interviews he said he did not see what happened and maintained that he could not provide any details, even when presented with the CCTV evidence of his close proximity. 1272. The CCTV evidence indicated that Mr Cole was in contact with Mr BB and also went to ground within an eight second period. On balance of all the witness evidence the most consistent scenario evidenced was that Mr BB wrapped his arms around Mr Cole’s upper body, and that either due to this contact or during this contact, Mr BB and Mr Cole both went to ground. 1273. Although Mr BB denied Mr Cole going to ground at this stage, all of the witnesses who provided specific evidence of a ‘bear hug’ or ‘rugby tackle’, i.e. Witness 39, Witness 20, Witness 36, Witness 11 and Witness 31, also stated that the same individual was on the ground with Mr Cole, some of them specifically naming Mr BB. While there are some issues of reliability regarding the accounts of Witness 39 (due to a lack of detail and her statement that it was not Mr BB who applied the ‘bear hug’) and Witness 31 (due to attributing the action to Mr AA), it should also be noted that other witnesses (Witness 24 and Witness 21), who did not see Mr Cole go to ground, still described a member of door staff being on the ground with him and, significantly, Witness 21 identified Mr BB by name as being on the floor while police tried to restrain Mr Cole on the ground. 1274. While the ‘bear hug’/‘rugby tackle’ description is most consistent, the specifics of where Mr BB made contact with Mr Cole were inconsistent: Mr BB said he made contact at Mr Cole’s waist/biceps, which was supported by Witness 31; Witness 11 said Mr BB made contact at the top part of Mr Cole’s chest; and Witness 20 stated Mr BB made contact around Mr Cole’s head and shoulders. It is considered that none of these descriptions can be confidently judged as preferable to the others due to the different perspectives of each witness and in consideration that the position of Mr BB’s grip on Mr Cole could have changed over time and as they went to ground. 1275. Finding 34: The evidence supports that PC Ross, PC Oates and PC Spicer were in close proximity to Mr Cole at this time and may have had some contact with him, but the force used by Mr BB was the dominant reason for Mr Cole going to ground. 1276. In respect of the police officer contact with Mr Cole before initially going to the ground, Witness 36 stated one male police officer and Mr BB were in contact with Mr Cole, and Witness 39 stated three police officers and Mr BB were in contact with Mr Cole, although neither could provide any further detail or descriptions. Mr BB and Mr AA stated one male and one female police officer were in contact with Mr Cole.

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1277. Witness 2 said police officers were involved, however ,his account is not considered reliable. He stated 15–20 police officers intervened before the male (who he stated was in a blue t-shirt) reached the door staff, which does not accord with the numbers of police officers at this point as established by CCTV and other evidence. He was also low on detail and noted that there were obstructions to his view. 1278. Witness 28 and Witness 25 do not appear to have witnessed any of the contact Mr AA or Mr BB had with Mr Cole and, due to the number of police officers they described, it is considered more likely that their description of the arrival of multiple police officers who then took Mr Cole to the ground refers to the second occasion when Mr Cole went to the ground, as discussed in finding 54 below. 1279. Witness 31, Witness 20 and Witness 11 described a single individual who took Mr Cole to the ground before several police officers arrived. 1280. Witness 36 and Witness 39 could not provide any detail of the police officers’ actions to take Mr Cole to the ground, and the only accounts which provide any real detail of police officers taking Mr Cole to ground at this stage are Mr BB and Mr AA. As discussed above it is considered that their accounts do not fully describe Mr BB’s involvement at this stage, and therefore it is reasonable to accept that, although PC Ross, PC Oates and PC Spicer were in close proximity to Mr Cole at this time and may have had some contact with him, it is considered most likely that Mr BB’s contact was the dominant reason for Mr Cole going to ground. 1281. Finding 35:The evidence supports that PC Ross’s justification for Mr Cole’s arrest was still made out at the time of his actual restraint and arrest, and therefore an entitlement to use reasonable force to effect Mr Cole’s arrest existed. 1282. As discussed in finding 28 above, it has been concluded that Mr Cole ran towards Mr AA with the apparent intention to assault him, which would allow the police officers to use reasonable force to prevent crime, arrest Mr Cole or assist in the arrest of Mr Cole. 1283. PC Ross explained that she had already decided that Mr Cole should be arrested for an offence under Section 5 of the Public Order Act. Although she was unable to effect this arrest moments earlier, the same conditions still applied at the time Mr Cole ran towards Mr AA. 1284. As such PC Ross would be able to rely on her previous justification for Mr Cole’s arrest, alongside additional justifications brought about by Mr Cole’s apparent attempt to assault Mr AA.

The first period of restraint on the ground 1285. As it has been concluded that Mr BB went to the ground with Mr Cole, while Mr AA remained in view of the CCTV on the nightclub’s forecourt, and there were no other door staff suggested as being involved with Mr Cole, it is considered more likely than not that, when the witnesses referred to a member of door staff in contact with Mr Cole on the ground, they are referring to Mr BB. 1286. Finding 36: In the investigator’s opinion, the evidence supports that Mr Cole was initially on the ground for a maximum period of 23 seconds between 01:47:34 to 01:47:57 before he returned to his feet.

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1287. Finding 32 concluded that Mr Cole went to ground between 01:47:34 and 01:47:42; the time that PC Ross is indicated to have moved to a ground position. 1288. The CCTV evidence indicated that PC Ross stood up at 01:47:53 and then indicated a general movement of a group rising up from the ground by 01:47:57. 1289. Witness 28, Witness 9, Witness 25, Witness 2, Mr BB and Mr AA all described Mr Cole on his feet while several police officers attempted to restrain him without the involvement of any door staff, before he was then taken to the ground by police officers. As discussed in findings 33 and 34, it is the investigator’s opinion that Mr Cole first went to ground as a result of the actions of Mr BB, and therefore the evidence of these witnesses would suggest Mr Cole returned to his feet before he went to the ground again due to the actions of police officers. 1290. Most significantly, Mr AA and PC Oates explicitly stated that Mr Cole returned to his feet after an initial period on the ground, and PC Kalyan stated that Mr Cole was on his feet when he became involved, i.e. after his arrival at 01:47:53 as clearly evidenced by the CCTV. 1291. PC Kalyan and PC Oates both gave evidence that Mr Cole resisted their attempts to arrest him and they then took Mr Cole to the ground with the assistance of PC Ross. In consideration of findings 33 and 34 and the CCTV evidence of PC Kalyan’s arrival at 01:47:53, this could only be possible if Mr Cole returned to his feet after he first went to ground. 1292. On the basis of the evidence from witnesses, police subjects, non-police subjects, and the CCTV evidence providing timing, it is the investigators opinion that the evidence supports that Mr Cole had returned to his feet by 01:47:57. 1293. Finding 37: The evidence supports that PC Ross, PC Oates and Mr BB were involved in Mr Cole’s initial restraint on the ground. 1294. From the CCTV evidence, the police officers first in the vicinity when Mr Cole was on the ground were PC Ross, PC Oates, PC Spicer and PS Withey. The CCTV evidence confirmed that this was before the arrival of PC Kalyan, Inspector Fosbury or any other police officers. 1295. PC Oates and PC Ross both described a doorman being on top of Mr Cole on the floor, specifically described in PC Ross’s notebook as a “ground pin”. They both stated Mr Cole was still struggling when they went to assist. 1296. PC Oates stated PC Ross was on Mr Cole’s right side trying to pin him down while he pushed Mr Cole’s friends away as they attempted to intervene. PC Ross stated she went to Mr Cole’s legs and PC Oates was on her right. 1297. PC Spicer and PS Withey could only describe a scene involving police officers and door staff restraining a male. PS Withey identified that a black doorman was involved but was unable to provide further detail. Both of them noted Mr Cole’s friends attempted to intervene; PC Spicer identified Witness 11 and PS Withey identified Witness 24 and Witness 31. 1298. Witness 20 and Witness 39 stated that several police officers and the individual indicated to be Mr BB were involved in the restraint of Mr Cole on the ground but were unable to provide any real detail of the contact, aside from Witness 39 stating the doorman was on Mr Cole’s legs, and Witness 20 describing the individual who rugby-tackled Mr Cole as on top of him. Both said Mr Cole was still struggling at this point.

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1299. Witness 31 said the doorman who took Mr Cole to the ground was putting “elbow digs” into him while three police officers restrained him. He did not provide any further detail of the contact by the doorman or police officers. This is considered less reliable, partially due to Witness 31’s identification of the doorman as Mr AA, but also because he indicated the police officers were aware of the ‘elbow digs’ and effectively told the doorman to stop, however, no police officer has provided any evidence of this use of force, which is considered unlikely in the circumstances. 1300. Witness 11 said that before the police officers became involved Mr BB was applying a neck hold to Mr Cole while on the ground and Mr Cole could not move. He said that the police intervened and Mr BB let go, but he did not see what the police did. 1301. Witness 21 described two police officers on top of someone who was still struggling, before he then saw Mr BB getting up from the ground. 1302. Mr AA did not provide much detail of this stage of events, stating only that police tried to get Mr Cole to the floor and got him down or “half down”, and Mr BB’s account was that Mr Cole had not gone to floor by this stage and remained on his feet and Mr BB extracted himself from the situation almost immediately. 1303. Witness 24 described a struggle between Mr Cole, police officers and doormen and stated he pulled a police officer indicated to be PC Kalyan away. Witness 24 said he saw Mr Cole face down on the floor with a police officer on top of him. 1304. PC Ross and PC Oates have identified themselves as being involved in the restraint of Mr Cole when he was initially on the ground, along with an unspecified doorman. Mr BB stated he was not involved while Mr Cole was on the ground, which was supported by Mr AA, although the specifics of their evidence conflicted and therefore undermined the reliability. 1305. The evidence from multiple witnesses as outlined above is sufficient for a tribunal to conclude that Mr BB was involved in the restraint of Mr Cole during his initial restraint along with PC Ross and PC Oates. 1306. Finding 38: The evidence supports that PC Spicer was not involved in the initial restraint of Mr Cole on the ground. 1307. PC Spicer provided an account in which he did not restrain Mr Cole because he attended to two individuals knocked to the ground. This account was recorded in his police notebook and has remained consistent across his interviews, and was lent some support by Witness 39’s description that an individual was “almost knocked to the ground” by Mr Cole at that time. 1308. However this was undermined by the CCTV evidence of his close proximity to Mr Cole at the time of restraint and his claim that he did not see anything of Mr BB’s contact with Mr Cole due to obstructions, which was also contradicted by the CCTV evidence. When pressed, PC Spicer stated he did not want to get involved because he was scared. 1309. It should be noted that there was no evidence that PC Spicer was on the ground with Mr Cole and, significantly, no other police officer identified PC Spicer as involved in Mr Cole’s restraint. The Local Authority CCTV footage also indicated PC Spicer was standing back during Mr Cole’s restraint, which would tend to support his explanation that he did not want to get involved.

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1310. In the absence of any positive indicators that PC Spicer was involved in the restraint of Mr Cole, there is sufficient evidence for a tribunal to find that his account that he was not involved is correct, irrespective of the issues over the reliability of his account. 1311. Finding 39: The evidence supports that PS Withey had minimal involvement in the initial restraint of Mr Cole on the ground. 1312. PS Withey was clearly identifiable on the Local Authority CCTV footage, and could be seen standing up at the time when Mr Cole was on the ground. PS Withey did not move out of view for this period and he did not move down to the ground before he started to push people away and then attempted to take hold of Witness 31. Within his accounts PS Withey was vague about the level of contact he had with Mr Cole and stated that, if there was any contact, it was only brief. The CCTV evidence sufficiently supports PS Withey’s evidence for a tribunal to accept on the balance of probabilities PS Withey had minimal or no contact with Mr Cole while he was initially on the ground. 1313. Finding 40: The evidence supports that PC Kalyan had minimal involvement in the initial restraint of Mr Cole on the ground. 1314. The CCTV evidence identified PC Kalyan’s arrival at 01:47:53. PC Kalyan’s description of this scene was consistent across accounts. He described PC Ross and PC Oates as trying to take Mr Cole’s arms, and the doorman as around Mr Cole’s waist, and said they were all standing up up at that point. He also described Mr Cole’s friends attempting to obstruct police officers. 1315. From the CCTV evidence it is considered most likely that Mr Cole was still on the ground for a maximum of four seconds after PC Kalyan’s arrival. However, by PC Kalyan’s account and Witness 24’s description, PC Kalyan was occupied by Mr Cole’s friends almost immediately on his arrival and therefore he would have had minimal contact with Mr Cole before he was back on his feet. 1316. Finding 41: The CCTV evidences that Inspector Fosbury was not involved in the initial restraint of Mr Cole on the ground. 1317. The CCTV identified Inspector Fosbury’s arrival at 01:47:57 and, as discussed in finding 36 above, the evidence is sufficient to conclude that Mr Cole was on his feet at this time. 1318. Finding 42: There is evidence that Mr Cole’s friends Witness 24, Witness 31 and potentially Witness 11 attempted to intervene in Mr Cole’s restraint and arrest. 1319. As outlined above all of the officers present during Mr Cole’s initial restraint stated that Mr Cole’s friends attempted to physically intervene in Mr Cole’s arrest, which was corroborated by the accounts of Witness 24 and Witness 31. 1320. Finding 43: There is evidence that Mr Cole struggled and attempted to resist arrest during the first period of restraint on the ground. 1321. PC Ross and PC Oates stated Mr Cole was struggling when they went to assist which was supported by the witness statements of Witness 20, Witness 39, Witness 21 and Witness 24. This is also supported by the witness descriptions of Mr Cole’s subsequent resistance when he was back on his feet. 1322. Finding 44: There is evidence that Mr BB may have briefly applied some force around Mr Cole’s neck while on the ground.

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1323. Finding 45: The evidence supports that PC Ross, PC Oates and Mr BB attempted to restrain Mr Cole on the ground while he resisted and his friends intervened, which created a scene of disorder. There is insufficient evidence to establish what force was applied to Mr Cole during the initial restraint on the ground. 1324. Witness 11’s account that Mr BB held Mr Cole in a “neck hold” is the most detailed description of the restraint of Mr Cole at this point and is consistent with some of the evidence, which described how Mr BB took hold of Mr Cole when they went to the ground; it is therefore considered plausible that this may have occurred. PC Ross and PC Oates did not describe seeing this contact despite their proximity and immediate involvement as evidenced by the CCTV footage. The only other descriptions of contact with Mr Cole across the other evidence was of a doorman (Mr BB) and police officers being “on top” of Mr Cole, although the specifics of Mr BB’s position were inconsistent, and there were no consistent specific positions attributed to the police officer contact. 1325. On the evidence, a tribunal could decide that it is most likely that Mr BB had some hold on Mr Cole which may have been around his neck initially, as an extension of his initial use of force to take hold of Mr Cole, but that this was for a short period and his contact with Mr Cole changed as PC Oates and PC Ross became involved. The evidence indicates it was then a situation where PC Oates, PC Ross and Mr BB attempted to restrain Mr Cole, while he resisted and his friends intervened, which presented a scene of disorder, supported by the lack of detail and inconsistent witness evidence. It is therefore not possible to confidently state what other force was applied to Mr Cole before he came back up from the ground.

Consideration of Mr Cole’s injuries being caused by his contact with Mr BB and during the initial period of restraint on the ground 1326. Finding 46: In the investigator’s opinion there is evidence that Mr Cole may have sustained the spinal fracture before he returned to his feet. 1327. As concluded in finding 33 the contact between Mr BB and Mr Cole was that Mr BB wrapped his arms around Mr Cole’s upper body and either due to this contact or during this contact, Mr BB and Mr Cole both went to the ground. The specific location of Mr BB’s contact with Mr Cole has not been determined but it is possible that Mr BB was in contact with Mr Cole around his neck or head during descent or on the ground. 1328. The investigator is unable to rule out the possibility that when Mr BB took hold of Mr Cole and they went to the ground together, it may have been with sufficient force to have hyperextended Mr Cole’s neck and so could have been the mechanism by which the spinal fracture was caused as described by Mr AK and Professor AL. 1329. However, findings 36, 50 and 53 (below) concluded that after his contact with Mr BB, Mr Cole returned to his feet and was physically capable enough to resist three police officers’ efforts to arrest him. 1330. Mr AK described the capabilities Mr Cole would have after he sustained the spinal fracture but before the displacement of the vertebrae or spinal cord injury occurred. He explained that Mr Cole would still be able to move his arms and legs

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and possibly walk after he sustained the spinal fracture, but would be in a great deal of pain. 1331. Professor AL has provided opinion also noting that the fracture would have caused pain, but noted that the spinal fracture could have occurred without any immediate neurological consequences, and it would be perfectly possible for Mr Cole to walk with such a fracture. Professor AL also repeatedly emphasised that the effects of the fracture and spinal cord injury were progressive in nature, and that the timeline of deterioration could not be determined in this case, but in his opinion was over a period of at least some minutes. 1332. In response to a specific question regarding the likelihood that Mr Cole would be capable enough to resist three police officers after sustaining the spinal fracture, Mr AK provided further clarification: He said he would have expected a change in Mr Cole’s behaviour, as [the fracture] would likely have caused severe and sudden neck pain. He said Mr Cole may still have been able to resist arrest, but it was much more likely that he would have been shouting about neck pain and trying to protect his neck than trying to engage in violence with the police or door staff. 1333. In response to this question, Professor AL reiterated that it was perfectly possible to suffer a spinal fracture of the type sustained by Mr Cole and to be walking around with normal physical effort. In his clarification report Professor AL added that there would be no neurological damage, i.e. paralysis, unless the spinal cord was damaged. 1334. He also noted that the spinal cord injury was incomplete and probably progressive over a period of unknown time; and therefore it would not be possible to definitively answer whether Mr Cole was capable of returning to his feet and resisting arrest after sustaining the injuries. As such, neither Mr AK nor Professor AL stated that it would not be possible for Mr Cole to return to his feet and resist arrest after the spinal fracture, and the behavioural impact within this timeframe is in dispute. 1335. In the investigator’s opinion the evidence suggests it is therefore possible that the spinal fracture occurred before he returned to his feet. 1336. Finding 47: On the basis of the current evidence and medical expert opinion, a tribunal could not find on the balance of probabilities that Mr Cole had sustained injury to his spinal cord at the time he returned to his feet. 1337. Mr AK stated that the spinal cord injury was a consequence of the spinal fracture, and would cause a rapid loss of function below the level of injury. This would indicate that if his spinal cord had been compromised, then Mr Cole would not have been able to return to his feet and resist the efforts of three police officers to arrest him, as discussed in findings 50 and 53. 1338. Professor AL also provided opinion that the spinal cord injury would cause weakness in the limbs, and would cause partial paralysis leading to respiratory failure. However, he has emphasised that these effects would be progressive and may not have occurred for some time. He stated “the spinal cord injury was incomplete and probably progressive over a period of time – unknown”, and noted that it was not possible to definitively answer whether Mr Cole could return to his feet and resist arrest after the spinal cord injury had occurred. He also noted it

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was perfectly possible that Mr Cole sustained the early stages of spinal cord injury without any change in demeanour over a period of time. 1339. In his clarification report, Professor AL added that partial paralysis would occur where the spinal cord has been damaged but not completely; the degree of paralysis being dependent on the degree of spinal cord injury. He noted that if there was complete damage to the spinal cord there was complete loss of neurological function of the central nervous system. He noted that Mr Cole did not have a complete spinal cord injury, but very nearly complete (although still noting that the injury was probably progressive over a period of time). 1340. Although these opinions broadly agree on the effects of the spinal cord injury, the disparity over the immediacy and totality of the effects is significant, as Mr AK’s opinion would tend to support that Mr Cole’s spinal cord was not compromised before he returned to his feet, whereas Professor AL’s opinion would support that it could have been but the neurological deficit had not taken effect or at least not to the extent that it prevented Mr Cole from returning to his feet. 1341. As such, there is conflicting medical opinion on whether Mr Cole would be able to return to his feet and resist arrest after having sustained injury to his spinal cord. 1342. Therefore, in the investigator’s opinion there is insufficient evidence on which a tribunal could conclude that Mr Cole’s spinal cord was compromised prior to his return to his feet. 1343. Finding 48: The spinal fracture to Mr Cole may have been caused by his contact with Mr BB. 1344. In consideration of the evidence that the contact between Mr Cole and Mr BB could have provided the mechanism of injury, and that the physical and behavioural effects of the spinal fracture may not have prevented Mr Cole from returning to his feet and continuing to resist arrest, it is the investigator’s opinion that the spinal fracture to Mr Cole could have been caused through his contact with Mr BB. 1345. The medical opinion from Mr AK and Professor AL agrees that the spinal fracture and spinal cord injuries could have occurred at the same time, or the spinal cord injury could have occurred at a later time. However, considering the difference in medical opinion regarding the immediacy of the effects of the spinal cord injury as discussed within finding 47, it is the investigator’s opinion that it is not possible to establish from the evidence of the surrounding events which was more likely. 1346. Finding 49: The spinal fracture to Mr Cole may have been caused during his initial restraint on the ground, involving PC Ross and PC Oates. 1347. The considerations for the initial police restraint of Mr Cole on the ground involving PC Oates and PC Ross are similar to those discussed in findings 46, 47 and 48. 1348. As noted within finding 45, there is insufficient evidence to establish what force was applied to Mr Cole by PC Ross or PC Oates during the initial period of restraint on the ground, but the evidence supports that it was a scene of disorder, with Mr Cole’s friends also attempting to intervene in his restraint. 1349. On the basis of the evidence available it is not possible to identify whether anyone involved in the disorder was individually responsible for force, or contributed to a combination of forces, which resulted in Mr Cole’s head being

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extended backwards in the mechanism of injury described by Mr AK and Professor AL. 1350. As discussed within finding 46, Mr Cole’s actions after this initial period of restraint would not preclude him having sustained the spinal fracture either before or during this period of restraint, and there is insufficient evidence to consider one scenario more likely than the other. 1351. It is therefore the investigator’s opinion that Mr Cole’s injuries may have been caused during his initial restraint on the ground by PC Ross and PC Oates; however, due to the lack of evidence of any specific actions it is not possible to direct responsibility towards any one of the parties involved. 1352. As discussed within findings 47 and 48, it is not possible to conclude whether Mr Cole’s spinal cord was compromised prior to his return to his feet.

Mr Cole’s return to his feet 1353. Finding 50: There is evidence that Mr Cole had returned to his feet by 01:47:57, but the evidence is insufficient to establish how this happened. 1354. As discussed above in finding 36, the evidence is sufficient to conclude that Mr Cole returned to his feet after the initial period of restraint, and was on his feet by 01:47:57. However, the only witnesses who specifically described Mr Cole’s return to his feet were PC Oates and Mr AA, and neither was able to provide any detail. Based on the disorder of the scene at the time as concluded above, it is considered likely that this would explain the lack of specific detail. As such the evidence is insufficient to establish the method by which Mr Cole returned to his feet. 1355. Finding 51: There is evidence that Mr BB was removed from contact with Mr Cole around the time that Mr Cole returned to his feet, and he had no further contact with Mr Cole. 1356. The evidence from Mr AA, Mr BB, PC Oates, PC Kalyan and Witness 21 was that Mr BB was removed from being in contact with Mr Cole by this stage, and Witness 28, Witness 9, Witness 25, Witness 20, Witness 2 all describe witnessing an occasion when Mr Cole was on his feet being restrained only by police officers before he was taken to the ground. 1357. The only accounts which indicated that Mr BB was still involved were from PC Ross, Inspector Fosbury and from Witness 39, however, the weight of evidence, in particular that of PC Oates and PC Kalyan, is sufficient for a tribunal to conclude Mr BB did not have any further contact with Mr Cole from the point that he was back on his feet. The evidence from PC Oates and PC Kalyan is also sufficient for a tribunal to find that Mr BB was not involved again after he removed himself. 1358. Finding 52: The evidence supports that, when Mr Cole returned to his feet and before he went back to the ground, the police officers involved with his restraint were PC Ross, PC Oates, PC Kalyan and Inspector Fosbury. 1359. The number of police officers described by witnesses as involved at this point ranged from two to six (aside from Witness 2 who stated between 10 to 15 police officers) but the CCTV evidence indicated that PS Withey and PC Spicer were not involved and that Mr Cole went back to the ground as the officers in the second police van arrived but before they exited the van.

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1360. Therefore the evidence suggests that the police officers in contact with Mr Cole, as evidenced by their own accounts, were PC Ross, PC Oates, PC Kalyan and to a lesser extent Inspector Fosbury. 1361. Finding 53: A tribunal could find that Mr Cole could speak, was physically able and continued to be non-compliant and resist arrest while being restrained on his feet by police officers. 1362. The witness accounts from Witness 28, Witness 25, Mr BB, Mr AA and Witness 9 all stated Mr Cole resisted or fought with police officers before he was then taken to the ground. Witness 28 stated that police officers held Mr Cole’s arms and he went down forwards. He said Mr Cole shouted as he went and connected with the ground on his stomach and chest. He identified a female police officer as being involved. 1363. Witness 20 stated a male and female police officer took Mr Cole to the ground, but was otherwise unable to provide any detail, which was also the case for Witness 2. 1364. PC Kalyan described being stood up with Mr Cole and taking hold of Mr Cole’s right arm. He said PC Ross was at his shoulders, and PC Oates had his left arm. He then described Mr Cole being taken to the ground while they still held his arms, and Mr Cole going down forwards in a horizontal descent. He said Mr Cole banged his head on the floor. 1365. PC Oates stated that Mr Cole attempted to get back to the doorman or to the nightclub and then Mr Cole was taken to the ground. He said PC Ross, PC Kalyan and Inspector Fosbury fell to the ground with him. 1366. Across all of her accounts PC Ross did not provide any description where police officers restrained Mr Cole on his feet or took him to the ground. In her second interview she did not answer any questions on the topic. 1367. Inspector Fosbury provided an account in which he took Mr Cole’s arm and then they were almost immediately pulled forward, or he was pushed or tripped and they fell to the ground. 1368. Mr BB stated that after he had removed himself from contact with Mr Cole, two police officers held Mr Cole before more came in. He said Mr Cole tried to strike the female police officer, and then four to six police officers took Mr Cole to the floor but he did not know how. 1369. Mr AA stated that Mr Cole was on his feet and two to three police officers attempted to pull his arms behind him and sweep his legs out from under him. He said Mr Cole was shouting and resisted their attempts to take him to the floor until more police officers joined in and Mr Cole was taken down by the sheer weight of numbers. He said that Mr Cole went down forwards with his arms held behind his back and he landed on his chest. 1370. There is consistent evidence from police officers and witnesses to conclude that Mr Cole supported himself on his feet, could speak and was physically able to the extent that he resisted restraint by the police officers before he went to ground again. 1371. Based on the consistency of the evidence provided by witnesses, door staff and police officers regarding Mr Cole’s actions it is the investigator’s opinion that a tribunal could conclude Mr Cole continued to resist the efforts of the police officers to restrain and arrest him before he went to the ground again. There is no

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contradictory evidence which suggested that Mr Cole became compliant at this stage.

The second occasion Mr Cole went to the ground 1372. Finding 54: The evidence supports that Mr Cole went to the ground a second time at approximately 01:48:04. 1373. The Local Authority CCTV footage showed movement within the crowd which was indicative of a group moving to the ground on the forecourt of the nightclub at 01:48:04. This would be consistent with Inspector Fosbury’s evidence that he fell to the ground shortly after he reached the scene of the restraint, shown on the CCTV footage as 01:47:57. 1374. This was also consistent with the evidence of PC A, PC E, PC C and PS G, who were shown by CCTV footage to have reached the scene between 01:48:12 and 01:48:20 and all described someone or multiple people on the ground when they first saw the scene. 1375. Finding 55: The evidence supports that Mr Cole went to the ground on the second occasion due to force applied by PC Ross, PC Oates and PC Kalyan, while Inspector Fosbury was also in contact with Mr Cole to a lesser degree. 1376. PC Kalyan and PC Oates stated they were in contact with Mr Cole when he went to the ground at this stage, and both used the description that Mr Cole was “taken to the ground”. They also stated that PC Ross was involved and, although PC Ross has omitted any detail of her involvement when Mr Cole went to the ground, there are multiple witnesses who identified her by stating that a female officer was involved. The evidence is therefore sufficient for a tribunal to be able to conclude that Mr Cole was deliberately taken to the ground by PC Oates and PC Kalyan with the involvement of PC Ross. 1377. Inspector Fosbury’s account suggested that, although he took hold of Mr Cole’s arm, he had minimal involvement in the action which took Mr Cole to the ground. The CCTV evidence indicated that he was in contact with Mr Cole for a short period of time before they went to the ground and it is also noted that, aside from witnesses who stated that there were more than three police officers present, there is no other evidence that indicated Inspector Fosbury had a greater degree of involvement at this stage. 1378. Finding 56: There is insufficient evidence for a tribunal to find that the decision to take Mr Cole to the ground was unreasonable. 1379. The evidence as discussed in finding 53 supports that Mr Cole continued to resist arrest while these police officers attempted to arrest him on his feet. The police officers were entitled to use reasonable force to detain Mr Cole and there is insufficient evidence to demonstrate that the decision to take Mr Cole to the ground to overcome his continued resistance and effect his arrest was unreasonable. 1380. Finding 57: The evidence supports that Mr Cole was taken to the ground on the second occasion in an uncontrolled manner, facing forwards while his arms were held. The police officers in contact with Mr Cole were PC Ross, PC Oates, PC Kalyan and Inspector Fosbury. Mr Cole connected with the ground around his chest and did not hit his head on the ground.

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1381. Finding 58: There is insufficient evidence available to establish the specific methods applied by the police officers to take Mr Cole to the ground. 1382. The evidence from witnesses and the police officers involved who have provided specific detail of the contact with Mr Cole at this stage is sufficiently consistent to conclude that Mr Cole went down in a forwards direction while his arms were held, and he connected with the ground with his front. 1383. However, beyond these aspects, there is insufficient specific detail to establish the exact methods applied to take Mr Cole to the ground, or to attribute any methods to specific individuals. 1384. No one described Mr Cole hitting his head on the ground apart from PC Kalyan, and the medical evidence established there was no injury to Mr Cole’s head or face. It is the investigator’s opinion that this is sufficient for a tribunal to find that Mr Cole did not hit his head on the ground when he fell. However, it is significant that PC Kalyan believed that Mr Cole hit his head at this time and he consistently maintained this belief across all of his accounts. 1385. Although it is found that Mr Cole did not hit his head on the ground, this belief from PC Kalyan, combined with the evidence from PC Oates and Inspector Fosbury that police officers fell to the ground with Mr Cole, is sufficient to find on the balance of probabilities that it was not a controlled takedown.

The second period of restraint on the ground 1386. Finding 59: On the second occasion Mr Cole was restrained on the ground, the evidence supports that the police officers involved were PC Ross, PC Kalyan and PC Oates. Inspector Fosbury made brief contact with Mr Cole on the ground before he disengaged. 1387. Inspector Fosbury stated he was on the ground for a short period and handed Mr Cole’s arm to PC Oates, an action which was supported by PC Oates. Inspector Fosbury stated he then got up and was immediately involved in pushing Mr Cole’s friends away and attempting to arrest Witness 31 with PS Withey’s assistance, and he had no further physical contact with Mr Cole. PS Withey supported the account of Inspector Fosbury’s involvement with Witness 31. 1388. The Local Authority CCTV footage indicated that Mr Cole went to the ground at around 01:48:04, and police officers PS G, PC A and PC E who arrived at the scene shortly after this, between 01:48:12 and 01:48:20, all described Inspector Fosbury and PS Withey on their feet and already involved with the arrest of Witness 31. They state that they then assisted in this arrest, and the only police officers who are seen on the Local Authority CCTV footage to be in the vicinity of where Mr Cole’s restraint is believed to take place are PC Spicer and PC C, who would appear to remain standing throughout. 1389. PC Ross wrote in her notebook that Inspector Fosbury assisted with a “ground pin” position, but did not provide any detail of this in interview other than stating that Inspector Fosbury was on Mr Cole’s right. It should be noted that this contact was put forward by PC Ross within the context that Inspector Fosbury was involved immediately after Mr Cole was taken to the ground by a doorman, which was contradicted by the CCTV, and she omitted all police officer involvement in Mr Cole being taken to the floor, contrary to evidence from PC Oates, PC Kalyan, Inspector Fosbury and multiple witnesses. Her account is therefore considered unreliable.

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1390. PC Kalyan identified himself, PC Ross and PC Oates involved in Mr Cole’s restraint on the ground and did not identify Inspector Fosbury or any other police officers as involved. PC Oates stated only that Inspector Fosbury gave him Mr Cole’s arm. 1391. No other police officers reported their involvement in the restraint of Mr Cole or identified any police officers except PC Ross, PC Oates and PC Kalyan being involved, with the exception of PC C. 1392. PC C identified PC Ross and PC Kalyan as involved in Mr Cole’s restraint and a third officer, who he identified as PC Spicer, but was not sure. Due to the evidence which indicated that PC Oates was the third police officer, it is considered likely that PC C mistakenly identified PC Oates as PC Spicer. 1393. It is considered unlikely that the involvement of any other police officer in Mr Cole’s restraint at this point would have gone unnoticed and unrecorded in all police officer accounts, in particular the accounts of PC Ross, PC Oates and PC Kalyan. 1394. The witness descriptions of the number of police officers who restrained Mr Cole on the ground at this stage varied between three to six police officers, but when pressed for detail, the number of police officers the witnesses actually described applying a method of restraint was either non-specific or between two and three police officers. It is plausible that the greater number stated by some witnesses may be due to PC Spicer and PC C being near to the scene of Mr Cole’s restraint and the sudden influx of additional police officers in the general area. 1395. On the balance of the witness evidence, alongside the CCTV evidence and accounts from the police officers present, it is considered more likely that the only police officers actually involved in the restraint of Mr Cole on the ground at this time were PC Ross, PC Kalyan and PC Oates. 1396. Finding 60: The evidence supports that PC Ross, PC Kalyan and PC Oates were all involved in the application of handcuffs to Mr Cole, which were applied to the rear. 1397. In their first accounts PC Ross, PC Oates and PC Kalyan provided detailed accounts of how they handcuffed Mr Cole to the rear. PC Oates stated that Mr Cole still resisted at this time and PC Ross said he “thrashed about”, but they only provided brief detail on whether they had to physically restrain Mr Cole. In their second interviews PC Oates and PC Kalyan declined to answer questions about it other than stating no one knelt on or applied pressure to Mr Cole. This is somewhat contradicted by PC Ross’s notebook entry which stated she and PC Oates were in contact with Mr Cole, then were joined by Inspector Fosbury and PC Kalyan who “assisted with ground pin”. In her first interview PC Ross stated she went straight to Mr Cole’s legs, and in her second interview, when questioned further, she stated she did not know or could not remember any further details. 1398. PC Ross’s account that she restrained Mr Cole’s legs at this point may not be considered credible, because she described this happening while a doorman was still restraining Mr Cole and has omitted the events of Mr Cole being back on his feet and going to ground a second time. It is also contradicted by PC Oates statement that PC Kalyan controlled Mr Cole’s legs. 1399. These police officers’ descriptions of how they handcuffed Mr Cole with two sets are fairly detailed, however, they are inconsistent with each other; PC Oates stated he was standing at Mr Cole’s left and handcuffed his left hand, while PC

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Ross handcuffed his right, and PC Kalyan was at his feet. In contrast PC Ross and PC Kalyan stated they were on Mr Cole’s left and handcuffed his left hand while PC Oates was on his right. 1400. In consideration of the police officers’ accounts, it is inherently implausible that, after they took Mr Cole to the ground and he struggled and “thrashed about”, they took no action to restrain him other than to hold his arms and attempt to handcuff him. Their conflicting evidence regarding their positions when handcuffing Mr Cole further weakens the credibility of their accounts at this time. However, they are sufficient to conclude that the handcuffs were jointly applied by PC Ross, PC Oates and PC Kalyan. 1401. Finding 61: A tribunal is unlikely to consider the application of handcuffs to Mr Cole during his restraint on the ground to be an excessive use of force in all the circumstances. 1402. The application of handcuffs to Mr Cole would have to be necessary, proportionate and reasonable in all the circumstances. Given the circumstances as PC Ross and PC Oates clearly perceived them to be at the time, i.e. that Mr Cole had been increasingly aggressive, had attacked Mr AA and then resisted arrest, it is the investigator’s opinion that application of handcuffs at this stage is unlikely to be considered an excessive use of force at the time Mr Cole was being restrained on the ground. 1403. Although Mr Cole may have stopped resisting shortly before the handcuffs were applied (as discussed in finding 69 below), this would have happened within a short space of time and the police officers could have still perceived Mr Cole to present a threat which required the use of handcuffs. 1404. Although PC Kalyan would not have had the same information regarding Mr Cole’s earlier actions, he would be entitled to assist PC Ross and PC Oates in their application of restraint to Mr Cole to effect his arrest. 1405. Finding 62: The evidence supports that one or more police officers knelt on Mr Cole during his restraint on the ground. 1406. Witness 20 stated that while on the ground a male police officer was on Mr Cole’s upper body, the female police officer had her knee in Mr Cole’s lower back, and a third police officer was also on top of him. He said the male and female police officers then handcuffed Mr Cole. 1407. Mr AA stated a police officer knelt in the small of Mr Cole’s back, another knelt across his legs and he stated he saw a police officer’s hand on the side of Mr Cole’s head. In his subsequent interview he stated a police officer had a forearm across the back of Mr Cole’s neck, another police officer knelt on his legs and another knelt on Mr Cole’s back. He stated Mr Cole struggled violently until a point when he just stopped moving, which allowed the police officers to handcuff him. 1408. Witness 1 could not provide detail of the restraint but stated Mr Cole shouted and was aggressive and abusive as they tried to deal with him. 1409. Witness 9 also said Mr Cole struggled and that two police officers knelt on him. He said at least one male police officer was knelt on Mr Cole’s neck. He did not know if Mr Cole stopped struggling before or after being handcuffed.

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1410. Witness 28 stated Mr Cole was restrained by his arms and legs by multiple police officers. He said a white male police officer had his knee on Mr Cole’s back. He said as the police officers got on top of him, Mr Cole went quiet. 1411. Witness 37 described a police officer on Mr Cole’s legs and two other police officers on his left. He said one of them possibly knelt on Mr Cole’s shoulder. He said Mr Cole was motionless but may have been yelling. He said Mr Cole was shaking from side to side a little when handcuffed. 1412. Witness 25 and Witness 12 both stated that they saw three or four police officers on Mr Cole and described it as “like a rugby mess” and “like a scrum” respectively. Neither could provide any more detail on the restraint. 1413. Witness 18 stated she saw a male police officer put his weight on Mr Cole’s legs, and there were others around his torso and head but she could not see if they were in contact. She said she did not see Mr Cole move. 1414. In his statement, Witness 21 said he saw two police officers get off Mr Cole who pulled his arms and handcuffed him to the rear, and a third police officer was stood next to them. In both his incident report and his statement Witness 21 said he did not see Mr Cole move and he thought he looked “dead” or “lifeless”. 1415. PC H stated three police officers tried to handcuff Mr Cole and identified a female police officer and an Asian police officer among them. He stated the female police officer held Mr Cole’s legs but could not provide details regarding the other two officers. He stated Mr Cole still struggled at this point. 1416. Witness 2 stated he could see police officers on their feet but leaning on Mr Cole, who struggled. He could not see any more detail. 1417. Witness 14 said Mr Cole was pinned to the floor by two male police officers in black without high-visibility clothing. He said one officer was on Mr Cole’s legs and another held his hands, which were handcuffed. 1418. Witness 32 was identified on CCTV at 01:48:26 in close proximity to where Mr Cole was indicated to have been restrained. He said Mr Cole was handcuffed to the rear with two sets of handcuffs. He said multiple police officers were on him, including a female police officer. He said one knelt on Mr Cole, one held his face and one held his legs. He said Mr Cole did not struggle at all. 1419. PC C was identified on CCTV at 01:48:28 and noted three officers involved in the restraint of Mr Cole as described above. He could not recall if Mr Cole moved, struggled or made any noise, but stated that he was handcuffed when he saw him. 1420. Of the nine witnesses above who provided any detail of the restraint of Mr Cole, seven of them stated that a police officer restrained Mr Cole’s legs, albeit two of these witnesses could not provide any further detail. 1421. Of the seven witness accounts which provided a reasonable level of detail regarding the restraint, six of them stated that at least one police officer knelt on Mr Cole; four stated this contact was on his torso, one stated it was on his neck, and one was non-specific about the location. 1422. The consistency of the witness accounts which stated that Mr Cole was held down by a police officer on his legs and at least one other knelt on him, combined with PC Ross’s notebook entry that officers applied a “ground pin”, i.e. a technique in which a police officer or police officers kneel on the detainee while

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holding their arm(s), is sufficient for a tribunal to be able to conclude that at least one officer knelt on Mr Cole. 1423. Finding 63: The evidence is insufficient to establish the exact use of force applied by PC Ross during the restraint of Mr Cole on the ground. However, it is the investigator’s opinion that the evidence is sufficient for a tribunal to be able to find that PC Ross knelt on Mr Cole in a position around his torso while he was face down on the ground. 1424. The witness accounts which provide the greatest level of detail and which are from individuals indicated to be in close proximity to the location of the restraint, and therefore considered the most reliable, are those from Witness 20, Mr AA and Witness 32, and to a slightly lesser extent those of Witness 14, Witness 9 and Witness 28. The other witnesses were either at a distance or made a declaration that they were unclear on what happened. 1425. Mr AA and Witness 20 described a police officer kneeling on Mr Cole’s lower back, and Witness 20 stated this was the female police officer. Both also stated another police officer applied force higher up on Mr Cole and Witness 28 and Witness 9 stated a male police officer was kneeling on Mr Cole’s back and neck respectively. Witness 32 said there was a police officer at Mr Cole’s head, another kneeling on him, and another was on his legs. 1426. In consideration of this specific identification of PC Ross kneeling on Mr Cole’s lower back, and the evidence that there was a male officer in a position which would block her from application of force higher up on Mr Cole, combined with her reference to use of a “ground pin” in her notebook and the implausibility of her statement that she only held Mr Cole’s arm while he struggled on the ground, it is considered that a disciplinary tribunal could conclude that PC Ross knelt on Mr Cole in some position around his torso. 1427. Finding 64: PC Ross’s application of a knee to Mr Cole’s torso is individually unlikely to have been the cause of the spinal injuries Mr Cole sustained, but it is possible she contributed to a combination of forces responsible for the spinal injuries Mr Cole sustained. 1428. In respect of the force used on the ground, PC Ross declined to answer the question of whether she knelt on Mr Cole and so has not provided any justification for this use of force. 1429. Any use of force to effect an arrest would need to be necessary, proportionate and reasonable in all the circumstances. A technique of kneeling on someone would be justifiable in some circumstances, and the “ground pin” technique is a recognised use of force for restraint of an individual while face down on the ground and includes application of a knee on top of the shoulder when it is correctly applied. 1430. Although the indication is that PC Ross knelt on Mr Cole around his torso, this action alone is not indicative of the mechanism that Mr AK and Professor AL stated was the likely cause of the spinal injuries Mr Cole sustained. 1431. However, it is possible that this use of force applied by PC Ross, in combination with other force(s) being applied to Mr Cole by PC Ross or other police officers, may have contributed to the spinal injuries Mr Cole sustained. 1432. This is discussed further in findings 79 and 80 below.

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1433. Finding 65: The evidence is insufficient to establish the exact use of force applied by PC Oates during the restraint of Mr Cole on the ground. However it is the investigator’s opinion that the evidence is sufficient for a tribunal to be able to find that PC Oates knelt on Mr Cole’s upper body and/or applied a forearm across Mr Cole’s neck and/or held Mr Cole’s head in some respect while he was face down on the ground. 1434. The witness accounts offered less evidence to differentiate which male police officer was on Mr Cole’s legs and which was nearer to his head; the only identifying evidence was from Witness 28 who described a 6ft, white police officer on Mr Cole’s back. 1435. However PC Oates stated PC Kalyan restrained Mr Cole’s legs, and stated his own position was within reach of Mr Cole’s arm. When combined with the positions of PC Oates on Mr Cole’s left and PC Kalyan behind Mr Cole when he was taken to the van, it is sufficient for a tribunal to be able to conclude on the balance of probabilities that PC Kalyan restrained Mr Cole’s legs and PC Oates was in a position closer to Mr Cole’s head. 1436. It should be noted that PC Oates stated he remained standing while Mr Cole was handcuffed, however, as discussed above his account is considered unreliable, and is considered to be outweighed by the witness statements, in particular those referenced above, which are considered most reliable. It is the investigator’s opinion that it is more likely than not that PC Oates was the male police officer positioned around Mr Cole’s upper body. 1437. The same witnesses refer to that police officer as having knelt on Mr Cole’s upper body, and/or applied a forearm across Mr Cole’s neck and/or held his head in some respect. It is not considered possible to make a determination on the exact position or method of force employed by PC Oates at this time based on the evidence available. 1438. Finding 66: PC Oates’s application of a knee to Mr Cole’s upper body and/or a forearm or arm on his neck and/or hold of Mr Cole’s head may have caused or contributed to a combination of forces responsible for the spinal injuries Mr Cole sustained. 1439. PC Oates declined to answer any questions in respect of the force he used to restrain on the ground so he has not provided any justification for this use of force. 1440. Given PC Oates’s position and his use of force as discussed within finding 65, it is possible that the use of force applied by PC Oates may have caused the spinal injuries Mr Cole sustained, or in combination with other force(s) being applied by other police officers, may have contributed to the cause of the spinal injuries Mr Cole sustained. 1441. This is discussed further in findings 79 and 80 below. 1442. Finding 67: The evidence is insufficient to establish the exact use of force applied by PC Kalyan during the restraint of Mr Cole on the ground. However it is the investigator’s opinion that the evidence is sufficient for a tribunal to be able to find that PC Kalyan knelt on or otherwise restrained Mr Cole’s legs during his restraint on the ground. 1443. As discussed above, the evidence indicates that PC Kalyan was the third police officer in contact with Mr Cole during the ground restraint, and he was identified

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by PC Oates in a position at Mr Cole’s legs, which would also be consistent with PC Kalyan’s position when Mr Cole was taken to the police van. Combined with the witness evidence that a police officer restrained Mr Cole’s legs, this is sufficient to conclude that PC Kalyan either knelt on, or otherwise restrained, Mr Cole’s legs at that time. 1444. Finding 68: The evidence supports that PC Kalyan’s restraint of Mr Cole legs did not cause Mr Cole any significant injury. There is insufficient evidence to find that this contributed to a combination of forces responsible for the spinal injuries Mr Cole sustained. 1445. PC Kalyan did not provide any detail regarding the ground restraint he applied except for his involvement in handcuffing Mr Cole. He declined to answer further questions in his second interview apart from his statement that no one knelt on or applied pressure to Mr Cole. As such he has not provided justification for his use of force on Mr Cole on the ground. 1446. Force or pressure on the legs of an individual is a method which carries low risk of injury and there is no evidence to suggest there was any use of force on Mr Cole’s legs that extended beyond their restraint (i.e. there is no suggestion of use of unarmed strikes, use of equipment, etc). It is therefore unlikely that this would be deemed an unreasonable use of force and it would not be individually responsible for the spinal injuries that Mr Cole sustained. 1447. There is insufficient evidence that PC Kalyan’s application of restraint to Mr Cole’s legs caused any significant injury to him or contributed to a combination of forces being applied which may have caused the spinal injuries Mr Cole sustained. 1448. Finding 69: The evidence supports that Mr Cole continued to struggle and resist arrest during the second period of restraint on the ground, but stopped struggling when he was successfully handcuffed or shortly beforehand. 1449. As discussed in finding 53, there is consistent evidence across all witnesses’ and police officers’ accounts that Mr Cole struggled with the police officers before he was taken to the ground. The evidence from Mr AA, Witness 1, Witness 9, Witness 2, PC H, PC Ross and PC Oates stated that he continued to do so, at least initially, while he was restrained by police officers on the ground. Witness 1 and Witness 37 also provided evidence that Mr Cole spoke or shouted while being restrained. 1450. There were only two witnesses who indicated a specific point when Mr Cole stopped struggling: Mr AA stated Mr Cole struggled violently while police officers attempted to restrain him and then all of a sudden he stopped, which was what allowed the police officers to handcuff him; Witness 28 stated that Mr Cole stopped moving when the police officers got on top of him. 1451. Only Witness 39 and Witness 24 stated Mr Cole struggled after the handcuffs were put on and Witness 24 provided a further statement which contradicted that position. 1452. There was no other evidence from witnesses or police officers that stated Mr Cole continued to struggle after being handcuffed, and it is notable that PC Oates and PC Kalyan both stated Mr Cole was passive after he was handcuffed.

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1453. In consideration of these accounts it is the investigator’s opinion that the evidence supports that Mr Cole stopped struggling when he was successfully handcuffed or shortly beforehand. 1454. Finding 70: The evidence supports that Mr Cole was restrained on the ground and handcuffed between 01:48:04 and 01:48:28. 1455. Witness 32 and PC C both stated that Mr Cole was handcuffed when they saw him. The CCTV evidence indicated that the latest point at which Witness 32 and PC C would have seen that Mr Cole was handcuffed was at 01:48:26 and 01:48:28 respectively. Based on this and the above conclusion that Mr Cole went to ground a second time at around 01:48:04, it is considered more likely than not that Mr Cole was restrained and handcuffed within approximately 24 seconds between 01:48:04 and 01:48:28. 1456. Finding 71: The evidence supports that Mr Cole’s friends did not cause any significant interference on the second occasion Mr Cole was restrained on the ground and they were demonstrably uninvolved at the time Mr Cole was lifted from the ground. 1457. There is evidence from the police officers and from Witness 21 that Mr Cole’s friends, i.e. Witness 31, Witness 24 and Witness 11, attempted to interfere with the police officers’ restraint of Mr Cole on the ground. However, this is indicated to have been early in the restraint; Witness 21 indicated it was shortly after Mr BB was removed from the situation; Inspector Fosbury stated it was when he was getting up; PC Kalyan’s accounts and PC Oates’s notebook entry stated it was before PC Kalyan assisted in the restraint. 1458. There is evidence from Inspector Fosbury, PS Withey, PS G, PC A and PC E that after Mr Cole went to the ground a second time, Witness 31 was then being arrested and therefore could not have intervened further. 1459. Witness 21 and Witness 36 said two of Mr Cole’s friends intervened so they stepped in and held Mr Cole’s friends back. They both said Mr Cole’s friends did not attempt to intervene again. This was supported by Mr AA’s account, and Witness 25 also said that Mr Cole’s friends stood and watched. 1460. PC Spicer also stated he was dealing with one of Mr Cole’s friends to prevent his interference in the restraint. PC H stated that on arrival he thought the three police officers who restrained Mr Cole had it under control, so his attention turned to two to three black males who were “being gobby” and protesting Mr Cole’s arrest. 1461. Witness 32 also stated Witness 24, Witness 11 and Witness 31 attempted to get to Mr Cole during the police restraint, however he stated they were stopped by police and Witness 31 was arrested. 1462. Witness 24 noted that before Mr Cole was taken to the van, Witness 11 picked up Mr Cole’s head and spoke to him, but Mr Cole did not answer and he appeared confused. PC Kalyan then pulled Witness 24 away. Witness 11 corroborated these actions, however, he stated it occurred while at the van. The CCTV footage from the taxi office at approximately 1.49am indicated actions by Witness 11 which would corroborate Witness 11’s account, and showed Witness 24 stood next to him before he was pushed away by PC Kalyan. This would tend towards Witness 24’s timing being mistaken and he is actually describing events at the back of the van.

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1463. Furthermore the CCTV demonstrated that Witness 24 and Witness 11 were outside the front of the taxi office between 01:48:26 to 01:48:36. This is significant, considering that Mr Cole was first seen on CCTV as lifted from the ground at 01:48:35. 1464. All CCTV evidence of Mr Cole’s other friends who were present, i.e. Witness 28, Witness 32, Witness 40 and Witness 20, demonstrated them to be passive observers and they did not interfere with the police officers at any stage. 1465. In consideration of this evidence a tribunal could find, on the balance of probabilities, that although Witness 24, Witness 11 and Witness 31 may have continued to interfere at the start of Mr Cole’s second restraint on the ground, Witness 24 and Witness 11 were then stopped by Witness 36, Witness 21 and PC Spicer, and Witness 31 was arrested by Inspector Fosbury with the assistance of PS Withey. After this point Mr Cole’s friends did not interfere further with Mr Cole’s restraint and they were demonstrably uninvolved at the time Mr Cole was lifted from the ground.

Mr Cole lifted from the ground 1466. Finding 72: The evidence supports that PC Ross, PC Oates and PC Kalyan first lifted Mr Cole from the ground at 01:48:35, before he was lowered again. He was then lifted up at 01:48:52 and moved towards the road. 1467. The CCTV evidence from the Local Authority showed Mr Cole was first lifted off the ground at 01:48:35 and his head appeared to be hanging forward, unsupported, before he was lowered out of view again. The movements seen on the CCTV footage suggested that he was lifted again at 01:48:52, which would correspond with the time that Mr Cole was clearly visible on the road at 01:48:58 when taken to the police van. PC Oates and PC Kalyan both declared their involvement when Mr Cole was lifted from the ground. 1468. PC Ross initially gave evidence that she did not lift Mr Cole and take him to the police van, however, this is outweighed by the CCTV evidence showing her carry Mr Cole and the accounts from PC Oates and PC Kalyan. 1469. Finding 73: In the investigator’s opinion a tribunal could reject the evidence provided by PC Ross, PC Kalyan and PC Oates of a “volatile, dangerous” scene and find that they were not prevented from performing a welfare check before Mr Cole was lifted from the ground. 1470. PC Oates gave evidence that once it was clear he was arrested, Mr Cole refused to co-operate. He said that Mr Cole’s friends still interfered, physically manhandled them and prevented them from doing their duty. 1471. PC Ross stated they did not perform any welfare checks because there was a “swarm” of people over them. She said it was dangerous, stressful, they were being fought with, and they could not for one second have performed a welfare check. 1472. PC Kalyan stated that they chose to get him in the van because it was quite volatile. He said that, although he was worried about Mr Cole having hit his head on the floor, they could not assess him because Mr Cole’s friends were still pushing and shoving them at that point. 1473. Inspector Fosbury stated that after he arrested Witness 31 he assessed the scene and, despite a large crowd, he could not see any aggression. The CCTV of

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him outside the nightclub confirmed he had finished dealing with Witness 31 by 01:48:53. 1474. Mr AA and Witness 21 were the only witnesses to comment on a welfare check prior to lifting Mr Cole up; they both stated that the police officers did not do any check on Mr Cole before they lifted him up. Mr AA said there was nothing which prevented them from doing this; there were no risks and no one interfered with the handcuffing or removal of Mr Cole. 1475. As discussed in finding 71, the evidence is sufficient for a tribunal to conclude that Mr Cole’s friends did not interfere in the restraint of Mr Cole or police officers’ actions in the period immediately before he was first lifted at 01:48:35, and by the officers’ own accounts Mr Cole was no longer struggling. Although there was a large crowd, having regard to the other evidence it is the investigator’s opinion that a tribunal could reject the evidence provided by PC Ross, PC Kalyan and PC Oates of a ‘volatile, dangerous’ scene and find that they were not prevented from performing a welfare check before Mr Cole was lifted from the ground. 1476. Finding 74: In the investigator’s opinion, a tribunal could find that PC Ross had sufficient information to enable her to recognise that a welfare check on Mr Cole before he was lifted from the ground was appropriate, and her explanation for the failure to do so is contradicted by the evidence. 1477. Witness 21 and Witness 35 were the only witnesses to provide any detail of Mr Cole’s condition immediately before he was lifted from the ground. 1478. Witness 21 described Mr Cole’s condition before he was lifted from the ground in his incident report and statement. He stated Mr Cole’s head was in an “unnatural position” and tucked underneath his body at a “funny/very bad angle”. He said he looked “lifeless” and he believed him to be dead at first. In his incident report Witness 21 wrote he felt the police officers would notice Mr Cole’s condition and should have checked him. In his statement he explicitly stated he felt the police should have performed a welfare check to see why Mr Cole had stopped struggling so as to prevent any further injury. 1479. Witness 35 said she saw the police officers appear to spread out, before she then saw Mr Cole directly facing her on his knees. She said by the positioning of his shoulders she assumed he was handcuffed. She said Mr Cole was facing her, but with his head hung down, “like the fight had gone out of him” and he was not saying anything. 1480. The evidence shows that at the point of Mr Cole being handcuffed, PC Ross was aware Mr Cole had been taken to the ground once (in an action she described as particularly forceful), and then had gone to ground a second time, had been restrained by three police officers and then had stopped struggling while in a face down position. 1481. In reference to her training and guidance PC Ross stated that after an individual was restrained on the ground they would be checked before the individual was lifted up. The national guidance on the medical implications of restraint also highlights that police officers should be alert to behavioural changes in individuals lying face down, specifically noting when an active individual becomes passive. 1482. Given the actions of Witness 24, Witness 11 and Witness 31 in the period before Mr Cole was handcuffed, it is noted that PC Ross may have had the perception that she was still in a situation where other members of the public were a risk to her, even if this was not the case. However, PC Ross has also recognised the

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national decision model, application of which would mean she would have been conducting a dynamic risk assessment of the situation and would have recognised that multiple police officers had arrived to assist and Mr Cole’s friends were no longer interfering with her actions. It is the investigator’s opinion that, given the medical implications, a tribunal could find that PC Ross should have made certain that there was a necessity to move Mr Cole without any welfare check before she did so. 1483. Finding 75: PC Oates recognised that, before he was lifted up, Mr Cole stopped moving and did not respond verbally or physically to their requests. The evidence supports that PC Oates did not perform a welfare check because he assumed that Mr Cole was being non-compliant and he failed to consider or he dismissed any potential injury as the cause. In the investigator’s opinion a tribunal could find that PC Oates had sufficient information to enable him to recognise that a welfare check on Mr Cole before he was lifted from the ground was appropriate, and his explanation for the failure to do so was contradicted by the evidence. 1484. In the same respects as PC Ross, at the time that Mr Cole was successfully handcuffed, PC Oates was aware Mr Cole had been taken to the ground once in a manner which he described with great emphasis on the gravity of the force involved. He knew Mr Cole had then gone to ground a second time, was restrained by three police officers and then had stopped struggling while in a face down position. PC Oates also noted that when on the ground Mr Cole did not move and did not respond verbally or physically to their request for him to get up. 1485. PC Oates declined to answer any questions regarding his training or the policies and procedures regarding welfare assessments, and he did not provide an explanation for the lack of any assessment of Mr Cole before he was lifted from the ground. However, he stated that he took Mr Cole to be refusing to co-operate and Mr Cole’s friends continued to physically manhandle them and prevented them from doing their duty. 1486. Although the same arguments as discussed for PC Ross would apply to PC Oates in respect of whether he could have had the perception that he was still in a situation where other members of the public were a risk, he has specifically stated Mr Cole’s friends intervened at the time Mr Cole was to be lifted from the ground, which is contrary to the evidence, as discussed in findings 71 and 73. 1487. As noted, the national police guidance highlights that police officers should be alert to behavioural changes in individuals lying face down, specifically noting when an active individual becomes passive, which PC Oates confirms he observed. 1488. PC Oates’s explanation is sufficient for a tribunal to conclude that he did not perform a welfare check because he made the assumption Mr Cole was being non-compliant and PC Oates did not consider, or dismissed, any potential injury as the cause. As he declined to answer further questions in interview he has not provided any reasoned basis for making this assumption. 1489. Finding 76: In the investigator’s opinion a tribunal could find that PC Kalyan had sufficient information to enable him to recognise that a welfare check on Mr Cole before he was lifted from the ground was appropriate, and his explanation for the failure to do so was contradicted by the evidence.

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1490. The evidence demonstrated that, at the time that Mr Cole was successfully handcuffed, PC Kalyan would not have been aware of the force used upon Mr Cole by the door staff or his initial restraint on the ground, but he was involved in the second occasion when Mr Cole went to the ground and he believed that Mr Cole hit his head on the descent. He also knew Mr Cole was then restrained by three police officers before he stopped struggling while in a face down position. 1491. PC Kalyan explained that he was worried about injury to Mr Cole’s head, but he could not assess him because it was a “volatile situation” and Mr Cole’s friends were still pushing and shoving them. He said they asked Mr Cole to get up, and then picked him up and his body was limp, but PC Kalyan thought Mr Cole was being passively resistant. 1492. In reference to his training he stated that, when someone was restrained on the floor their welfare was paramount, and noted welfare considerations regarding the position of someone’s head and neck and their breathing during restraint. 1493. As discussed in relation to PC Oates and PC Ross, PC Kalyan’s explanation that Mr Cole’s friends intervened at this point is contradicted by other evidence, and considering that PC Kalyan noted that Mr Cole hit his head on the ground it is the investigator’s opinion that PC Kalyan may have had an even greater duty to ensure that Mr Cole was not injured before he was moved, so that he should have made certain that there was a necessity to move Mr Cole without any welfare check before he did so. 1494. Finding 77: The evidence supports that, when lifted from the ground, Mr Cole did not move, he did not support his own head and did not support his weight on his feet. 1495. Witness 20 said he thought something was wrong with Mr Cole when he was lifted, because he could not get up and the police struggled to pick him up. Mr AA, Witness 1, Witness 21 and Mr BB all gave evidence that Mr Cole did not stand. 1496. Witness 35, Witness 25, Witness 1, Witness 9, Mr BB, Mr AA and Witness 21 described Mr Cole’s head hanging down, and Mr AA and Witness 21 stated they saw that Mr Cole’s “eyes were rolling”. 1497. Some of the witnesses provided their interpretation of Mr Cole’s condition at that time. Witness 35 said it was “like the fight had gone out of him”. Witness 9 said he thought Mr Cole was drunk or so tired that he was weak. Mr AA thought Mr Cole became “very compliant” because he was winded. Witness 21 described immediate concerns for Mr Cole’s welfare because he clearly could not stand. Witness 1 stated Mr Cole either could not or did not want to stand. 1498. No witnesses stated he moved in any real sense apart from his eyes opening and “rolling in his head”. The police officers’ evidence of his condition at this point corroborated that Mr Cole did not move, although they have only provided brief details. 1499. Based on the consistency of the witness evidence and what can be seen on the CCTV footage, it is the investigator’s opinion that a tribunal could find on the balance of probabilities that, at the time Mr Cole was lifted from the ground, Mr Cole did not support his own head or support his own weight on his feet. 1500. Finding 78: Despite the witnesses’ different interpretations of Mr Cole’s condition, a tribunal could find that there were sufficient indicators at this

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time that the officers could or should have recognised that his condition may be due to injury. 1501. While the witness evidence highlighted above, most notably from Witness 21, demonstrates that Mr Cole’s condition caused some witnesses to have concern for his welfare, there are also various accounts given by witnesses and subjects that they believed his behaviour was due to intoxication, tiredness or non- compliance, rather than injury. 1502. Despite the witnesses’ different interpretations of Mr Cole’s condition, as discussed in findings 74, 75 and 76, a tribunal could find that there were sufficient indicators at this time that the officers could or should have recognised that his condition may be due to injury.

Consideration of Mr Cole’s injuries being caused during the second occasion he went to ground and was restrained, and/or was lifted from the ground. 1503. Finding 79: In the investigator’s opinion, it is possible the spinal fracture was sustained by Mr Cole during his contact with PC Ross, PC Oates and PC Kalyan when he was taken to the ground at approximately 01:48:04 or while he was restrained on the ground on the second occasion. However, a tribunal would be unable to find that either was more or less likely to be the cause of the spinal fracture than the contact with Mr BB or the initial period of restraint. 1504. As discussed in findings 46, 47, 48 and 49 it cannot be excluded that the fracture to Mr Cole’s neck occurred during his contact with Mr BB, or during the initial period of restraint involving PC Ross and PC Oates. It is also not possible to establish whether the spinal cord injury occurred during either of those events. 1505. As discussed in findings 58 and 59, it is the investigator’s opinion that the only individuals who applied force to Mr Cole during the second take down and period of restraint on the ground were PC Ross, PC Oates and PC Kalyan, with some contact from Inspector Fosbury. However, this was minimal and he quickly disengaged. 1506. It is the investigator’s opinion that the specific methods applied by PC Ross, PC Oates and PC Kalyan to take Mr Cole to the ground cannot be established on the evidence available, as discussed in findings 57 and 58, but the evidence is sufficient to find that it was not a controlled takedown. As such it is possible that the force applied to Mr Cole by these officers during the takedown could have hyperextended his neck and could therefore provide the mechanism which caused the spinal fracture. 1507. As discussed in finding 69, Mr Cole continued to struggle and resist restraint while he was on the ground. 1508. Mr AK described the fracture as a highly unstable injury and, although Mr Cole may have been able to move his arms and legs, the injury would be extremely painful. Mr AK also said that, after the fracture was sustained, it was much more likely that Mr Cole would have been shouting about neck pain and trying to protect his neck than engaging in violence. 1509. Professor AL also stated it was an unstable injury associated with pain, but stated that it was perfectly possible for Mr Cole to have received the fracture without any immediate neurological consequences; the effects of the fracture and spinal cord

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injury were progressive in nature, and the timeline of deterioration could not be determined. 1510. It is therefore not possible to be precise on whether Mr Cole received the spinal fracture or spinal cord injury at an earlier stage but was still able to struggle during the second period of restraint. 1511. While finding 70 noted that Mr Cole was restrained and handcuffed within a 24- second period of being taken to the ground, the precise time that Mr Cole stopped struggling cannot be established. However, on the basis of the medical evidence from Mr AK and Professor AL, the point at which Mr Cole stopped struggling is not necessarily indicative of the point of injury, and therefore this would not assist in determining at what stage he suffered the spinal fracture or spinal cord injury. 1512. As discussed in findings 48 and 49, Mr BB’s contact with Mr Cole could have provided the mechanism of injury, and there is insufficient evidence of detail within the initial period of restraint to rule out that the mechanism of injury occurred at that time. Similarly, there is insufficient evidence of detail within the second occasion Mr Cole went to ground or the second period of restraint to rule out that the mechanism of injury occurred during either of those events. The evidence available is therefore insufficient for a tribunal to reach a finding that the spinal fracture was more likely to have been caused when he was taken to the ground on the second occasion or during the second period of restraint. 1513. Both Professor AL and Mr AK clearly stated that Mr Cole’s spinal fracture and spinal cord injury may have been caused at the same time or the spinal cord injury may have been caused at a later time, and it cannot be medically determined which is the case. 1514. As discussed in findings 46, 47, 48 and 49, both the spinal fracture and spinal cord injury could have been caused through Mr Cole’s contact with Mr BB, during the initial period of restraint, a combination of the two, or were not caused during either. 1515. It is similarly the case that the spinal fracture and spinal cord injury could have been caused during the second occasion he was taken to the ground, the second period of restraint on the ground or a combination of these events and/or the initial contact with Mr BB or initial restraint. 1516. Mr AK provided opinion that the spinal fracture would not cause the spinal cord injury unless the spinal alignment was affected and the vertebrae were displaced. 1517. This was echoed by Professor AL’s opinion that it was perfectly possible to have damage to the spinal column without damage to the spinal cord, and it was only when the instability [of the fracture] was exacerbated by movement of the head and neck that pressure came on the spinal cord. 1518. If Mr Cole had sustained the spinal fracture by the time the second ground restraint was applied, a use of force on Mr Cole’s neck which affected his spinal alignment may have led to the spinal cord injury and the neurological deficit. 1519. Although this would seem plausible, and finding 65 concluded that PC Oates used force around Mr Cole’s neck or head, the uncertainty regarding the location of the force PC Oates applied to Mr Cole and what other force may have been applied to Mr Cole at the time, combined with the uncertainty of the point when Mr Cole’s injuries occurred, mean that there is insufficient evidence for a tribunal to find it more likely than not to have been the case.

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1520. These points have been considered in respect of PC Oates due to findings 65 and 66 that he was in closest proximity and applied force around Mr Cole’s upper body, neck or head. Equally there is insufficient evidence of any use of force individually by PC Ross or PC Kalyan during the ground restraint which would account for Mr Cole’s injuries, or demonstrate that they were a result of a collective use of force by these officers. 1521. It is also possible that Mr Cole sustained the spinal fracture during the events discussed above, but the fracture was only displaced and the spinal cord damaged as a result of him being lifted from the ground without spinal precautions. 1522. It follows from the above that, despite findings 63, 65 and 67, regarding the positions of PC Ross, PC Oates and PC Kalyan during their restraint of Mr Cole, there is insufficient evidence for a tribunal to attribute responsibility for Mr Cole’s injuries directly to any individual(s). 1523. Finding 80: In the investigator’s opinion, although it is not possible for a tribunal to establish exactly when the injuries to Mr Cole occurred, a tribunal could find that the spinal cord injury had occurred either before Mr Cole was first lifted from the ground at 01:48:35, or was caused due to Mr Cole being lifted from the ground at that time without spinal precautions. Therefore the spinal fracture must also have occurred by this time. 1524. The loss of function exhibited by Mr Cole once he was lifted from the ground as discussed in findings 77 and 83 (below), is consistent with the descriptions provided by Mr AK and Professor AL of the neurological deficit caused by damage to Mr Cole’s spinal cord, which could only occur after the spinal fracture had been sustained. 1525. Mr AK specifically noted that the high spinal cord injury could have occurred at the scene of the restraint or could have occurred when Mr Cole was lifted and his head fell forward, flexing the C2 vertebra on the C3 vertebra. He also provided opinion [based on the CCTV footage] that when Mr Cole was carried across the ground, the weight of his head was not supported and it could be seen in extreme flexion. Mr AK stated Mr Cole’s physical state during this transfer strongly suggested neurological deficit had already occurred. 1526. This is consistent with Professor AL’s opinion that Mr Cole would have suffered paralysis or partial paralysis following the injuries. Professor AL noted that the extent of the paralysis would depend on the extent of the spinal cord injury and that it was not possible to provide an exact measurement of the degree of paralysis unless a neurological examination occurred. However, he also provided opinion based on his interpretation of the enhanced CCTV of Mr Cole at this time, as “[Mr Cole] is limp and therefore it is highly likely, certainly on the balance of probabilities, that he has already suffered the onset of paralysis”. 1527. It is therefore the investigator’s opinion that both of the injuries had occurred once Mr Cole had been lifted from the ground without spinal precautions at 01:48:35, and Mr Cole was suffering from neurological deficit from this time at the latest. 1528. Finding 81: In the investigator’s opinion, a tribunal could find that the injuries to Mr Cole occurred within the parameters of the initial contact from Mr BB (01:47:34 to 01:47:42) and the time that he was lifted from the ground by PC Ross, PC Oates and PC Kalyan at 01:48:35. However, the evidence is insufficient for a tribunal to determine the specific time(s) or cause(s) of the

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injuries. Consequently, a tribunal could not find any individual responsible for the injuries. 1529. As discussed in the findings above, in the investigator’s opinion it is possible that the spinal fracture may have been caused by:  Mr Cole’s contact with Mr BB (finding 48);  Mr Cole’s initial restraint on the ground which involved PC Ross and PC Oates (finding 49);  Mr Cole’s contact with PC Ross, PC Oates and PC Kalyan when they took him to the ground prior to the second period of restraint (finding 79);  Mr Cole’s contact with PC Ross, PC Oates and PC Kalyan during the second period of restraint on the ground (finding 79). 1530. In respect of the spinal cord injury, there is conflicting medical opinion on whether Mr Cole could have sustained the spinal cord injury before he returned to his feet around 01:47:57 (finding 47). In consideration of the other events, in the investigator’s opinion, it is possible that the spinal cord injury may have been caused by:  Mr Cole’s contact with PC Ross, PC Oates and PC Kalyan when they took him to the ground prior to the second period of restraint (finding 79)  Mr Cole’s contact with PC Ross, PC Oates and PC Kalyan during the second period of restraint on the ground (finding 79).  PC Ross, PC Oates and PC Kalyan lifting Mr Cole from the ground without spinal precautions at 01:48:35 (finding 80). 1531. In the investigator’s opinion, the evidence and medical opinion is sufficient for a tribunal to find that the earliest possible point of injury was Mr Cole’s contact with Mr BB and that both injuries must have occurred by the time Mr Cole had been lifted from the ground by PC Ross, PC Oates and PC Kalyan. 1532. However, in the investigator’s opinion, the evidence is insufficient to establish all detail of what occurred between these two events, and the medical opinion does not allow precise identification of the point of either injury, therefore a tribunal would be unable to establish the time(s) and cause(s) of Mr Cole’s injuries. 1533. Due to these ambiguities it is the investigator’s opinion a tribunal could not find any individual(s) responsible for Mr Cole’s injuries.

Mr Cole’s passage to the police van 1534. Finding 82: The evidence shows Mr Cole was conveyed to the police van by PC Oates, PC Ross and PC Kalyan. 1535. The CCTV evidence from the Local Authority and taxi office and the identification evidence within the subject officers’ interviews demonstrated that PC Oates, PC Ross and PC Kalyan were the only police officers who transported Mr Cole to the police van. 1536. Finding 83: In the investigator’s opinion, a tribunal could conclude that Mr Cole was carried to the police van while his legs dragged behind him and his head hung down unsupported; further, that Mr Cole did not walk and did not hold his head up or look around himself at this stage; accordingly that

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at this stage Mr Cole would have been suffering from neurological deficit caused by injury to his spinal cord. 1537. The police officers’ evidence of Mr Cole’s passage to the van was initially consistent: PC Oates stated he did not walk normally, but walked slowly and without effort; PC Kalyan said Mr Cole walked and “hobbled” to the van; and PC Ross stated Mr Cole was “assisted” to the van. However, PC Ross undermined her account by her statement that she was not involved in Mr Cole’s passage to the van and she only arrived at the van after him, which the CCTV demonstrated was not the case. 1538. PC C also stated that Mr Cole walked to the van, but was bent over and his knees were kinked. 1539. After they were shown the CCTV footage PC Oates and PC Kalyan both acknowledged that Mr Cole did not walk to the van and PC Kalyan said he was obviously wrong in his previous account. PC Ross acknowledged that Mr Cole did not walk to the van, but further undermined the credibility of her account of this period by making an uncertain identification of herself and stating she was still not sure she carried Mr Cole to the van, despite PC Kalyan and PC Oates positively identifying her from the footage. 1540. There was some witness evidence which stated that Mr Cole walked: In Mr AA’s first police interview he stated Mr Cole tried to take a few steps and fumbled like he had lost the use of his legs. However, he contradicted that position in subsequent interviews where he stated Mr Cole made no attempt to walk and his legs dragged on the floor; Witness 37 thought Mr Cole walked to the van, although he was in the smoking area of the nightclub at some distance; Witness 39 stated Mr Cole struggled and was “quite slouchy”; and as mentioned above Witness 24 provided an initial statement that Mr Cole struggled during his passage to the van; however, he contradicted this in a later statement. 1541. Mr BB, Witness 28, Witness 20, Witness 32, Witness 25, Witness 11 and Witness 14 stated Mr Cole did not walk and was carried, with his legs dragging behind him. These accounts are strongly supported by the taxi office CCTV footage and the Local Authority CCTV footage. It is noted that the first few seconds of the Local Authority CCTV footage cannot be made out properly due to the lighting, however, the taxi footage was clear and there were only three seconds of the Local Authority CCTV footage which were not also covered by the taxi office CCTV footage. 1542. PC Oates said that, during his passage to the police van, there were no obvious injuries to Mr Cole; his eyes were open and he was looking around. PC Kalyan said Mr Cole and PC Ross talked. The CCTV footage clearly contradicted this description by PC Oates, and after they were shown the CCTV both PC Oates and PC Kalyan acknowledged Mr Cole’s head was hanging down. 1543. Mr AA stated Mr Cole’s head was down, his mouth open and his eyes were half- closed and “rolling in his head”. Witness 28, Witness 32, Witness 25 and Witness 14 also said Mr Cole’s head was down. Mr Parson and Witness 32 said there was no noise from Mr Cole, which was also supported by PC C who said there was no communication or dialogue. 1544. In interview PC Ross, PC Oates and PC Kalyan provided their interpretations of Mr Cole’s behaviour at that stage. PC Ross and PC Oates stated that they thought he refused to co-operate and was passively resistant or non-compliant.

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PC Kalyan initially said Mr Cole was co-operative and listening in his first interview, then in his second interview he stated Mr Cole passively resisted. 1545. Witnesses Witness 21, Witness 20, Witness 11, Witness 25 and Witness 14 provided their interpretation of Mr Cole’s condition while he was being taken across the road, and described him as “lifeless”, “a dead weight”, “like a rag doll” and “like jelly”. Witness 32, Witness 25 and Witness 14 all expressed an interpretation that something was wrong with Mr Cole. 1546. Mr AA also stated Mr Cole was “a dead weight” but maintained his opinion Mr Cole was winded and would be fine when he recovered his breath. Mr BB thought Mr Cole had “given up the fight” and was not concerned for his welfare. 1547. It should also be noted that Mr AK and Professor AL provided medical opinion that Mr Cole’s neck had been fractured and his spinal cord compromised by the time he was taken to the police van, and therefore neurological deficit would have been caused. 1548. Mr AK stated that once the neurological deficit occurred Mr Cole would not be able to move purposefully or respond to conversation appropriately, it would cause a rapid loss of power below the level of injury, the arms and legs would become limp and any physical resistance to restraint would disappear. He also stated it is likely that Mr Cole’s difficulty breathing would have started as soon as his head fell forward. 1549. Professor AL’s opinion similarly described the effects of the damage to the spinal cord as a loss of neurological function below the level of damage, and noted that an injury at C2/3 affected the upper and lower limbs and breathing. 1550. He stated that Mr Cole would have weakness of the limbs, but noted this may not have been instantaneous but progressive over seconds and minutes followed by difficulty in breathing and then unconsciousness. He noted that the timeframe on the progression of the effects was variable. When asked to comment on whether Mr Cole could walk, stand, talk or move his legs after being removed from the ground, Professor AL stated he could only comment that the CCTV suggested Mr Cole was “limp, i.e. partially paralysed” at this time. 1551. He was unable to comment further on Mr Cole’s likely abilities but noted it was still possible for Mr Cole to speak, as he was still breathing at that time. 1552. Within his clarification report Professor AL added that the extent of paralysis at the time would depend on the extent of the spinal cord injury and it was not possible to provide an exact measurement of the degree of paralysis unless a neurological examination occurred. 1553. He further explained that a spinal cord injury causing respiratory arrest as in Mr Cole’s case would deprive the brain of oxygen and within five, certainly ten, minutes the heart would stop. He provided expert opinion that, allowing for the time for the paramedics to arrive, he believed that Mr Cole was breathing while being transported in the police van till arrival at the police station. It should be noted, however, that Professor AL also highlighted the variables under consideration and emphasised that there was no sliding scale or exact measurement in relation to paralysis, respiratory arrest and subsequent cardiac arrest. He also stated it was not possible to give an exact timescale. He clarified his opinion that, having viewed the CCTV at this time, Mr Cole appeared not to be using his lower limbs and appeared limp, and on the balance of probabilities he had suffered the onset of paralysis; however, he emphasised that although his

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lower limbs were not being used it did not mean that Mr Cole was completely paralysed at that time beyond reasonable doubt. 1554. In consideration of the weight of witness evidence, the CCTV footage, the police officers’ accounts which have either been retracted or deemed unreliable, alongside the condition of Mr Cole described by witnesses before and during his passage across the road, combined with the medical opinion, it is the investigator’s opinion that a tribunal could find, on the balance of probabilities, that Mr Cole did not walk and did not hold his head up or look around himself at this stage, and he would have been suffering from neurological deficit caused by injury to his spinal cord. 1555. Finding 84: It is the investigator’s opinion that a tribunal could find that at the time Mr Cole was carried across the road PC Oates, PC Ross and PC Kalyan should have recognised that his condition was due to injury, and a tribunal could further find that the officers knew that to be the case at the time they gave evidence. 1556. Although witnesses described Mr Cole as “lifeless”, “a dead weight”, “like a rag doll” and “like jelly”, no witness specifically stated that they believed Mr Cole to be ill or injured. 1557. However PC Ross, PC Oates and PC Kalyan took Mr Cole to the van and were in physical contact with him for the duration, and so were in a better place to assess Mr Cole’s condition. As discussed above at this stage Mr Cole’s spinal cord would have been compromised and he would be unable to move purposefully or respond to conversation appropriately. 1558. Due to their proximity, it is the investigator’s opinion that these officers must have been aware that in complete contrast to his earlier behaviour Mr Cole did not move purposefully or respond to conversation appropriately. While these officers have stated that they felt that Mr Cole was uncooperative or exercised “passive resistance” at this time, their knowledge that he had been taken to the ground and restrained before he subsequently became inactive should at least have given them cause for concern. 1559. As set out in finding 83 above, a reasonable tribunal would be unlikely to accept the evidence of PC Oates, PC Ross and PC Kalyan that Mr Cole walked, “hobbled” or “was assisted” to the van. 1560. It would be open to a tribunal to infer from this that the police officers have subsequently recognised that they should have known that Mr Cole was seriously ill or injured at this time.

The events at the rear of the police van 1561. Finding 85: The CCTV evidence shows that Mr Cole arrived at the police van at 01:49:07 and was moved inside the police van by 01:53:26. 1562. The Local Authority and taxi office CCTV footage clearly established the time parameters when Mr Cole arrived at the back of the police van and when the doors of the police van were shut with Mr Cole inside. 1563. Finding 86: The evidence supports that PC Ross, PC Oates, PC Kalyan and PS Withey were the only police officers directly involved with Mr Cole at the back of the police van.

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1564. The Local Authority and taxi office CCTV footage at 01:49:07 confirmed that Mr Cole was initially laid on the floor at the back of the van by PC Ross, PC Oates and PC Kalyan. PC C was present and opened the doors, but did not make contact with Mr Cole at any stage. Witness 24 and Witness 11 were at the back of the van in close proximity at an early stage before PS Withey and PC Spicer reached the back of the van and intervened. PC Spicer, PC C and initially PS Withey were then occupied with Witness 24 and Witness 11. PC Spicer and PC C then dealt with Mr Cole’s other friends who were standing away from the back of the van. 1565. PC Spicer stated he did not arrive at the back of the van until after Mr Cole was in and the doors were closed. This is demonstrably false from the CCTV, however PC Spicer can be clearly monitored throughout his presence at the back of the van and it is apparent that he spent the duration dealing with Witness 24, Witness 11 and Mr Cole’s other friends. 1566. The CCTV evidence demonstrated that after the arrest of Witness 31, Inspector Fosbury moved to the front of the nightclub and he only walked over to the rear of the van with PC H once Mr Cole was already there. 1567. Inspector Fosbury stated he only had a brief glimpse of Mr Cole because he was involved with speaking to PC H, PC A and PS G, and he also went to move his vehicle which had been blocking the road. This is supported by CCTV evidence, although Inspector Fosbury is shown to be at the rear of the van for a greater length of time than he portrayed in his initial accounts. Despite this the CCTV evidence demonstrated that he did not become directly involved with Mr Cole during this time. 1568. From all the police officers’ accounts, the only police officers who were indicated to have any real involvement with Mr Cole during this time were PC Ross, PC Oates and PC Kalyan at first, then PS Withey when he made the decision for Mr Cole to go to custody. No other police officers were indicated by their own accounts or those of other police officers as involved with Mr Cole at the back of the police van, which was supported by the CCTV evidence of the police officers’ positions and movements. 1569. Finding 87: The evidence supports that Mr Cole’s friends did not take any action which interfered with the handling of Mr Cole from 01:49:57 onwards. 1570. The CCTV evidence demonstrated that Mr Cole’s friends and the other police officers present attended the back of the van at different times. It also demonstrated that only the initial presence of Witness 24 and Witness 11 at the van could be considered to interfere with the police officers’ dealings with Mr Cole. Although Witness 32 moved closer to the van for twelve seconds at 01:50:41, he could be seen as completely passive and his only action was to stand nearby with his hands in his pockets. 1571. Other than this brief presence of Witness 32, all of Mr Cole’s friends were clearly separated from 01:49:57 onwards, and did not take any action which could be considered to interfere with the police officers. This was supported by the comments from Witness 11, Witness 24, Witness 28 and Witness 20 who all stated they were blocked from getting near Mr Cole and were told to go away. PC C, PC H, PC Spicer and PC B supported this with their statements that they blocked Mr Cole’s friends from interfering and maintained a sterile area for the police officers who dealt with Mr Cole.

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1572. Finding 88: Once Mr Cole was at the back of the police van, he was largely obscured from the view of CCTV and witnesses due to obstructions. The majority of police officers present were also prevented from observing Mr Cole due to obstructions or distractions. 1573. After Mr Cole was lifted up to the van by PC Ross, PC Oates and PC Kalyan, they were almost entirely obscured on the CCTV footage due to the obstructions of traffic and the other police officers and witnesses at the back of the van, aside from occasional moments when they could be partially seen. 1574. There is less witness evidence for the events at the back of the van. The CCTV evidence demonstrated this is likely to be due to Mr Cole’s position where the line of sight to him was blocked from the sides by the van doors, and largely blocked from other angles because there were between seven to eleven police officers standing at the back of the van between Mr Cole and any potential witnesses for the majority of the time. 1575. In respect of police witnesses, the CCTV also showed that PC Spicer, PC C and PC B predominately dealt with or monitored Mr Cole’s friends and faced away from the rear of the van. PC H and Inspector Fosbury were set back from the rear of the van and would appear to have been in conversation with each other, or with PC A and PS G. This was also evidenced across the police officers’ accounts. This provides explanation for the relatively scant amount of information from these police officers regarding Mr Cole at the rear of the van. 1576. Finding 89: There is no evidence that the subject police officers were aware of the ambulance which approached while Mr Cole was detained at the rear of the police van. 1577. Finding 90: There is no evidence that PC E, the officer who directed the ambulance away, was aware of the facts that should have caused concern for Mr Cole’s welfare. 1578. None of the subject police officers described being aware of the ambulance which approached on Mill Street and was a distance of three cars away for around 72 seconds before it manoeuvred to turn around and then drove away. The CCTV and witness evidence shows that the subject police officers were either dealing with Mr Cole or his friends during this time. It is therefore accepted that it is likely they were unaware of this ambulance. 1579. The evidence demonstrated that the police officer seen to approach the ambulance, PC E, remained with Witness 31 at the rear of the other police van, and did not have any dealings with Mr Cole. On the balance of probabilities, a tribunal could not find that PC E was in a position to be aware of any medical concerns for Mr Cole. 1580. Finding 91: The evidence supports that Mr Cole did not stand when he first arrived at the rear of the van. 1581. In respect of Mr Cole’s actions at the rear of the van, PC Oates stated Mr Cole was initially standing at the back of the van, before he sat down facing outwards with his legs hanging out of the van. PC Kalyan said Mr Cole sat down, and then stood up, then sat down again. 1582. PC Ross initially said Mr Cole did not stand but was leant forward into the van, and then in her second interview she said he was standing leaning into the van.

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1583. PC C stated he saw Mr Cole was lying at an angle facing into the van, with his abdomen in contact with the front edge of the cell and his feet on the ground. He described his body as rigid, but could not provide detail on how his head was positioned. PC B said he saw Mr Cole facing into the van with his head up, and was at waist height so he assumed Mr Cole was on his knees or crouched down. 1584. PS G stated he saw Mr Cole sitting in the van slumped or leaning forward with his head up and eyes open and his legs hanging over the edge of the van. Inspector Fosbury, PS Withey and PC C also stated Mr Cole sat in the van with his legs over the edge. 1585. The CCTV evidence clearly demonstrated that Mr Cole did not initially stand at the back of the van; he was laid on the ground with no discernible movement. The CCTV also showed that Witness 11 and Witness 24 approached Mr Cole and Witness 11 bent down, which corroborates Witness 11’s account that he had to hold Mr Cole’s head up at this time to look at him and Mr Cole’s expression was blank. He said that, when he spoke to Mr Cole, he did not seem to understand. This is also described by Witness 24 (although he stated this occurred before Mr Cole was taken to the van) who stated that Witness 11 lifted Mr Cole’s head and asked if he was okay, but Mr Cole did not answer and appeared confused. Witness 28 also noted that Witness 11 spoke to Mr Cole but he did not respond. 1586. The CCTV footage showed that PC Ross, PC Oates and PC Kalyan then lifted Mr Cole to the rear of the van, facing into the van. Mr Cole was then obscured and the CCTV footage does not assist to establish whether Mr Cole stood at the back of the van at that time. The later CCTV footage briefly showed Mr Cole’s feet in the right position for him to have been sitting at the rear of the van. 1587. As discussed in findings 79 and 83, it is the investigator’s opinion that Mr Cole had suffered neurological deficit due to damage to his spinal cord by the time he reached the police van. 1588. Mr AK provided medical opinion that once the spinal cord was compressed it would cause rapid loss of power below the level of injury; the arms and legs would become limp and any physical resistance to restraint would disappear. He also stated that it was likely Mr Cole would have started having difficulty breathing. 1589. Professor AL’s opinion, as noted above, similarly comments that Mr Cole was “limp, i.e. partially paralysed” at this time, but that it was not possible to provide an exact measurement of the degree of paralysis. 1590. The inconsistent and conflicting evidence from PC Ross, PC Kalyan and PC Oates of Mr Cole’s position and actions when standing at the back reduces their credibility. In consideration of the witness evidence and CCTV evidence of Mr Cole’s condition before he was lifted to the van out of view, and the medical opinion which tends towards Mr Cole being incapable of standing at the back of the van at this stage, it is considered that the weight of evidence is sufficient for a tribunal to be able to conclude Mr Cole did not stand at the back of the van. 1591. Finding 90: The evidence supports that Mr Cole was lifted up to the back of the van and was leant on the edge of the van facing into the van, but did not support himself on his feet at this time. He was then turned around and placed into a sitting position at the rear of the van. 1592. Given Mr AK’s opinion of Mr Cole’s capabilities at this stage, i.e. that he would have a rapid loss of power below the level of injury and his arms and legs would

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become limp, which is at least partially supported by Professor AL’s opinion of Mr Cole being ‘limp/partially paralysed’ at this time, considered alongside the CCTV footage of Mr Cole being lifted forward facing to the van, and the evidence from PC Ross, PC C and PC B of Mr Cole’s position at the van, in the investigator’s opinion a tribunal could find that it is most likely that Mr Cole was initially held up against the back edge of the cell of the van, facing forwards, but was not supporting himself on his feet. 1593. Given the police officers’ descriptions and the consistency of the evidence which indicated that Mr Cole was sitting at the back of the van, in the investigator’s opinion a tribunal could find it more likely that Mr Cole was turned around by the police officers and placed into a sitting position at the back of the van. 1594. Finding 91: The evidence supports that Mr Cole stated “My neck” or “My neck hurts” one or two times while at the rear of the police van. 1595. As discussed in finding 86, the only police officers who dealt with Mr Cole at the back of the van were PC Ross, PC Oates, PC Kalyan and PS Withey. The only accounts which described Mr Cole perform any action by his own accord were provided by these officers. 1596. PC Ross said Mr Cole complained of neck pain. PC Oates stated Mr Cole said “My neck, my neck” but did not speak after that and did not respond any further. PC Kalyan recorded in his notebook and stated in interview that Mr Cole complained about his neck, then PC Ross asked for his name and he replied “Julian”. PS Withey wrote in his notebook that Mr Cole complained about his neck and in interview he said he heard Mr Cole say “My neck hurts” once. 1597. PC C said he heard someone say that the male complained about his neck and he attributed this to PC Ross. PC B stated he did not hear Mr Cole speak or police officers speak to him. Witness 32 said he did not hear anyone except Witness 11 speak to Mr Cole. 1598. The recording of PC Ross’s request for an ambulance made at Greyfriars police station demonstrated that PC Ross reported Mr Cole had complained of a neck injury. 1599. Mr AK stated that after the neurological deficit Mr Cole would be unable to follow simple commands with his arms, it was likely he would have started having difficulty breathing, and the suggestion that Mr Cole was able to act appropriately, engage in conversation, move purposefully or respond to conversation appropriately was implausible, and it was also implausible that he could recover enough to do this. 1600. Professor AL provided opinion that, although Mr Cole was suffering partial paralysis at this time, if he was able to breathe then he would be able to speak. 1601. In his clarification report Professor AL explained his expert opinion based on the timing of Mr Cole’s cardiac arrest was that Mr Cole was breathing while being transported in the police van until arrival at the police station, although he noted it was not possible to give an exact timescale. 1602. The most cogent evidence which established that Mr Cole complained about his neck at some stage is the reference contained within PC Ross’s request for an ambulance; it is implausible that PC Ross would have reported a complaint of neck injury to the ambulance service if it did not occur. Although the subject officers’ evidence of Mr Cole’s condition in this period has not been accepted in a

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number of respects the weight of evidence from police officers, and significantly, the contemporaneous evidence of PC Ross’s request for an ambulance are sufficient for a tribunal to be able to conclude Mr Cole did make comment regarding his neck while at the back of the police van. 1603. The most consistent description was that Mr Cole stated “My neck” or “My neck hurts” no more than two times. The medical opinion from Professor AL would support that Mr Cole was able to make these statements at this time despite his injuries, and the opinion from Mr AK does not conflict with this, as he only stated it was implausible for Mr Cole to “engage in conversation” and that he would likely have difficulty breathing. It is the investigator’s opinion that this would not preclude Mr Cole from speech as basic as “My neck” or “My neck hurts”. 1604. While PC Kalyan stated that Mr Cole gave his name to PC Ross, PC Ross provided no record that she asked Mr Cole’s name before the journey to Greyfriars police station and the only name she recorded was ‘Owens’. There was no other evidence which supported that Mr Cole said anything except for the basic comments about his neck. For these reasons it is considered that a tribunal could find it unlikely that Mr Cole provided his name while at the back of the van. 1605. Finding 94: The evidence shows that Mr Cole did not put his trainer on while at the back of the police van. 1606. PC Kalyan stated that Mr Cole was given his trainer and he put it on, and PC Oates stated they asked Mr Cole to put his trainer on and then his trainer was on his foot, although he could not recall how it was put on. 1607. This action is contradicted by the CCTV evidence; PS Withey was seen to take Mr Cole’s trainer from Witness 24 and place it in the back passenger section of the van, then Mr Cole’s feet were seen immediately before he was placed into the cell of the van with one trainer missing. It was also contradicted by PC Ross’s statement that she picked up Mr Cole’s trainer from the rear of the van at Greyfriars police station, and paramedic Witness 7’s statement that she saw one of Mr Cole’s trainers at the rear of the van at Greyfriars police station. 1608. Finding 95: The evidence supports that PC Ross informed Mr Cole of his arrest at the van. Although he could have been notified sooner it is the investigator’s opinion a tribunal would be unlikely to find that the delay amounted to a breach of the standards of professional behaviour. 1609. The evidence from PC Ross and PS Withey sufficiently demonstrated that PC Ross was the arresting officer, and that she did not inform Mr Cole of his arrest until he was at the rear of the police van before he was moved into the cell of the police van. PC Ross said that she felt that she informed Mr Cole of his arrest at the appropriate time. 1610. As discussed in finding 71, the evidence supports that there was no interference in the officers’ dealings with Mr Cole at the point that he was handcuffed and then lifted from the ground, and therefore PC Ross could have notified Mr Cole of the reasons for his arrest at that time. 1611. Despite the finding that that it was not the earliest opportunity for Mr Cole to be notified of his arrest, it is accepted that he was notified within a short time of being handcuffed, and it is the investigator’s opinion a tribunal could not find on the balance of probabilities that the delay would amount to a breach of the standards of professional behaviour.

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1612. Finding 96: The evidence supports that Mr Cole did not have a visible physical injury, but he presented as physically and mentally unresponsive. 1613. There was a greater level of evidence which described Mr Cole’s condition at the back of the police van. 1614. PC Ross stated that physically Mr Cole seemed to be fine; she said he had no obvious injury, no signs of injury and did not display any behaviour he was unwell. 1615. PC Kalyan wrote in his notebook that Mr Cole was “groggy” when he spoke and said he did not see any injuries to Mr Cole’s head. 1616. PC Oates said Mr Cole’s eyes were wide open and he assumed he was alert and conscious. He said Mr Cole did not display any signs of pain, and there were no signs of injury or illness and nothing obvious to suggest there was anything medically wrong. He maintained this was the case when Mr Cole was put into the van and said his eyes were open and he looked around. 1617. PS Withey said Mr Cole was coherent when he complained about his neck, and when he was in the van he could see in Mr Cole’s eyes that he was conscious. He said Mr Cole was not floppy and was upright. 1618. Inspector Fosbury stated from his position there was no visible indication that Mr Cole was hurt. 1619. PS G said Mr Cole had a “glazed expression”, and PC B stated that he thought Mr Cole was conscious because he held himself up, although he saw Mr Cole from behind and his view was obstructed. He said he did not see any injury. 1620. Witness 11 said that when he got to the rear of the police van he had to hold Mr Cole’s head up to look at him and Mr Cole’s expression was blank. He said when he spoke to Mr Cole, he did not seem to understand. 1621. The CCTV evidence indicated this to be when Mr Cole was laid on the ground by the van after he was carried across the road. Witness 24 also stated that Witness 11 lifted Mr Cole’s head and asked if he was okay, but Mr Cole did not answer and appeared confused. Witness 28 also noted that Witness 11 spoke to Mr Cole but he did not respond. 1622. Witness 11 said Mr Cole was up and breathing but his whole demeanour had changed from being able to walk, talk and generally be coherent to being the total opposite. Witness 20 said Mr Cole’s head bounced when he was put in the cell and his eyes slowly opened and closed. He said that, when Mr Cole was asked if he was okay, he did not answer or acknowledge the question. Witness 32 described Mr Cole as ‘paralytic with no control’. 1623. There was no evidence from any police officers or witnesses that Mr Cole had any non-behavioural sign of physical injury at this time. 1624. This was supported by the expert opinion of Mr AK who stated that Mr Cole did not have any evidence of injury to his head, and confirmed that the fracture of his neck and spinal cord injury would not have any visual signs. It was also supported by Professor AL’s expert opinion and his reference to the medical notes which stated “no external sign of injury”. 1625. Professor AL also noted there was no evidence of any injury to Mr Cole apart from the spinal fracture and spinal cord injury, for which he listed only behavioural signs as observable.

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1626. The evidence from PC Ross, PC Oates and PS Withey of Mr Cole’s behaviour and demeanour presented him as alert, conscious, looking around, coherent and with no indication that he was not in a healthy state. The evidence from PC Kalyan and PS G that Mr Cole was “groggy” and had a “glazed expression” contradicted this but neither described any other sign of injury. 1627. In stark contrast, the evidence from Witness 11, Witness 24, Witness 28, Witness 32 and Witness 20 presented Mr Cole as clearly incapacitated, which would be consistent with the CCTV evidence of Mr Cole’s condition when he was taken to the police van. The CCTV footage also supported the descriptions of events provided by Witness 11 and Witness 24, and confirmed that they were both in a position to directly observe Mr Cole’s condition at this time. 1628. The medical opinion from Mr AK also corroborated the evidence from Witness 11, Witness 24, Witness 28, Witness 32 and Witness 20, and the CCTV evidence, with his description that once Mr Cole was injured, he would suddenly become limp and unresponsive, and this change in behaviour would be clearly observable, even to a layperson. 1629. Professor AL’s opinion was also that Mr Cole was limp and partially paralysed at this time, and that for an outside observer, the signs would be Mr Cole complaining of neck pain, progressive weakness of the limbs and then difficulty in breathing, although he has noted that the timeline of deterioration in this case could not be determined but was over a period of at least some minutes. 1630. When all evidence of Mr Cole’s condition from the point at which he was handcuffed is considered alongside the objective evidence of the CCTV footage, medical opinion of Mr Cole’s capabilities and presentation after injury and the findings above which go against the subject police officers’ descriptions of events, it is the investigator’s opinion a tribunal could find that their descriptions of Mr Cole’s condition are not credible. 1631. In the investigator’s opinion, the evidence is sufficient for a tribunal to find that Mr Cole was not alert, coherent or presenting in a healthy condition, and although Mr Cole did not have a visible physical injury, he presented as physically and mentally unresponsive. 1632. Finding 97: It is the investigator’s opinion that a tribunal could find that, at the time Mr Cole was at the rear of the police van, PC Oates, PC Ross, PC Kalyan and PS Withey should have recognised that his condition was due to injury. A tribunal could also find that these police officers knew that to be the case at the time they gave evidence. 1633. PC Ross said she thought Mr Cole’s change of behaviour was because he was handcuffed and police officers were now in control of the situation. In respect of his complaints of neck injury, PC Ross said that people would complain of injury all the time and they would have to “go through the motions”. 1634. PC Oates said he thought Mr Cole was refusing to co-operate as he had done all night, and he assumed Mr Cole may have worn himself out. He said a lot of experienced police officers were present and he assumed if there was something wrong with Mr Cole “someone would have noticed”. 1635. PS Withey said there were numerous occasions when someone complained of injuries that were not real; people would feign injury or illness to get themselves de-arrested and he was not convinced Mr Cole had a serious injury. In his

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notebook and in interview he said he was not overly worried about Mr Cole’s injuries or condition at that point. 1636. PS G stated that when he saw Mr Cole with a “glazed expression” it was the appearance of someone resigned to their arrest or who had drunk alcohol to excess. 1637. Witness 11 said he was worried about Mr Cole being arrested, rather than about his health, because he was up and breathing. Witness 20 said he attempted to ask if Mr Cole was okay and Witness 32 stated he was concerned for Mr Cole, because he knew Mr Cole was not drunk but presented as though he was paralytic. He stated he was not sure why Mr Cole was in that state and the police officers did not seem to know. 1638. The witnesses who commented on Mr Cole’s condition when he was at the police van did not specifically state they believed him to be ill or injured. However, as discussed in findings 82 and 86, PC Ross, PC Oates and PC Kalyan were in close proximity to Mr Cole for the duration that he was at the rear of the police van, without any significant interference from any bystanders. 1639. For the reasons given above, the descriptions of Mr Cole’s condition at this time given by PC Ross, PC Oates and PC Kalyan may not be considered by a tribunal to be credible. Therefore no reliance can be placed on their claims that there was no indication that Mr Cole may have been suffering from serious injury. The evidence that PC Ross asked whether Mr Cole should be taken to hospital in itself indicates she recognised a potential welfare concern at the time, and she has not provided an explanation other than her implication it was to “go through the motions”. 1640. It would be open to a tribunal to infer from this that these police officers have subsequently recognised that they should have known that Mr Cole was seriously injured at this time, and have misrepresented Mr Cole’s condition in an effort to avoid criticism. 1641. Finding 98: A tribunal could find that no one performed an adequate medical assessment or welfare check on Mr Cole before the decision to take him to custody or before he was transported away from the scene. 1642. Despite the statements from PC Ross, PC Kalyan and PS Withey that Mr Cole complained about his neck, the only evidence of any examination or assessment of Mr Cole’s condition was put forward by PC Ross and PC Kalyan as the request for Mr Cole to move his legs. 1643. As discussed in finding 96 it is the investigator’s opinion that Mr Cole was physically and mentally unresponsive at this time, and the evidence of his condition from the subject officers may not be considered to be credible. 1644. Mr AK provided opinion that Mr Cole would be suffering neurological deficit at this time, leaving him unable to move purposefully, and he would be unable to follow simple commands with his arms. 1645. Professor AL provided opinion that Mr Cole would have progressive weakness in the limbs and was partially paralysed at this time, but it was not possible to provide an exact measurement of the extent of paralysis.

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1646. However, Professor AL also provided opinion that the spinal cord damage was incomplete, and so movement of his arm was possible. He also emphasised that it was not possible to determine the timeline of the deterioration. 1647. As such, there is contradictory medical opinion on whether Mr Cole would be able to move his limbs in response to a request from PC Ross at this time; Mr AK provided opinion that he would not be able to do so, whereas Professor AL provided opinion that it was possible. 1648. Therefore the investigator cannot attach more weight to one or the other medical opinion to reach a finding on whether Mr Cole physically could have moved his legs in response to a request from PC Ross . 1649. However, PC Ross said Mr Cole moved his legs in response to her request while he was standing leaning into the van; PC Kalyan said Mr Cole did so while sitting at the van; PC Oates does not make any reference to this instruction or any welfare check by PC Ross, and PS Withey stated that no one examined Mr Cole or asked if he had any other injuries. 1650. A tribunal could find that these contradictory accounts undermine PC Ross’s claim that Mr Cole moved his legs at her request. 1651. Furthermore, PC Ross’s claim that she saw Mr Cole’s legs move would not justify her lack of further assessment. She has stated that she has been given no training on recognising or dealing with spinal injuries, and therefore she was in no position to conclude that movement of the legs would negate a serious injury, especially given the risks involved. 1652. PC Oates also stated he did not check for injuries because doing so may exacerbate a neck injury. However, this is a contradictory argument as he either thought there may be a neck injury and should have taken measures to obtain treatment, or he did not think there was a neck injury and therefore would not have exacerbated it by examination. PC Oates has also undermined his own justification by stating he has no medical training or knowledge of neck injuries. 1653. PC Kalyan stated someone checked Mr Cole’s head for injury, and PC Ross, PC Oates and PS Withey tried to make sure of Mr Cole’s wellbeing and see what sort of injury he had. However, given that none of the officers make any reference to this and it was directly contradicted by PS Withey, and given the overall lack of credibility of PC Kalyan’s description of events at the back of the van, a tribunal could find that this aspect of his account is not considered credible. 1654. In the investigator’s opinion, the evidence is sufficient for a tribunal to find that, although the police officers stated there was no visible injury to Mr Cole, there was a lack of adequate action to check for injury or otherwise assess his wellbeing before he was taken away from the scene. 1655. Finding 99: The evidence supports that PS Withey made the decision that Mr Cole should be taken to custody and not to hospital. The evidence supports that he did not receive or obtain any information to make this decision except for Mr Cole’s comment about his neck and PS Withey’s sight of Mr Cole; further, that PS Withey assumed that Mr Cole was feigning injury and did not carry out or order a welfare check to verify his assumption.

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1656. In respect of the decision to take Mr Cole to custody, as concluded in findings 93 and 96, Mr Cole did not have a visible physical injury, but he stated “My neck” or “My neck hurts”, and was otherwise physically and mentally unresponsive. 1657. PC Ross said she asked PS Withey whether Mr Cole should go to custody or go to hospital. She said she did not know what prompted her to ask the question, but thought it was because he was a custody-trained sergeant and because they would frequently arrive at custody to be told that a detainee should be taken to hospital. 1658. PC Oates said that PC Ross asked PS Withey “Should we call an ambulance?”, but did not state why the question was asked. 1659. PC Kalyan said only that PC Ross relayed information back to PS Withey and told him that Mr Cole had banged his head. 1660. PS Withey said PC Ross asked him “Custody or ambulance?” but acknowledged that no one examined Mr Cole or asked if he had any other injuries. 1661. In the investigator’s opinion the evidence is sufficient to find that PC Ross put the question to PS Withey, and PC Oates and PC Kalyan were also present when this occurred, but none of them provided any detail of the what had happened to Mr Cole, i.e. that he had been forcefully taken to the ground by a doorman, then taken down again by police, and had then become passive or unresponsive. 1662. PC Kalyan’s statement that PS Withey was informed of a potential head injury was not evidenced by anyone else and in the investigator’s opinion a tribunal could not find it credible. 1663. PS Withey’s account demonstrated that he did not seek any further information to make his decision, either through questions to the police officers who dealt with him or through examination or questions to Mr Cole. PS Withey confirmed he did not carry out or instruct any form of welfare check to allow him to make a reasoned decision. 1664. When asked to explain his decision, PS Withey explained his experience was that detainees would feign injury to avoid arrest and he was not convinced at that time that Mr Cole had a serious injury. He recorded in his notebook and in interview that he was not overly worried about Mr Cole’s condition. 1665. PS Withey was a custody-trained sergeant, meaning that he had a greater level of training in respect of first aid and conducting a risk assessment for an individual. Due to his higher rank and custody-trained status, PS Withey would undoubtedly have been aware that, when PC Ross asked him for a decision on custody or hospital, she would defer to his judgement and would follow his instruction. However, he did not take steps to gather information to make a robust decision. 1666. Finding 100: The evidence supports that PC Ross, PC Oates and PC Kalyan deferred to the decision making of the police officers around them and did not take direct responsibility for decisions regarding Mr Cole’s welfare. 1667. PS Withey stated that it was a matter for individual police officers to gauge the information that they had to consider whether an ambulance should have been called.

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1668. The evidence demonstrates that PC Ross did not do this, but instead put the question to PS Withey, despite her greater level of knowledge of events and her direct contact with Mr Cole. 1669. PC Oates suggested that if something was wrong with Mr Cole then one of the police officers there would have noticed. 1670. PC Kalyan stated that PS Withey was informed that Mr Cole hit his head and that “someone’”checked Mr Cole for head injuries, but a tribunal may find that this description is not credible. He has not otherwise explained why he did not ensure that the head injury he believed to have occurred was included within the decision to take Mr Cole to custody. 1671. This evidence is sufficient for a tribunal to conclude that PC Ross, PC Oates and PC Kalyan deferred to the decision making of the police officers around them and did not take direct responsibility for the decisions regarding Mr Cole’s welfare. 1672. Finding 101: The evidence supports that PC Ross and PC Oates assumed Mr Cole was non-compliant and/or feigning injury. 1673. PC Ross has explained that she thought Mr Cole’s condition was due to non- compliance and made comments within interview of “people say it all the time” and “We have to go through the motions”. This implies that she thought Mr Cole was feigning injury. 1674. PC Oates stated he thought Mr Cole was refusing to co-operate and was passively resistant or non-compliant. He also stated he assumed Mr Cole may have worn himself out. 1675. A tribunal could find that these accounts demonstrate that PC Ross and PC Oates clearly noted a change in Mr Cole’s demeanour, but have relied upon assumptions of non-compliance or feigning injury to explain their actions.

Mr Cole’s passage into the cell of the police van 1676. Finding 102: The evidence indicates that PC Ross and PC Oates moved Mr Cole into the cell of the police van between 01:52:49 and 01:53:14. 1677. The involvement of PC Ross and PC Oates in Mr Cole’s placement in the cell of the van is supported by the CCTV footage. PC Ross gave evidence that she pulled Mr Cole into the van and the CCTV footage showed that Mr Cole’s legs moved out of view at the same time that PC Ross was bent down within the cell. The evidence therefore supports the timing for Mr Cole’s placement in the van, which the CCTV would place at 01:52:49. 1678. Shortly afterwards a police officer without high-visibility clothing crouched down in the cell of the van. PC Oates identified himself as involved in Mr Cole’s placement into the van so it would be reasonable for a tribunal to conclude that he was the second police officer. The CCTV footage showed that both PC Ross and PC Oates were out of the cell of the van by 01:53:14. 1679. Finding 103: The evidence supports that Mr Cole was sitting on the floor of the van between the two seats with his back against the perspex or one of the seats. 1680. In reference to Mr Cole’s movement into the cell of the police van, PC Ross said she pulled him in from under his arms and PC Oates shuffled his legs into the van, then Mr Cole was sat up in the cell. PC Oates wrote in his notebook that he

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and PC Ross assisted Mr Cole into the van, and on PC Oates’s request Mr Cole pulled his legs in. In interview PC Oates emphasised that Mr Cole pulled his legs into the cell on his own. PS Withey stated Mr Cole was pulled into the van by PC Ross and PC Oates, and said his legs would have been moved around into a seated position, but he did not know how that happened. PC Kalyan said Mr Cole pushed himself back or was pushed back into the cell and was sat on the floor. 1681. Witness 11 stated that police officers had to physically put Mr Cole in the cell. Witness 20 said the police officers picked Mr Cole up one step at a time and dragged him across the floor before he was placed with his back to the wall and he slid down the wall. Witness 32 said Mr Cole was put in the van front first with his legs hanging out of the van, before his legs were swept in, but he did not see him sitting in the van. PC C was the only police witness to describe Mr Cole in the van and could only state that he was sitting on the floor with his back against one of the seats with his legs bent, feet on the floor and knees in the air. 1682. While there were few specific details about Mr Cole’s position within the cell of the van, the consistent details were that Mr Cole was sitting on the floor between the two seats and had his back against the perspex or against a seat. 1683. Finding 104: In the investigator’s opinion, a tribunal could find that once at the police van Mr Cole did not move his legs at any time or push himself back in the police van; Mr Cole was placed into the cell of the van and had his legs moved for him by the police officers. 1684. In their notebooks and interviews PC Ross and PC Kalyan said Mr Cole moved his legs after being asked. In interview PC Ross said this was while he was standing leaning into the van. PC Kalyan said Mr Cole was sitting at the van when PC Ross spoke to him and asked him to move his legs. PC Oates stated Mr Cole pulled his legs into the van at his request when he was being moved into the cell of the van. 1685. Although PC Ross, PC Kalyan and PC Oates all stated that Mr Cole moved his legs, the detail of when this occurred was inconsistent, and no one else reported Mr Cole to have moved, which undermines the reliability of their accounts. 1686. PC Oates’s account that Mr Cole pulled his legs into the van was also contradicted by PC Ross, who stated PC Oates moved his legs for him. PC Kalyan’s suggestion that Mr Cole may have pushed himself back in the van is contrary to all other evidence regarding his movement into the cell and also lacks plausibility considering that Mr Cole was handcuffed to the rear. 1687. The witness evidence from Witness 11, Witness 20 and Witness 32 contradicts the accounts from PC Oates and PC Kalyan, as does the overall evidence of Mr Cole’s condition after he was handcuffed. 1688. Mr AK provided opinion that by this time Mr Cole would have suffered a rapid loss of power, his arms and legs would become limp and he would be unable to follow simple commands with his arms ,or move purposefully. 1689. Professor AL provides opinion that Mr Cole was “limp, i.e. partially paralysed” at this time, and would have progressive weakness in the limbs, but has provided opinion that movement of his arm was possible and the timeline for deterioration cannot be determined. 1690. As discussed previously, there is contradictory medical opinion on whether Mr Cole would be able to move his limbs after the damage to his spinal cord. This

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means that the investigator cannot rely on the medical opinion to state that it would not be possible for Mr Cole to move his legs after the point of injury. 1691. However, the officers’ accounts of Mr Cole moving his legs are contradictory, as discussed above, and when considered alongside PC Oates’s and PC Kalyan’s demonstrably incorrect evidence that Mr Cole’s trainer was placed back onto his foot, it is the investigator’s opinion that a tribunal could find that these police officers’ accounts that Mr Cole moved his legs or put himself into the cell of the police van, are not credible. 1692. In the investigator’s opinion a tribunal could find that once at the police van Mr Cole did not move his legs at any time in the deliberate manner described by these police officers or push himself back into the police van.

Consideration of Mr Cole’s injuries being caused by his placement in the police van 1693. Finding 105: In the investigator’s opinion, a tribunal could find that Mr Cole’s breathing difficulties would have developed when he was put in the cell of the van, during the journey, or when he was removed from the van and sat at the back of the van in the yard, all without spinal precautions. 1694. Mr AK provided expert opinion that the lack of oxygen to the brain would be a complication of a progressive respiratory failure, brought about by poor positioning of the airway and the paralytic effects of the spinal cord injury on the diaphragm and chest wall muscles. 1695. Mr AK added that Mr Cole’s difficulties breathing (secondary to an obstructed airway) would start as soon as Mr Cole’s head fell forward, but would have continued and been exacerbated in the back of the police van if Mr Cole’s head and neck were not properly positioned. 1696. Professor AL also provided expert opinion that the compression of the spinal cord would cause paralysis of the muscles of breathing, causing a respiratory arrest, which in turn caused lack of oxygen to the brain. He also noted that damage to the right vertebral artery may have been an additional cause of lack of oxygen to the brain. 1697. In his discussion of the timing, Professor AL stated that the respiratory arrest experienced by Mr Cole would deprive the brain of oxygen and within five to ten minutes his heart would stop. He also noted that, if the heart was stopped for between five to ten minutes, then it would not start again, although he emphasised that the cardiac arrest may have been preceded by several minutes of irregular heartbeat. 1698. As noted above, in his clarification report Professor AL added that, based on the timing of Mr Cole’s cardiac arrest, he believed Mr Cole was breathing, i.e. had not suffered respiratory arrest, while being transported in the police van till arrival at the police station, although he noted it was not possible to give an exact timescale, and throughout his opinion he has emphasised that the onset of paralysis could have been progressive. 1699. As discussed in finding 93, the evidence supports that Mr Cole was able to make some comment regarding his neck while at the back of the police van, and therefore Mr Cole’s respiratory muscles were not entirely paralysed at this time and his airway was not obstructed to the extent that he could not breathe at all.

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Witness 11 also gave evidence that Mr Cole “was breathing” before he was put in the back of the police van. 1700. As discussed in findings 102 and 103, Mr Cole was moved into a different position when he was placed into the cell of the police van between 01:52:49 and 01:53:14. Based on the evidence of the case there is no suggestion that Mr Cole’s position changed in any significant way until he was then removed from the police van at Greyfriars police station at approximately 01:59am. As discussed in finding 116 below, Mr Cole was unconscious by the time of the arrival of paramedics at 2.10am and he went into cardiac arrest when he was transferred to the ambulance, indicated as 2.16am on the CCTV and recorded as 2.18am on the patient care form. 1701. The indications are therefore that Mr Cole’s breathing difficulties could have developed when he was put in the cell of the van, during the journey, or when he was removed from the van and sat at the back of the van in the yard, supported by police officers, all of which occurred without him having any neck or spinal support. 1702. As discussed in finding 103, Mr Cole was positioned on the floor of the van cell between the seats of the van. In the investigator’s opinion, a tribunal could find that his placement in this relatively confined space without neck support could have contributed to progressive respiratory difficulties, which is supported by the opinion of Mr AK, and would not be contradicted by the opinion of Professor AL.

Mr Cole’s transport to Greyfriars police station 1703. Finding 106: A tribunal could find that Mr Cole may have attempted to respond to questions during the journey to Greyfriars police station, but he was incoherent and he did not engage in conversation. 1704. The evidence of Mr Cole’s transport from the scene to Greyfriars police station is provided only from the accounts PC Oates, PC Spicer and PC Ross. 1705. These accounts all state that the cell light was turned on and PC Ross stood at the back of the van and monitored Mr Cole throughout the journey to Greyfriars police station. This action is in accordance with guidance on the transportation of detainees. There is no evidence to the contrary but it is noted that the accounts of these officers, particularly PC Ross and PC Oates, when they can be tested against other evidence about Mr Cole’s condition, have been contradicted by other evidence. Therefore, no great reliance can be placed on their accounts of the journey to Greyfriars police station, which cannot be tested. 1706. The evidence put forward by PC Ross and PC Spicer was that PC Ross was the only police officer in a position to observe or interact with Mr Cole, aside from what was audible to PC Spicer or PC Oates. There is no evidence to contradict this position. 1707. PC Ross provided a notebook entry that Mr Cole gave his surname as “Owens”, and in interview she said Mr Cole was conscious and spoke to her throughout the journey, although she stated she could not really understand him and the only specific response she could remember was when he said his name was “Owers” or “Owens”.

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1708. PC Spicer wrote in his notebook that Mr Cole engaged but was incoherent. In interview he stated he could hear Mr Cole responded incoherently at the right time to answer questions. 1709. In his notebook and interview PC Oates stated he could hear that PC Ross and PC Spicer spoke to Mr Cole, but could not hear any response over the sound of the van. 1710. Both PC Spicer and PC Oates reported hearing PC Ross say “Oh, so your name is Owers?” 1711. As discussed in finding 93 it is accepted that Mr Cole was able to make basic comments about his neck before he was put into the van, and therefore a tribunal may find it is plausible that Mr Cole attempted to respond to PC Ross’s questions. 1712. Professor AL also provided opinion that if Mr Cole was able to breathe then he would be able to speak, although he has not provided comment on the extent to which Mr Cole could speak or converse. 1713. However in consideration of PC Ross’s inability to provide any detail of Mr Cole’s responses and her comment that she could not understand him, along with PC Spicer’s evidence that he was incoherent and combined with the opinions of Mr AK that Mr Cole would not be able to engage in conversation and would have been going into progressive respiratory failure during this time, it is considered that a tribunal could find that, although Mr Cole may have attempted to respond, PC Ross’s account that they had a conversation is not credible. 1714. Finding 107: In the investigator’s opinion a tribunal could find that Mr Cole did not move his legs during the journey to Greyfriars police station. 1715. In her police notebook PC Ross wrote that Mr Cole moved around in the cell, and in interview she stated Mr Cole moved his legs, however she was inconsistent within in the same interview; she first stated he moved his legs onto one of the seats, then later said he moved only one leg onto the seat then back down. 1716. Mr AK provided opinion that Mr Cole would not be capable of moving purposefully at this time, after his spinal cord was compressed and he was suffering neurological deficit. 1717. Professor AL has provided opinion that the damage to Mr Cole’s spinal cord was incomplete and although he has stated Mr Cole appeared to be “limp” and therefore suffering “partial paralysis”. 1718. Professor AL has also provided opinion that Mr Cole would have progressive weakness in the limbs, but that it was not possible to provide an exact measurement of the degree of paralysis, and the timeline for deterioration cannot be determined. 1719. As such there is contradictory medical opinion on whether Mr Cole would be able to move his limbs after the damage to his spinal cord. 1720. In consideration of the evidence of Mr Cole’s condition at the time he was put into the cell of the police van, as discussed in findings 96 and 104, alongside the findings which conflict with PC Ross’s previous descriptions of Mr Cole’s movement and condition, it is the investigator’s opinion that a tribunal could find her description that Mr Cole moved his legs in the van is not credible. Given the overall evidence of Mr Cole’s condition and the previous findings in relation to his

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movement after being handcuffed, it is the investigator’s opinion that a tribunal could find that Mr Cole did not move his legs during the journey. 1721. It should also be noted that PC Ross stated there was no change to Mr Cole’s condition and offered nothing to account for Mr Cole being conversant “throughout the journey” but then inexplicably incapacitated when they opened the doors of the van at Greyfriars police station. A tribunal may consider this to further undermine her description of Mr Cole’s behaviour and condition during the journey.

Mr Cole’s arrival at Greyfriars police station and removal from the police van 1722. Finding 108: The evidence supports that Mr Cole did not walk or attempt to walk when removed from the van at Greyfriars police station. 1723. The CCTV evidence and accounts from PC Ross, PC Oates and PC Spicer demonstrated that as soon as they parked within the rear yard of Greyfriars police station they went directly to the rear of the van and Mr Cole was removed from the van cell. 1724. PC Oates wrote in his notebook and stated in interview that Mr Cole did not follow instructions to leave the van and when he was taken a few steps Mr Cole could not stand on his feet and kept dropping his weight or dropping to his knees. PC Ross described Mr Cole as unco-operative and said his legs were “floppy” and he would not take his weight. Conversely, PC Spicer said he did not use his legs. 1725. PC Ross and PC Oates both reiterated their opinion that Mr Cole was being deliberately non-compliant or his condition was due to alcohol or drugs. PC Spicer also stated he formed the impression Mr Cole may be displaying passive resistance but said he did not want to make that assumption. 1726. Mr Cole’s passage out of the van at this stage was not visible on the CCTV footage, but when he came into view it showed he was carried by PC Spicer and PC Oates and his legs dragged behind him. For the short amount of time that he was visible there was no discernible movement from Mr Cole. 1727. In consideration of this footage combined with PC Spicer’s account, the medical opinion from Mr AK of “loss of function” and from Professor AL of “partial paralysis”, and the previous findings in relation to Mr Cole’s condition, in the investigator’s opinion a tribunal could find that Mr Cole did not walk or attempt to walk. 1728. Finding 109: A tribunal could find that Mr Cole did not speak while at Greyfriars police station. 1729. PC Ross stated that Mr Cole still complained about his neck at this stage, which then caused her to call an ambulance. This was contradicted by PC Spicer, PC Oates and PC D all of whom said they did not hear Mr Cole speak. 1730. There is contemporaneous evidence of the records of the call in which PC Ross reported a “male complaining of a neck injury”, which supports her account, albeit PC Ross may have reported this in reference to his earlier comments about his neck while still at the scene. 1731. As discussed in finding 93, Professor AL’s opinion would support that Mr Cole could speak if he was breathing, and this is not contradicted by Mr AK’s opinion.

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1732. Both Mr AK and Professor AL provided opinion that the spinal cord injury would cause Mr Cole respiratory difficulties due to the paralysis of the muscles which control breathing, and that these effects would be progressive, however, there is uncertainty regarding the extent of the breathing difficulties at this time. 1733. Despite this uncertainty in the medical opinion, PC Ross’s evidence is contradicted by the other officers, and considering the previous findings in relation to Mr Cole’s condition, a tribunal could find it more likely that Mr Cole did not speak at this stage. 1734. Finding 110: The evidence supports that Mr Cole’s handcuffs were repositioned from the rear to the front by PC D. 1735. The CCTV footage and police officers’ accounts demonstrate that when PC D arrived, Mr Cole was taken back to the rear of the van. These police officers all stated this was because there was a queue to enter custody, and they wanted to change the position of Mr Cole’s handcuffs to his front which would make him more comfortable and easier to transport. 1736. The evidence which described the change of the position of Mr Cole’s handcuffs was inconsistent. The positions of police officers conflicted and PC D stated he changed the position of Mr Cole’s handcuffs unassisted while PC Ross stated that she moved Mr Cole’s right handcuff. 1737. Given that PC D provided a high level of detail on the process of how he moved Mr Cole’s handcuffs, and that it is inherently implausible that he would declare his involvement to this level of detail if he was not involved, it is considered more likely than not that PC D was the police officer who repositioned Mr Cole’s handcuffs. 1738. Finding 111: The evidence supports that PC Ross was responsible for the decision that the handcuffs should be reapplied to Mr Cole’s front while in the yard at Greyfriars police station. In the investigator’s opinion, PC D’s contact with Mr Cole and the repositioning of his handcuffs would be unlikely to engage any breach of the standards of professional behaviour. 1739. While it has been found that PC D repositioned Mr Cole’s handcuffs, PC Ross was the arresting officer and as Mr Cole was under her care she would take ownership of the decision to keep him in handcuffs. 1740. The evidence of PC D’s involvement is sufficient to show that he suggested the repositioning of Mr Cole’s handcuffs for the benefit of Mr Cole and the officers dealing with him. 1741. Although PC D was in close contact with Mr Cole while he repositioned the handcuffs, the CCTV footage demonstrated this was only brief and there is insufficient evidence to indicate that he knew or must have known that Mr Cole was in a poor state of health. 1742. In the investigator’s opinion, PC D’s contact with Mr Cole and his actions to reposition the handcuffs would be unlikely to engage any breach of the standards of professional behaviour. 1743. Finding 112: The evidence supports that PC Ross did not provide justification for the use of force through continued application of handcuffs to Mr Cole while waiting for an ambulance to attend.

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1744. Application of handcuffs is a use of force that would need to be justified on each occasion that they are used. PC Ross stated that Mr Cole’s handcuffs were moved to his front because the ambulance was on his way, he was compliant and it would be more comfortable to him, but has not justified why they would still be necessary at that stage. 1745. Finding 113: In the investigator’s opinion, a tribunal may find that Mr Cole did not move of his own volition while at Greyfriars police station. 1746. PC Spicer and PC Ross both stated that, when Mr Cole’s hands were free during the repositioning of his handcuffs, Mr Cole slid to one side and put his hand out to stop himself from falling. PC D stated PC Spicer and PC Ross held Mr Cole by the shoulders at this stage and stated he did not see Mr Cole move during his involvement. PC Oates stated that he and PC Ross held Mr Cole to support him so that he would not fall. 1747. Mr AK provided opinion that Mr Cole would be limp and unresponsive at this time, he would not be able to move purposefully, and he would be unable to follow simple commands with his arms. 1748. Professor AL provided opinion that Mr Cole would have progressive weakness of the limbs with an unknown timeframe, however, he noted that Mr Cole suffered partial paralysis and movement of his arm was possible. 1749. In his clarification Professor AL explained that the extent of paralysis could not be determined. 1750. As such there is conflicting medical opinion on whether it was possible for Mr Cole to move his arm at this stage, and therefore it does not assist to establish if Mr Cole did move his arm. 1751. However, in consideration of the conflicts within the accounts from PC Spicer and PC Ross, and in consideration that it could only have happened during the change of handcuff position, during which PC D would have been in a prime position to notice any movement, particularly a fall by Mr Cole, and furthermore PC Oates noted that Mr Cole was supported so he did not fall, in the investigator’s opinion a tribunal may find that Mr Cole did not move his arm to stop himself falling. 1752. Finding 114: Around the time that an ambulance was called, Mr Cole made noises indicative of an airway obstruction. 1753. The police officers accounts indicated that PC D then left the other police officers and Mr Cole and returned into Greyfriars police station, which was supported by the CCTV footage. 1754. PC Ross and PC Oates stated that Mr Cole then made a gargling or “regurgitation” noise, and PC Spicer said he made a “crackling” or “rasping” noise. 1755. The relative consistency of these descriptions and the evidence from Mr AK that the noises would have been indicative of an airway obstruction consistent with the ventilatory failure, and the opinion of both Mr AK and Professor AL that Mr Cole’s condition would progress to respiratory failure, is sufficient to conclude on the balance of probabilities that Mr Cole made these noises as a progression of his breathing difficulties.

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The request for an ambulance 1756. Finding 115: PC Ross called for an ambulance at approximately 2.02am. 1757. PC Ross stated that she called an ambulance, which was supported by the accounts from PC Spicer and PC Oates as well as contemporaneous evidence from the police incident log, radio transmissions and the EEAS Incident Details Log. This objective evidence sufficiently demonstrated that the call was made at approximately 2.02am and that PC Ross reported that Mr Cole complained about a neck injury. 1758. PC Ross stated in her first interview that she called for an ambulance because Mr Cole continued to complain about his neck. She did not expand on the decision and, when asked to explain her decision in her second interview, she said she did not know why she called an ambulance. 1759. PC Oates wrote in his notebook that the ambulance was a precautionary measure, but in interview he said it was because of the “regurgitation” noise made by Mr Cole. PC Spicer stated it was because of his condition but declined to provide any further explanation in interview. 1760. Despite the inconsistent explanation for the decision to call an ambulance, given the circumstances, it is considered most likely that PC Ross at this stage either recognised or considered that Mr Cole’s condition was not due to non-compliant behaviour and then took appropriate action to seek medical attention for him. 1761. Although at this point PC Ross took prompt action to seek medical attention for Mr Cole, it serves to demonstrate that Mr Cole could have received medical attention at an earlier stage if the police officers who dealt with him had not made the assumption that his condition and behaviour were due to non-compliance, and highlights the adverse effects of a failure to treat a potential injury as genuine until proven otherwise. 1762. Finding 116: The evidence supports that, in the period before the ambulance arrived, Mr Cole did not speak or move, and he was unconscious by the time the paramedics arrived. 1763. None of the police officers described any attempt to perform first aid on Mr Cole or otherwise assess him while they waited for an ambulance to arrive. PC Spicer and PC Oates both said they supported Mr Cole with the assistance of another police officer, so that he would not fall. They said they continued to talk to him although he did not talk back. Paramedic Witness 7 also provided evidence that, on their arrival, an officer had to support Mr Cole to prevent him from falling, which was corroborated by paramedic Witness 33, although he did not state that this prevented Mr Cole from falling. 1764. PC Spicer said Mr Cole offered no resistance or assistance and was unco- operative and “in a daze”. He said he stopped Mr Cole from toppling over. 1765. PC Ross stated Mr Cole still whispered about his neck and made the gargling noise until a very short time before the paramedics arrived. PC Oates stated that Mr Cole’s head was limp and he still made the “regurgitation” sound. 1766. The evidence from the paramedics, who can be seen to reach Mr Cole at approximately 2.10am, stated that Mr Cole was unconscious and did not respond to stimuli.

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1767. The evidence from PC Oates and PC Spicer and the paramedics’ descriptions of Mr Cole’s condition on their arrival is consistent with the medical opinions from Mr AK and Professor AL of progressive respiratory failure which led to hypoxia/cerebral anoxia. PC Ross’s statement that Mr Cole continued to whisper complaints about his neck is contradicted by this evidence of his condition and a tribunal could find it to be implausible in the circumstances. 1768. None of the police officers described a specific point at which Mr Cole became unconscious, but this is evidenced by the accounts and records of the paramedics describing his condition on their arrival.

The arrival of paramedics 1769. Finding 117: The evidence supports that PC Ross informed paramedics that Mr Cole was “chatty”, walked to/from the police van and did not show any sign of ill-health until they arrived at Greyfriars police station, at which point he collapsed. A tribunal could find that this was an inaccurate description which was not corrected by PC Oates or PC Spicer. 1770. PC Ross confirmed that she gave the paramedics a handover. The paramedics Witness 7 and Witness 33 both said PC Ross (as the only female officer present) informed them Mr Cole was “chatty” in the van. Witness 33 said she told them he was “fine” in the van, but when he got out he made a funny sound, suddenly sat down and became difficult to rouse. Witness 33 said PC Ross told them that Mr Cole walked towards the back of the van at the station before he sat down. Witness 7 said PC Ross told them Mr Cole was “fine” when he was arrested, had walked to the van and had been “chatting” during the journey. It was only when they started to get Mr Cole off the police van that he “went all floppy and collapsed”. 1771. This content of the handover was supported by the content of the Patient Care Record. 1772. As discussed in the various findings above, the information given by PC Ross to the paramedics and repeated in her evidence that Mr Cole was ‘fine’ after arrest and that he walked to/from the police van before he collapsed is demonstrably incorrect and her account that he was ‘chatting’ during the journey to Greyfriars police station is not credible. 1773. The CCTV evidence showed that PC Oates and PC Spicer were present when this handover was provided but the evidence demonstrates that they did not correct PC Ross’s description of Mr Cole’s actions or condition. 1774. Finding 118: The evidence supports that PC Ross, PC Oates and PC Spicer did not inform the paramedics of a possible neck injury. 1775. The evidence is sufficient to find that, although PC Ross reported a possible neck injury when the ambulance was requested and this was featured on the EEAS Incident Details Log, she did not repeat this information to the paramedics on their arrival.

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1776. The information PC Ross provided to the attending paramedics was given in the presence of PC Spicer and PC Oates, who also failed to inform the paramedics of a potential neck injury. 1777. Finding 119: In the investigator’s opinion, a tribunal could find that the handover information provided to the paramedics and the omission of a potential neck injury affected the paramedics’ treatment of Mr Cole. 1778. Notwithstanding that the complaint about a neck injury was featured on the EEAS Incident Details Log, the accounts from Witness 7 and Witness 33 and the content of the Patient Care Record show that they acted on the information received from the officers on their attendance. 1779. The evidence from Witness 7 and Witness 33 regarding their examination and treatment of Mr Cole demonstrated that the cause for Mr Cole’s condition was not obvious to them. They both explained the difficulty in identifying a neck injury and said that the main reasons to suspect a neck injury would be due to a complaint of neck pain, or if the history suggested there may have been a neck injury. 1780. They said that due to the patient history they received, they felt the cause of Mr Cole’s condition may be a drug overdose and neither were alerted to a potential for a neck injury or to Mr Cole’s complaints of neck pain. Therefore they had no cause to suspect a neck injury and they did not use any neck injury precautions on Mr Cole. 1781. In the investigator’s opinion, the evidence is sufficient that a tribunal could find that the information provided by PC Ross and the lack of any mention of the potential neck injury, as discussed in findings 117 and 118, misled the paramedics, so that they failed to identify the possibility of a neck injury, and therefore did not apply neck injury precautions. 1782. As stated by Mr AK, Witness 7 and Witness 33, the movement of an individual with a neck injury without spinal precautions may exacerbate the injuries, and as such there may have been significant consequences for PC Ross’s failure to provide an accurate and complete handover to the paramedics. 1783. However, it should be noted that Professor AL has praised the paramedics’ ability and expertise in resuscitating Mr Cole after his cardiac arrest and provided opinion that on the balance of probabilities he did not believe there was any worsening of Mr Cole’s spinal cord injury caused by any failure of information between the police officers and the paramedics, which was evidenced by the fact that Mr Cole could subsequently breathe spontaneously. 1784. Finding 120: PC Ross notified custody sergeant PS F of the situation. 1785. The CCTV and police officers’ statements then demonstrated that PC Ross informed the custody sergeant at Greyfriars police station, PS F, of the situation. 1786. Mr Cole was then in the care of paramedics and was shortly afterwards taken to Bedford Southwing Hospital. Subject officers’ conduct 1787. The investigator’s opinions regarding whether there is a case to answer for misconduct or gross misconduct are set out below for each subject officer, separated in relation to the standards of professional behaviour.

PC 322 Hannah Ross, PC 5741 Nicholas Oates and PC 5890 Sanjeev

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Kalyan

Use of force 1788. In reference to findings 22 and 35, it is the investigator’s opinion that there is insufficient evidence for a tribunal to find that the reasons given for Mr Cole’s arrest were not made out. If this is the case, PC Ross, PC Oates and PC Kalyan would have been entitled to use force to effect Mr Cole’s arrest, provided it was necessary, reasonable and proportionate. 1789. Findings 10, 43, 53 and 69 found that Mr Cole was combative and continued to resist arrest until the point when he was successfully handcuffed or shortly beforehand, and therefore it is considered there is insufficient evidence for a tribunal not to accept the necessity of these officers’ use of force to effect his arrest. 1790. Findings 20, 24 and 34 found that the force applied by PC Ross and PC Oates before Mr Cole’s contact with Mr BB was minimal, and finding 27 concluded that the force used on these occasions did not cause his injuries. For these reasons it is considered unlikely that a tribunal could find that the force used on these occasions was unreasonable or disproportionate. As concluded in findings 17, 40 and 52, PC Kalyan did not have any significant contact with Mr Cole until Mr Cole had returned to his feet after the first period he was on the ground. 1791. Findings 46, 47, 48 and 49, concluded that, in the investigator’s opinion, the spinal fracture to Mr Cole could have occurred during his initial contact with Mr BB, or during the initial period of restraint involving PC Ross and PC Oates. 1792. Findings 55, 57, 58, 59, 63, 64, 65, 66, 67, 68, 79 and 80, found that in the investigator’s opinion, the spinal fracture to Mr Cole also could have occurred on the second occasion Mr Cole went to ground or during the second period of restraint on the ground. 1793. As discussed in findings 79, 80 and 81, although it is the investigator’s opinion that a tribunal could find Mr Cole had suffered both spinal injuries by the time he had been handcuffed and removed from the ground, a tribunal would be unable to establish which event or events were more likely to have caused the injuries. 1794. As such there is insufficient evidence to establish the cause of the injuries to Mr Cole, or to find they were caused deliberately or were foreseeable as a result of force deliberately used. 1795. Due to these considerations, and in particular the ambiguity over the actual action(s) which caused Mr Cole’s injuries and the person(s) responsible, it is the investigator’s opinion that a reasonable misconduct hearing or meeting would be unable to make a finding of gross misconduct or misconduct for any of these officers, and therefore there is no case to answer against PC Ross, PC Oates or PC Kalyan for their use of force. 1796. Findings 111 and 112 concluded that the evidence shows PC Ross was the police officer responsible for the decision for continued application of handcuffs to Mr Cole while in the yard at Greyfriars police station, but she did not provide justification for the necessity of this use of force. 1797. Due to the evidence of Mr Cole’s condition at this stage as discussed in findings 113 and 116, it is the investigators opinion that a reasonable misconduct hearing or meeting may determine that this use of force was unnecessary, unreasonable,

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or disproportionate. However as this was for a short duration and would not appear to have caused any significant injury to Mr Cole, it is considered unlikely that this conduct would be considered serious enough to warrant dismissal. It is therefore concluded there is a case to answer for misconduct for PC Ross in respect of this use of force.

Orders and instructions/Duties and responsibilities 1798. As discussed in findings 73, 74, 75, 76 and 78, in the investigator’s opinion a tribunal could find that PC Ross, PC Oates and PC Kalyan were not prevented from performing a welfare check on Mr Cole before they lifted him from the ground, and they all had sufficient information available to them to recognise that a welfare check should have been carried out. 1799. As discussed in findings 79, 80 and 81, in the investigator’s opinion, having evaluated the evidence, it is not possible to say whether the spinal fracture Mr Cole sustained was displaced before he was lifted to his feet or as a result of doing so. However, in accordance with national police guidance, and as discussed by Mr AK, where there is a risk that there may be a neck injury the person should be left on the ground, their neck immobilised and urgent medical assistance should be sought. 1800. In the investigator’s opinion, a tribunal may find that a welfare check before Mr Cole was lifted from the ground may have allowed the officers to apply the above precautions and obtain medical assistance, which may have avoided the tragic consequences that have occurred in this case. 1801. The evidence shows PC Ross was the arresting officer and dealt directly with Mr Cole continuously from the point of his arrest through to his handover to the paramedics. PC Oates similarly dealt with Mr Cole continuously for this period with the exception of the journey to Greyfriars police station when he drove the police van, and PC Kalyan dealt with Mr Cole directly from the point of arrest until he was taken away from the scene. 1802. Findings 78, 84 and 97 discussed the opportunities for which a tribunal could find that the officers should have recognised that Mr Cole’s condition was due to injury. When considered alongside the evidence in support of Mr Cole’s complaint about his neck, the change in his demeanour from active physical resistance to a lack of physical and verbal responsiveness, and the officers’ knowledge that Mr Cole had forcefully gone to ground twice, it is the investigator’s opinion a tribunal could find that PC Ross, PC Oates and PC Kalyan should have been on notice that Mr Cole may have suffered a serious injury, and this should have engaged their training for such. 1803. Additionally, PC Kalyan said he saw Mr Cole hit his head on the ground, which should have engaged the specific risk assessment training for a potential head injury. Furthermore, in his comments regarding his training, PC Kalyan has demonstrated that he was aware of the police requirements in respect of the welfare of a detainee, was aware of the warning signs of a non-visible head injury and was aware of the requirements to seek immediate medical attention for a potential head injury. 1804. There is also positive evidence that PC Ross recognised that Mr Cole’s behaviour might have been due to serious injury or illness because she asked PS Withey if Mr Cole should be taken to hospital.

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1805. However, as discussed in finding 98, a tribunal could find that there was no adequate medical assessment or welfare check to confirm Mr Cole’s condition before the decision to take him to custody was made. 1806. The only justification provided was that they thought Mr Cole was feigning injury or was non-compliant. However, in the investigator’s opinion a tribunal could find there was no reasonable basis to reach these conclusions, and as a matter of incontrovertible fact, Mr Cole was not feigning injury. Furthermore, a tribunal could find that the officers should not have formed assumptions as to the cause of Mr Cole’s condition or used these to dismiss the need for Mr Cole to be medically assessed. 1807. These officers all provided descriptions of Mr Cole’s condition which have been contradicted by CCTV footage and other objective evidence. A reasonable misconduct hearing or meeting may infer from these officers’ incorrect accounts, that Mr Cole’s condition as demonstrated by the objective evidence, provided sufficient information for them to know that he should receive medical examination, and the officers recognised this at the time they gave evidence. 1808. The evidence shows that PC Oates, PC Ross and PC Kalyan were all aware that no adequate welfare check or risk assessment of Mr Cole’s condition was undertaken, but, as discussed in findings 99 and 100, they deferred to PS Withey’s decision to take him to custody without providing him with sufficient information to make that decision, and none of these officers took sufficient responsibility for Mr Cole’s welfare. 1809. The national police guidance and training placed duties upon PC Ross, PC Oates and PC Kalyan regarding the risk assessment and treatment of detainees in police custody, and requirements to take a detainee to hospital or otherwise seek medical assistance. These duties existed individually and collectively for these officers, all of whom were in a position to take responsibility for Mr Cole’s welfare due to their direct dealings with him. 1810. In consideration of all the above it is the investigator’s opinion that a reasonable misconduct hearing or meeting may determine that PC Ross, PC Oates and/or PC Kalyan failed to abide by police regulations and force policies and/or were not diligent in the exercise of their duties and responsibilities regarding Mr Cole’s welfare. 1811. A tribunal could find that an adequate welfare check before Mr Cole was lifted from the ground may have prevented the displacement of the spinal fracture, and an adequate welfare check at any stage subsequently should have resulted in Mr Cole receiving earlier medical treatment, which may have lessened the consequences of his injuries. For this reason the gravity of the failures is such that dismissal may be justified. 1812. It is therefore the investigator’s opinion that there is a case to answer for gross misconduct for PC Ross, PC Oates and PC Kalyan for potential breach of their duties and responsibilities and/or orders and instructions.

Honesty and integrity 1813. In relation to the accounts given by PC Ross, PC Oates and PC Kalyan, it is the investigator’s opinion that a tribunal could find there are notable points in which their versions of events are not considered credible. In particular the descriptions of Mr Cole’s speech and movements after having sustained injuries, which would

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leave him incapable or unlikely to be capable of performing these actions. PC Kalyan also stated that, after Mr Cole hit his head, he was examined and PS Withey was informed of a potential head injury, which is also contradicted by the evidence. 1814. The nature of these officers’ descriptions are such that it is questionable whether they can be attributed to a mistaken belief that they occurred, and a tribunal may find that PC Ross, PC Oates and/or PC Kalyan deliberately gave inaccurate versions of events to portray Mr Cole in a more able condition than he actually was, so as to absolve them of any failure to recognise the need for medical attention. 1815. Some aspects of these officers’ individual evidence, which in the investigator’s opinion are contradicted by other evidence, were also put forward by the other subject officers, such as evidence that Mr Cole’s friends continued to interfere before he was lifted from the ground, descriptions of his movements at the van, and the movement of his arm in the yard at Greyfriars police station. 1816. Of particular note is the evidence put forward by PC Oates and PC Kalyan that Mr Cole put on his trainer while at the back of the van. As discussed in finding 94, the evidence shows this not to be the case. It should be considered, however, that Inspector Fosbury gave evidence that at the debrief held immediately after the events, he was informed by the officers that Mr Cole walked to the van, got himself in and put his own trainers on. From this evidence a tribunal may infer that either PC Oates or PC Kalyan provided an account of events that was not purely based on their own recollection, but incorporated details that they learnt from other officers. 1817. On this basis a tribunal may find that these officers have colluded in relation to their evidence. 1818. As discussed in findings 117 and 118 the evidence shows that PC Ross also provided the paramedics with a description of Mr Cole’s condition and behaviour which a tribunal could find to be incomplete and/or misleading. Further to this a tribunal could find that PC Oates was present when that description was given to the paramedics but did not correct the information. As discussed in finding 119, a tribunal could find that this resulted in the paramedics treating Mr Cole differently than if they had been given the correct information. 1819. In consideration of all the above it is the investigator’s opinion that a reasonable misconduct hearing or meeting may determine that PC Ross, PC Oates and/or PC Kalyan have not been honest or acted with integrity and, if so, the gravity is such that dismissal may be justified. 1820. It is therefore the investigator’s opinion that there is a case to answer for gross misconduct for PC Ross, PC Oates and PC Kalyan for potential lack of honesty and integrity.

PS 634 Andrew Withey

Use of force 1821. The CCTV evidence demonstrated PS Withey was not involved with events at the nightclub until he responded to the request for assistance from PC Oates, when the CCTV showed him run towards the centre of the disturbance where PC Ross and PC Oates were involved in the first restraint of Mr Cole on the ground.

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1822. Although PS Withey would have been entitled to use reasonable force to assist in the arrest of Mr Cole, as discussed in finding 39, the evidence indicates he had minimal or no involvement in Mr Cole’s arrest, because he almost immediately engaged in preventing Witness 24, Witness 11 and Witness 31 from interfering in Mr Cole’s arrest. 1823. The evidence demonstrated that PS Withey was then involved in assisting Inspector Fosbury’s arrest of Witness 31 and he was not involved in Mr Cole’s arrest or his welfare until Mr Cole had been taken to the rear of the police van. 1824. On this basis it is the investigator’s opinion that a reasonable misconduct hearing or meeting would be unable to make a finding of gross misconduct or misconduct against PS Withey in respect of his use of force during the arrest and restraint of Mr Cole, and therefore there is no case to answer for PS Withey regarding use of force.

Orders and instructions / Duties and responsibilities 1825. As concluded in findings 93, 96 and 97, the evidence indicates Mr Cole exhibited symptoms of injury and complained of injury while at the rear of the police van, and a tribunal could find that PS Withey was in a position to observe both. 1826. The evidence demonstrates PS Withey made the decision that Mr Cole should be taken to custody and not to hospital. 1827. A tribunal could find that when he made the decision that Mr Cole should not be taken to hospital, PS Withey should have been completely satisfied that he had taken steps to accurately assess the situation. As a custody officer PS Withey was trained to a higher level of risk assessment and first aid than the other officers present, but, as discussed in findings 98 and 99, PS Withey did not conduct a welfare assessment or instruct it. As the supervising officer PS Withey would also be aware that the other police officers would defer to his decision. 1828. PS Withey’s explanation demonstrated that he assumed Mr Cole was feigning injury, however, a tribunal could find that PS Withey had no reasonable basis to decide that Mr Cole was feigning injury, which as a matter of incontrovertible fact, he was not. Furthermore, a tribunal could find that PS Withey should not have formed any assumptions as to the cause of Mr Cole’s condition or used this to dismiss the need for Mr Cole to be medically assessed. 1829. It should also be noted that the evidence indicates that he triggers within the national guidance which required a detainee to be taken straight to hospital, i.e. a lack of full consciousness, any problem understanding or speaking, any loss of balance or problems walking or any weakness in one or more arms and legs, were all being displayed by Mr Cole at the time, as concluded in finding 96. 1830. In consideration of all the above it is the investigator’s opinion that a reasonable misconduct hearing or meeting may determine that PS Withey failed to abide by police regulations and force policies and/or was not diligent in the exercise of his duties and responsibilities. 1831. The consequences of PS Withey’s decision are significant, given that it prevented Mr Cole from receiving prompt and appropriate medical care, such that it may have contributed to the severity of his injuries. Therefore the gravity is such that dismissal may be justified.

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1832. It is therefore the investigator’s opinion that there is a case to answer for gross misconduct for PS Withey for potential breach of his duties and responsibilities and/or orders and instructions.

Honesty and integrity 1833. In the investigators’ opinion there are no significant discrepancies in the evidence provided by PS Withey which would suggest that he has provided a dishonest account of events. 1834. It is therefore the investigator’s opinion that a reasonable misconduct hearing or meeting would be unable to make a finding of gross misconduct or misconduct against PS Withey for a lack of honesty and integrity, and therefore there is no case to answer.

PC 381 Peter Spicer 1835. As noted, PC Spicer retired from Bedfordshire Police on 16 October 2015, and therefore no misconduct or performance proceedings can be applied to him. However, it is still a requirement for the investigator to draw conclusions on whether there would have been a case to answer for misconduct or gross misconduct against PC Spicer as a result of the investigation.

Use of force 1836. As concluded in findings 11 and 12, the evidence supports that, although PC Spicer had some initial contact with Mr Cole, this was brief and minimal and PC Spicer then stood back from any further contact with Mr Cole until he was taken to Greyfriars police station. 1837. On this basis it is the investigator’s opinion that a reasonable misconduct hearing or meeting would be unable to make a finding of gross misconduct or misconduct against PC Spicer in respect of his use of force during the arrest and restraint of Mr Cole, and therefore there is no case to answer for PC Spicer regarding use of force. 1838. Within his evidence PC Spicer stated that he stood back from contact with Mr Cole due to fear of the situation. This is not considered to be a conduct matter as there was no duty on PC Spicer to arrest Mr Cole and it is understandable that on occasion a police officer may be in a situation where they are in fear of their own safety. 1839. If PC Spicer had not retired the investigator would have recommended that aspect was considered by PC Spicer’s line management for any welfare or performance management actions that would benefit PC Spicer.

Orders and instructions/Duties and responsibilities 1840. As concluded in finding 86, the evidence indicates PC Spicer did not have any direct involvement in the welfare considerations for Mr Cole until after Mr Cole was in the cell of the van. The evidence sufficiently demonstrates that PC Spicer went over to the van to deal with Witness 11 and Witness 24 for PC Spicer’s duration at the rear of the van; he did not become involved with Mr Cole and there were multiple other police officers between him and Mr Cole.

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1841. For these reasons it is the investigator’s opinion a tribunal could not find that PC Spicer had any involvement or responsibility for Mr Cole’s welfare assessment at the rear of the police van or the decision to take him to custody. 1842. After the decision to take Mr Cole to police custody, PC Spicer was then in the rear of the police van as Mr Cole was transported to Greyfriars police station. 1843. As discussed above, the only evidence of what occurred in the police van during the journey was from PC Ross and PC Spicer, and to a lesser extent PC Oates, who was driving the van. PC Spicer stated that PC Ross was standing against the cage monitoring Mr Cole during the journey and he could not see Mr Cole. In this case PC Spicer would be aware that PC Ross was taking charge of welfare needs for Mr Cole. Although this account cannot be tested against any objective evidence, there is also no evidence to indicate PC Spicer was in a position to observe or take responsibility for Mr Cole’s condition during the journey. 1844. At Greyfriars police station the evidence shows PC Spicer opened the doors at the rear of the van and he lifted Mr Cole out. As such a tribunal could find he would have been in a position to assess Mr Cole’s condition, and his contact with Mr Cole should have immediately alerted him to Mr Cole’s unresponsiveness at this time. Although PC Ross called an ambulance shortly after their arrival at Greyfriars police station, there was still a period in which Mr Cole was carried away from the van, then back towards the van, and then had his handcuffs repositioned. PC Spicer’s account demonstrates he noted Mr Cole’s condition, and he said he thought Mr Cole may be displaying passive resistance, but he did not want to make that assumption. 1845. Despite his statement that he did not want to make an assumption of passive resistance, there is no evidence that PC Spicer took any action to conduct a welfare assessment of Mr Cole or obtain medical assistance for him. 1846. In the investigator’s opinion a tribunal could find that PC Spicer was in a position to recognise Mr Cole’s need for immediate medical assistance from the moment that he opened the doors of the cell and was in direct contact with Mr Cole, however, he did not take any action to obtain assistance for him. 1847. Although an ambulance was called for Mr Cole shortly afterwards, any failure to identify and react to a need for urgent medical assistance can have significant consequences. For this reason the gravity of this failure is such that dismissal may be justified. 1848. On this basis it is the investigator’s opinion that there is a case to answer for gross misconduct for PC Spicer for potential breach of his duties and responsibilities and/or orders and instructions.

Honesty and integrity 1849. In relation to PC Spicer’s accounts of events, the majority of his accounts are consistent with the other evidence of events. However, this is with the exceptions of his account that he was dealing with two individuals on the ground around the time that Mr Cole first went to ground, and his description that Mr Cole moved his hand to break his fall while at Greyfriars police station. A tribunal could find that these descriptions are contradicted by the evidence discussed in findings 34 and 113, and as his description that Mr Cole moved his hand at Greyfriars police station is consistent with PC Ross’s account, a tribunal could find that he has colluded in his evidence.

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1850. As discussed in finding 117 a tribunal could find that PC Spicer was present when PC Ross provided the paramedics with an incomplete and misleading description of Mr Cole’s condition and behaviour, but he failed to correct that information. As discussed in finding 119 a tribunal could find that this resulted in the paramedics treating Mr Cole differently than if they had been given the correct information. 1851. In consideration of all the above it is the investigator’s opinion that a reasonable misconduct hearing or meeting may determine that PC Spicer has not been honest or acted with integrity, and if so, the gravity is such that dismissal may be justified. 1852. It is therefore the investigator’s opinion that there is a case to answer for gross misconduct for PC Spicer for potential lack of honesty and integrity.

Inspector 5461 Lee Fosbury

Use of force 1853. As found in findings 17, 41 and 52, the evidence indicates Inspector Fosbury did not have any contact with Mr Cole until Mr Cole was back on his feet having been to the ground once. 1854. Inspector Fosbury was then seen on CCTV footage heading to the position of Mr Cole’s restraint and reaching forwards. Inspector Fosbury would have been entitled to use reasonable force to assist in the arrest of Mr Cole. 1855. As concluded in findings 52 and 55 there was no evidence that Inspector Fosbury’s involvement in taking Mr Cole to the ground amounted to more than his stated action of taking hold of Mr Cole’s arm, following which he fell to the ground. As discussed in finding 59, the evidence indicates that, once on the ground, Inspector Fosbury handed Mr Cole’s arm to PC Oates then disengaged. He then took action to move Mr Cole’s friends away before he arrested Witness 31. The CCTV evidence shows that, after Mr Cole had been taken to the van, Inspector Fosbury moved to the front of the nightclub. 1856. As discussed in relation to PC Ross, PC Oates and PC Kalyan, there is insufficient evidence to establish the cause of the injuries to Mr Cole’s neck or establish the person(s) involved. Furthermore, there is insufficient evidence to indicate that Inspector Fosbury applied any greater use of force than taking hold of Mr Cole’s arm to assist in his arrest. 1857. It is therefore the investigator’s opinion that a reasonable misconduct hearing or meeting would be unable to make a finding of gross misconduct or misconduct against Inspector Fosbury in respect of his use of force during the arrest and restraint of Mr Cole, and therefore there is no case to answer for Inspector Fosbury regarding use of force.

Orders and instructions/Duties and responsibilities 1858. As discussed in findings 80 and 81, in the investigator’s opinion, Mr Cole injuries had been sustained by the time he was lifted from the ground at 01:48:35. 1859. In consideration of Inspector Fosbury’s awareness of Mr Cole’s condition after this point, the evidence shows Inspector Fosbury was demonstrably uninvolved until Mr Cole had reached the police van, and he provided an explanation that he then did not get a direct view of Mr Cole because other police officers obstructed him, which is plausible based on the evidence of the scene. He also stated that

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during this time he was preoccupied as he spoke to different police officers and assessed his available resources because he intended to close the nightclub. This is supported by the account of PC H and the accounts of Mr AA and Witness 36, who described their conversation when Inspector Fosbury asked them to close the nightclub. 1860. Inspector Fosbury also provided explanation that, although he was the highest ranking police officer, in the absence of his direct involvement in Mr Cole’s welfare through being informed or noticing that Mr Cole was injured, he would not have responsibility for Mr Cole. He explained that each police officer was empowered with their own responsibilities. 1861. Based on the evidence of Inspector Fosbury’s involvement with Mr Cole and the evidence discussed in finding 96 that Mr Cole did not have visible injuries which Inspector Fosbury would have observed from a removed position, it is the investigator’s opinion that a reasonable misconduct hearing or meeting would be unlikely to conclude that Inspector Fosbury was responsible for Mr Cole’s welfare after arrest and would be unable to make a finding of gross misconduct or misconduct against Inspector Fosbury for his actions regarding Mr Cole’s welfare. As such there is no case to answer for Inspector Fosbury regarding his duties and responsibilities and/or orders and instructions.

Honesty and integrity 1862. In the investigator’s opinion there are no significant discrepancies in the evidence provided by Inspector Fosbury that would suggest that he has provided a dishonest account of events. 1863. It is therefore the investigator’s opinion that a reasonable misconduct hearing or meeting would be unable to make a finding of gross misconduct or misconduct against Inspector Fosbury for a lack of honesty and integrity, and therefore there is no case to answer. Suspect door staff actions 1864. This is a summary of the investigator’s opinion of the findings that can be reached in respect of the actions of the door staff. These are included for completeness and to satisfy the terms of reference for the investigation. As noted above, the Commissioner may make a referral to the Crown Prosecution Service if they consider that the door staff may have committed a criminal offence and that it is appropriate to do so. However, the IPCC has no role in relation to the licensing or conduct of door staff. It will be for the Commissioner to determine whether the report should be shared in whole or in part with the licensing authorities.

Mr AA 1865. As discussed within findings 1 and 2, Mr AA decided to eject Mr Cole from the nightclub, which would be within his remit as a member of security staff employed by a private venue; Mr AA would have a common law entitlement on behalf of the owner to ask Mr Cole to leave and to use reasonable force to require him to do so. However, the evidence did not establish that any door staff used excessive force to remove Mr Cole from the nightclub. 1866. Similarly, once Mr Cole was outside the nightclub Mr AA would have a common- law entitlement to use reasonable force to prevent Mr Cole from re-entering the

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nightclub, but, as concluded in finding 3, the evidence did not establish that any excessive force was used to do so. 1867. As discussed within finding 28, when Mr Cole ran towards Mr AA at approximately 1.47am, Mr AA perceived that this was with the intention to assault him. 1868. If this was a genuinely held belief, Mr AA would have had a common-law entitlement to use reasonable force to defend himself. 1869. As discussed in findings 29 and 30, the evidence indicates that the force used by Mr AA in response to Mr Cole’s run towards him was not excessive and did not cause the injuries to Mr Cole’s neck. Mr AA did not have any further contact with Mr Cole. 1870. As discussed in finding 5 there is evidence that there was some form of provocation of Mr Cole from Mr AA. The Commissioner may wish to bring this matter to the attention of the Security Industry Authority.

Mr BB 1871. Mr BB was working at the front entrance of the nightclub at the time that Mr Cole was ejected and, in the same respect as Mr AA, Mr BB would have a common- law entitlement to use reasonable force to prevent Mr Cole from re-entering the nightclub. As concluded in finding 3, the evidence did not establish that any excessive force was used to do so. 1872. As discussed in finding 31, Mr BB stated that he reacted to Mr Cole’s run towards Mr AA because he witnessed Mr Cole attempt to strike Mr AA and was about to attempt to strike Mr AA again. 1873. If this was a genuinely held belief, Mr BB would have had a common-law entitlement to use reasonable force to defend Mr AA. 1874. As discussed in findings 33, 34, 44 and 45, the evidence indicates that Mr BB made contact with Mr Cole and wrapped his arms around his waist, upper body or head/shoulder area and that during this contact they both went to the ground. While on the ground, Mr BB continued to restrain Mr Cole for a period and may have briefly applied some force around Mr Cole’s neck while on the ground, before PC Ross and PC Oates joined the restraint of Mr Cole. 1875. As discussed in findings 46, 47, 48 and 49, it is the investigator’s opinion the evidence indicates that Mr Cole may have sustained the spinal fracture due to the force used by Mr BB. 1876. However, as discussed further in findings 79, 80 and 81, the evidence supports that it is possible Mr Cole suffered the injuries during the second occasion he went to ground or the second period of restraint on the ground, neither of which involved Mr BB, and it is not possible to determine which event or events were more likely to have caused the injuries.

Conclusions relating to post-incident events

Identification of the need for post-incident procedures

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1877. The evidence demonstrates that Inspector Fosbury took immediate steps to inform duty inspector CI V and also notified the Control Room Inspector, Inspector I. 1878. Both Inspector I and CI V noted that PSD should be informed and CI V noted that a PIM may be required. They both noted the need to preserve scenes. 1879. The evidence shows that these officers took steps to inform the appropriate parties and discussed actions to preserve evidence. These actions were taken promptly and before the condition of Mr Cole had been fully established, and before the full police involvement and suggestion of door staff involvement was known. 1880. Although there is no contemporaneous evidence of an overt decision to implement post-incident procedures at this time, the actions taken by Inspector Fosbury, CI V and Inspector I would appear to be in line with the initial stages of the post-incident procedures. The audio recording of CI V’s conversation with Inspector I at 2.46am, in which CI V noted a PIM may be required, also demonstrates that CI V was aware that post-incident procedures may need to be applied.

Collection and preservation of evidence 1881. The accounts from Inspector Fosbury, CI V and recordings of radio transmissions sufficiently demonstrate that, after being informed of Mr Cole’s condition at Greyfriars police station, Inspector Fosbury left the scene at the nightclub and returned to Greyfriars police station. He also took prompt action to appraise CI V of the situation. CI V informed him that he had been dealing with a serious incident in the south of the county and there would be a delay before he could get to Bedford.

1882. The evidence shows Inspector Fosbury took immediate action to ensure Mr Cole was accompanied to the hospital (by DC J and DC AD), then also arranged for other officers to attend the nightclub to close the club and treat it as a crime scene. The scene was secured, CCTV was obtained from the nightclub and from the local authority, photographs of the scene were taken and details of staff members and potential witnesses were obtained.

1883. Greyfriars police station custody was closed and the CCTV secured. The police van in which Mr Cole was conveyed to the police station was also secured as a scene.

1884. The audio recordings demonstrate that Inspector Fosbury quickly identified he should not deal with postincident matters due to his involvement in the incident, and that the matter should be notified to PSD. However, after it was established that DI K was already deployed on another incident and there would be a delay in CI V’s attendance, Inspector Fosbury took action to complete post-incident requirements to preserve evidence and secure the relevant scenes, i.e. the nightclub, Greyfriars police station, the van which transported Mr Cole, and evidence from Mr Cole himself.

1885. The evidence shows that Inspector Fosbury was left in the position of being the only inspector who could immediately deal with the incident despite his

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involvement in it. He was correct in his early identification that, for greater integrity, he should not be involved in the post-incident procedures, but in the investigator’s opinion the requirement to secure evidence should not have been delayed and therefore it may be considered reasonable that Inspector Fosbury took action to ensure evidence was preserved despite his involvement in the incident.

1886. The evidence demonstrates that CI V was also conscious that the post-incident procedures should be dealt with by someone unconnected with the incident, and he expected PSD to adopt this role. After being informed that PSD were not going to attend, he took immediate action to contact DI K (who could not attend due to a separate serious incident in Luton), and he then tasked Acting Inspector W to attend and provide supervision.

1887. In the investigator’s opinion, the evidence demonstrates that prompt action was taken to secure all appropriate scene evidence and identify potential witnesses, and, although ideally Inspector Fosbury would not have been involved in this process, the need to preserve evidence took precedence and CI V took prompt action to replace Inspector Fosbury at the earliest opportunity after becoming aware that PSD were not going to attend.

Notification to PSD 1888. The call recording evidence demonstrates that, within his initial call to Inspector I at 2.37am, Inspector Fosbury highlighted that PSD should be informed. Inspector I then took steps to contact PSD, and although there would appear to be some initial difficulty identifying the ‘on call’ PSD representative, Mr Q contacted Ms S and provided a briefing of the incident, shortly before Inspector I spoke to Ms S at 2.50am.

1889. The evidence demonstrates that Ms S was informed that a person in custody had gone into cardiac arrest in the rear yard of a police station, that the duty Inspector could not attend, and that Inspector Fosbury had been involved. Ms S then sought advice from DCI U.

1890. The evidence of the advice Ms S received from DCI U consists of her account, DCI U’s account, Ms S’s notes, and the audio recording of Ms S’s call back to Inspector I.

1891. This audio recording of Ms S’s call back to Inspector I demonstrates that she provided suitable instructions regarding the preservation of scenes and securing of evidence, and corroborates the evidence of the guidance DCI U provided on these aspects.

1892. However, the evidence regarding the decision to deploy is conflicting. DCI U stated that he advised Ms S to establish more information about the person’s condition, and that she should get ready to deploy and then contact him once she had further information so that a decision regarding whether to notify the IPCC could be made. 1893. Ms S’s notes of this advice corroborated the instruction to get ready to go out, but also stated “Wait and see if the person dies/injuries”.

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1894. In her account, Ms S explained that DCI U advised her that they would not go to Greyfriars police station unless the injured person died or further details were known. 1895. The audio recording of the call from Ms S to Inspector I demonstrates that, after learning that the injured party was stable, and then ensuring that evidence preservation was being appropriately handled, Ms S advised Inspector I to make contact later in the morning when they had established the officers’ names and the condition of the injured party. She then stated that if the injured party died she would deploy, but otherwise PSD would not deploy at that time. 1896. There is no objective evidence to establish the exact conversation that took place between Ms S and DCI U, and therefore the conflicts cannot be resolved. There is insufficient evidence to establish whether there was a miscommunication or a misinterpretation of advice from DCI U, resulting in Ms S believing that deployment would only be necessary if the injured party died. It also cannot be established whether DCI U was informed at that time that police were involved in the disorder at the nightclub.

1897. However, ultimately, the initial information provided to PSD was that a male had been in a physical altercation with police and had then suffered a cardiac arrest while in the custody of the police. In the investigator’s opinion, this would sufficiently constitute an ‘adverse incident’ and one in which there was a clear threat to life. This alone is considered to engage the criteria for the IPCC to be informed and therefore, in the investigator’s opinion, PSD should have deployed to assist with post-incident procedures and to gather further information for the purposes of informing the IPCC. 1898. Although this is considered to be a flawed decision, the evidence indicates this to be an error of judgement or a miscommunication on the part of DCI U or Ms S. In either case it is considered unlikely that a reasonable tribunal would deem this to amount to a breach of the standards of professional behaviour for either party.

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Notification to the Police Federation 1899. The evidence from the officers’ accounts, audio recordings of communications and contemporaneous records demonstrate that there was no consideration of informing the Police Federation of the incident until Acting Inspector Z did so at 2.45pm, after DCI U determined that post-incident procedures should be applied.

1900. The evidence shows that the focus of the actions taken following the incident clearly concerned the identification and preservation of evidence, including the accounts from the officers involved, and identification of the next of kin, but did not consider support mechanisms for the officers involved. This is further evidenced by the accounts indicating CI V intended the officers to go back on patrol after completing their notebook entries, despite some of the officers being visibly affected by the incident.

1901. In the investigator’s opinion the evidence indicates that the lack of notification to the Police Federation was an oversight, most likely as a result of the failure to formally invoke post-incident procedures, which itself was potentially as a consequence of the lack of deployment of PSD at the time.

1902. As Bedfordshire Police did not have a local policy clarifying the procedures for dealing with post-incident management, the individual responsibility for notifying the Police Federation has not been defined. As such this is not considered to be an individual failing, but more a product of a lack of clearly defined roles and expectations.

Notification to IPCC 1903. Within his account, DCI U stated that, when he was initially called by Ms S at 2.55am and informed of the incident, he asked that she update him when further information was obtained so that a decision could be made about referring the matter to the IPCC.

1904. As discussed above, PSD did not deploy to obtain further information and the next update they received or obtained was around 8am, at which point both DCI U and Ms S deployed, after being informed of the extent of Mr Cole’s injuries.

1905. DCI U stated that after his arrival at Greyfriars police station he received additional information and realised the investigation would need to be independent, but he felt he needed to obtain more information before making a referral to the IPCC. The accounts from DCI U and Ms S state they then took steps to obtain more information via the CCTV evidence and paperwork at that stage.

1906. The evidence demonstrates that DS O relayed an update on Mr Cole’s condition to DCI U between 12.20pm and 12.37pm, noting that Mr Cole may die from his injuries. DCI U then asked Ms S to contact the IPCC, and she was able to make contact between 1.30pm and 2pm. 1907. The evidence shows that the IPCC decision not to deploy at that time was based on 12 hours having passed since the incident, that the officers involved had gone

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off duty and that otherwise evidence had been secured. However, the IPCC ‘on call’ SI noted that the IPCC would have deployed at the time of the incident.

1908. It is clear from the evidence that DCI U considered the need for a referral to the IPCC from the time he was made aware of the incident. 1909. As discussed above, it is arguable that at the time there was already enough information to identify an ‘adverse incident’, and one in which there was a clear threat to life, which would warrant referral to the IPCC.

1910. However, DCI U noted that he felt there was insufficient information on which to base a referral to the IPCC, which was then compounded by the lack of deployment by PSD to gather further information.

1911. After PSD received further information at around 8am that Mr Cole had ‘life- changing injuries’ including a fractured neck, the referral to the IPCC was still not made until an update from the hospital around 12.30pm indicating that Mr Cole may die from his injuries. 1912. Based on the available evidence, it is considered most likely that the decision on whether the IPCC should be notified was hinged on whether Mr Cole was going to die, and therefore overlooked the mandatory requirement to refer all incidents involving serious injury to a person following direct or indirect contact with the police. 1913. The evidence demonstrates that the delay not only prevented the IPCC from responding to the immediate aftermath of the incident, but also resulted in a decision not to deploy at the time of the notification due to the impact of the delay.

Obtaining officer evidence 1914. The evidence demonstrates that, following the incident, Inspector Fosbury and CI V asked all of the principal officers involved in the incident to write pocket notebook accounts of the incident, and this occurred at Greyfriars police station.

1915. However, Inspector Fosbury noted that he conducted a debrief before the accounts were written and was informed of various specific details of the events, including that Mr Cole had walked to the van, got himself in and put his own trainers on. It has not been possible to identify who provided the specifics of the information, and the ‘Bed-safe debrief’ report does not record these details.

1916. The evidence is sufficient to conclude that the debrief took place before the officers had completed their accounts, which is contrary to the ACPO Authorised Professional Practice guidance. 1917. Furthermore, there is no record of what was discussed at the debrief which is sufficient in detail to consider whether the debrief could have influenced the individual officers’ recollection of events prior to completing their initial accounts. 1918. This would also be contrary to Chapter 7 of the Authorised Professional Practice on Armed Policing: “In the initial stages all actions taken by, and in respect of, principal officers in relation to securing evidence, discussion undertaken and notes made must be documented.”

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1919. The evidence is sufficient to conclude that the officers were not instructed that they should not confer before they wrote their pocket notebooks. 1920. There is no positive evidence to indicate that the officers conferred before writing initial accounts in their pocket notebooks, but conversely there is no evidence of any safeguards being applied to ensure that they did not confer. 1921. This is supported by the comments from the PIM, Acting Inspector AC, who stated he acted in “a very much reduced capacity” due to the post-incident procedures being some 15 hours after the event. He stated that he did consider anonymity and giving a conferring warning, but, given the elapsed timescales, the fact they had already provided personal accounts and the fact that they had gone off duty and returned, there was little benefit in covering these issues. 1922. In consideration of the details Inspector Fosbury stated he was provided with at the debrief, i.e. details of Mr Cole’s actions and condition when he was moved to the police van, it is clear this could have influenced the accounts of the officers present.

1923. Furthermore, as discussed in the main report, there are various aspects of some of the subject officers’ accounts which are similar, but are considered to be incorrect when balanced against the weight of other evidence, and this would give rise to the suggestion that the officers may have colluded in relation to their evidence.

1924. In consideration of all the above, it is the investigator’s opinion that the delayed application of post-incident procedures circumvented the safeguards over the officers’ accounts which are intended to obtain best evidence and protect the officers. This has allowed the integrity of the officers’ accounts to be undermined.

Application of post-incident procedures 1925. The evidence shows that the formal decision to initiate post-incident procedures was made around 2.20pm by DCI U, who instructed Acting Inspector Z to locate a PIM. Acting Inspector Z stated she then took steps to obtain a PIM and a Police Federation representative, and also to secure the attendance of the principal officers.

1926. All six principal officers involved had finished their shifts and gone off duty by that time. Acting Inspector Z noted that she contacted all of them, but two (Inspector Fosbury and PC Spicer) were unavailable to attend.

1927. Acting Inspector Z stated that there was also difficulty in locating a PIM due to a lack of an ‘on call’ rota, until she eventually obtained assistance from Acting Inspector AC from Hertfordshire Constabulary, who agreed to attend despite the fact he was not on duty, had none of his PIM paperwork and would be delayed in reaching Greyfriars police station due to its distance from him.

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1928. Acting Inspector AC gave evidence noting that he was acting as PIM in “a very much reduced capacity” due to the delay, which also affected his consideration of the conferring warning which he felt was then of little benefit.

1929. In the investigator’s opinion, the evidence demonstrates that, although post- incident procedures were eventually applied, the delay meant that the officers had already provided accounts without the safeguards over the integrity of their evidence, and without the appropriate support mechanisms for the officers. Given that only four of the six principal officers attended the post-incident procedures and only two chose to make additional statements, it is the investigator’s opinion that the delay in application could not be redressed retrospectively. 1930. In the investigator’s opinion, despite the efforts of Acting Inspector Z and Acting Inspector AC, the delay in application of post-incident procedures had multiple negative consequences which rendered them largely ineffective.

Identification of Mr Cole and notification of his next of kin 1931. The evidence from police accounts, audio recordings of communications and the Storm system demonstrates that establishing Mr Cole’s condition and his identity, and notifying his next of kin were immediate priorities after the incident. The evidence shows that CI V personally attended the hospital to establish the extent of Mr Cole’s condition, despite two CID officers being there are the time, and he then tasked the CID officers to establish Mr Cole’s identity and his next of kin. 1932. It should be noted that, although the CID officers had attended hospital, the Storm log noted that they had been unable to establish his identity, and it should be noted that Mr Cole did not have any identification on him at the time of his arrest, because he had given these to his friends earlier during the events. 1933. The first identification of a possible name for Mr Cole was recorded on the Storm log at 3.18am, as “Julian Owens” or “Justin Owens”, which was provided by the arresting officers. As noted in the substantive report, PC Spicer made an entry in his notebook from a conversation with Mr Cole’s friend that Mr Cole’s first name was “Justin” or “Julian”, and PC Ross recorded that Mr Cole provided his surname as “Owens” during the van journey. The subsequent entries on the Storm log demonstrated that enquiries were made based on the surname “Owens”, which clearly did not assist. 1934. Later Storm entries from 4.04am evidenced the enquiries to establish Mr Cole’s identity from officers speaking to witnesses at the scene at the nightclub, and PC AI was able to provide Mr Cole’s name, a possible year of birth and a possible London district for his home address, which was information obtained from Witness 24 and Witness 11. The Storm log again demonstrated attempts to identify Mr Cole’s next of kin from this information, but these were unsuccessful. 1935. The evidence indicates that DC J then liaised with PS G at the scene and obtained details that Mr Cole was a student at Bedford University, and DC AD then attempted to telephone Bedford University staff, but could not make contact. The evidence indicates DC J and DC AD remained at the hospital during this time until they received an update on Mr Cole’s condition at 5.50am. They then left the hospital to attend Bedford University at 6.20am. 1936. The audio evidence of DC AD’s call at 7.48am and the Storm entries at this time demonstrated that that he had identified Mr Cole’s home address in London from

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Bedford University, and had attempted to make contact on two telephone numbers but had been unsuccessful. He therefore asked for the Metropolitan Police Service to attend the address to inform Mr Cole’s next of kin. The subsequent Storm entries and audio recordings demonstrate that contact was made with the Metropolitan Police Service at 7.54am, and that by 8.49am Mr Cole’s family had been informed.

1937. The evidence therefore demonstrates that Bedfordshire Police made continual efforts to identify and inform Mr Cole’s next of kin, but these efforts were hampered because the arresting officers were unaware of Mr Cole’s correct identity. It should be noted Mr Cole did not have any identification on his person and the information received from Witness 24 and Witness 11 was insufficient to identify Mr Cole’s next of kin from police information sources. The difficulties in making contact with Bedford University and unsuccessful attempts to make telephone contact with Mr Cole’s family added further delay.

1938. As such, in the investigator’s opinion, the evidence is insufficient to establish any individual or collective failings that caused the delay in initial contact with Mr Cole’s family; the delay in initial contact was caused by the difficulties in establishing Mr Cole’s identity and the contact details for his next of kin.

Family liaison and the provision of information 1939. The evidence from the Storm Log demonstrates that Mr Cole’s family were contacted by the MPS by 8.49am and notified of Mr Cole being injured. Subsequent entries between 9.27am and 10.03am show that CID were aware Mr Cole’s family were seeking contact from Bedfordshire Police. 1940. The Storm Log confirms that DS O deployed DC AJ to the hospital at 10.37am to assess whether forensic samples could be obtained, but DS O noted that DC AJ was not FLO trained, and there is no suggestion DC AJ was tasked to provide information to Mr Cole’s family. An entry on the Storm Log at 11.03am recorded that DS O asked for the DI to consider a FLO for deployment to the family, further supporting that DC AJ was not intended to act as FLO. Mr Cole’s uncle noted that, while at the hospital, DC AJ made contact with them but did not provide any information other than some very brief timings of the incident.

1941. There is no evidence that the request for a FLO was acted upon before 1pm. The evidence from officers’ accounts indicates that Acting Inspector Z started trying to organise a FLO between 1pm and 2.20pm, although she was also taking steps to organise other matters for the post-incident procedures, such as the attendance of a Police Federation representative, a PIM and the principal officers. 1942. The evidence shows that Acting Inspector Z was able to speak to Family Liaison Co-ordinator PS AB at around 3.37pm. However, despite her efforts PS AB was unable to make contact with an available FLO at that time, so instead agreed to attend Greyfriars police station. The evidence indicates PS AB attended Greyfriars police station at around 4.30pm and was able to contact FLO DS P, who then also attended the station to receive a briefing. 1943. PS AB recorded in her rough book that she and DS P received a briefing from DS O at 5.30pm. PS AB and DS P then agreed an initial verbal strategy at 6.48pm,

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before DS P left the station at 7.40pm to meet the family, arriving at Addenbrooke’s Hospital at around 9pm. 1944. On the basis of the evidence, it is clear that Mr Cole’s family requested contact from Bedfordshire Police almost immediately after being notified of Mr Cole being in hospital. 1945. At this time it was already approximately seven hours since Mr Cole had been taken to hospital and, following the requests from Mr Cole’s family, another 11 hours elapsed before they received any information from Bedfordshire Police, apart from the very basic details provided by DC AJ. 1946. The evidence indicates that there were problems identifying an officer who could fulfil the specialist role of FLO, due to the lack of a FLO ‘on call’ system over the Bank Holiday weekend. 1947. This may explain the delay in deployment of a FLO. However, in circumstances where deployment of a FLO is going to be delayed, there should have been a contingency to ensure that Mr Cole’s family were not left without any information and their requests for contact unanswered. 1948. Although DC AJ was not at the hospital in the capacity of a FLO, it is foreseeable that his presence would make him a focal point for questions from Mr Cole’s family, and his inability to provide information has clearly damaged the relationship between Bedfordshire Police and Mr Cole’s family at a critical time. 1949. The evidence shows that Acting Inspector Z took ownership of obtaining a FLO, with the knowledge of CI R and DI N. By 2.20pm a critical incident had been declared and Superintendent L had documented his ‘Gold Strategy’ which included “to cater for the needs of Mr Cole’s family and provide them with reassurance and confidence in Bedfordshire Police’s response to the incident”. He stated he also appraised DCC T, who was satisfied with the management of the incident. 1950. The evidence shows that, throughout the management of the incident, the need to make contact with Mr Cole’s family was highlighted as a priority by senior management. However, in the investigator’s opinion, as soon as it became apparent that there would be a delay in FLO deployment, further action should have been taken by senior management to address the situation. 1951. Although not attributable to any individual, in the investigator’s opinion the delay in meaningful contact with Mr Cole’s family was a serious failing which would damage public confidence in Bedfordshire Police, and has evidently damaged Mr Cole’s family’s confidence in Bedfordshire Police.

Initial family liaison meeting 1952. In relation to the information to be provided to Mr Cole’s family by FLO DS P, it is noted that, although PS AB recorded in her rough book that she and DS P received a briefing from DS O at 5.30pm, there are no records of what was discussed.

1953. The notes of the meeting between DS P and Mr Cole’s family broadly agree, and they demonstrate there was no mention of the police restraint of Mr Cole until it was raised by Mr Cole’s family.

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1954. Mr Cole’s family were informed that Mr Cole had been drinking and had subsequently had an altercation with door staff at the nightclub. They were also informed that Mr Cole was “chatty” or talking to the police officers in the police van before their arrival in the yard of the police station, when Mr Cole “went quiet” and went into suspected cardiac arrest. 1955. The notes by Mr Cole’s family also record that they were informed officers tried to resuscitate Mr Cole when he went into cardiac arrest, which was not the case. 1956. In consideration of the evidence as discussed in the main report, the suggestion that Mr Cole drank alcohol before and while at the nightclub has been supported by witness evidence and by the toxicology. 1957. The report that Mr Cole was ‘chatty’ while being transported to the police station has conversely been deemed to be inaccurate. However, the source of this information can be traced to PC Ross, and there is no suggestion DS P could have been in a position at that time to know that it was not accurate. The inaccuracy of the information provided by PC Ross has been addressed within the main report. 1958. These aspects of the information provided by DS P do not establish a deliberate attempt to provide false information. 1959. However, the criticisms raised by Mr Cole’s family are more focused on the information being deliberately selective, with the intention of deflecting criticism away from the police and cast Mr Cole in a negative light. 1960. In the investigator’s opinion, the information provided by DS P would appear to be a reasonable summary of the sequence of events that was known at the time, with an exception regarding the police involvement in the restraint of Mr Cole. 1961. The lack of information regarding the police involvement in the restraint of Mr Cole and the information provided that “a bouncer from the club had been arrested on suspicion of assault” with another one being sought, would appear to direct the responsibility for Mr Cole’s injuries towards the door staff of the nightclub, rather than the police. 1962. This exception demonstrates that the information provided was not a full picture of what was known to Bedfordshire Police at that time. While there is insufficient evidence to support that this was a deliberate attempt to mislead Mr Cole’s family or deflect blame away from Bedfordshire Police, the selective information clearly allows the perception that this was the case, and therefore undermines public confidence in Bedfordshire Police as well as Mr Cole’s family’s confidence in Bedfordshire Police. 1963. The view may be taken that DS P knew or should have known that police officers were involved in the restraint of Mr Cole, but there is no record of the briefing provided to DS P, and there is no evidence or reasonable inference that DS P provided information under her own motive to mislead Mr Cole’s family, or was providing the information at the instruction of another individual with such motive.

Officer conduct during post-incident events 1964. In the investigator’s opinion, there were several failings in the handling of the post incident events, most notably the lack of immediate deployment of PSD and the consequent delays in notifying the IPCC or invoking post-incident procedures

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(including instruction not to confer), and most significantly the delay in making any meaningful contact with Mr Cole’s family and the information that they were provided. 1965. However, in consideration of all the evidence of the events, the issues are demonstrated to be due to resourcing issues, lack of ‘on call’ arrangements for adverse incidents over the Bank Holiday weekend, and errors of judgement that would not amount to any breach of the standards of professional behaviour. 1966. As such it is the investigator’s opinion that there is insufficient evidence to demonstrate any individual culpability which would amount to a case to answer.

Performance 1967. If disciplinary charges are not directed or brought, then an appropriate authority may invoke unsatisfactory performance procedures and in some circumstances can be directed to do so. A matter should only be dealt with as either misconduct or unsatisfactory performance, not both. 1968. The Commissioner may wish to consider whether, on the basis of the evidence presented above, the actions of any of the above officers or police staff, although not amounting to a case to answer for misconduct, fell below the standard expected and that his or her performance was unsatisfactory.

Provisional organisational learning recommendations 1969. After reviewing this report, the Commissioner will consider whether learning has been identified for any organisation involved in the investigation. If any learning is identified, the Commissioner can make organisational learning recommendations and send these to the organisations in question under separate cover. 1970. Recommendations can include improving practice, updating policy or changes to training. 1971. Often these recommendations and any responses to them are published on the recommendations section of the IPCC Website. 1972. The Investigator draws attention to the following matters for which the Commissioner may wish to make a recommendation.

Bedfordshire Police

Greyfriars police station CCTV 1973. As noted above, the CCTV cameras in the yard of Greyfriars police station were all positioned on the same wall relatively close together, which meant that all cameras had a similar vantage point. 1974. On 10 January 2014, the Commissioner wrote to the Chief Constable of Bedfordshire Police to highlight issues regarding the CCTV coverage at Greyfriars police station. The Commissioner wrote: 1975. “You will be aware that issues can arise about the state of a detainee, and what happened when they arrived at the police station. This is an issue in [the Julian Cole investigation], where he was never formally taken into the custody suite”.

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1976. “Unfortunately… the CCTV coverage of the yard is not comprehensive and because of the position that the van was parked, full view of the back of the van, including when the doors are opened and the detainee removed is not available.” 1977. “We would recommend that the position of CCTV cameras in custody suite yards is assessed and cameras placed so that full coverage of the yard, including the backs of vans when doors open is available. At Greyfriars police station… we believe this may be achieved by the placing of a reverse view camera at the gate (all the current cameras show roughly the same view).” 1978. A response was received from the Chief Constable of Bedfordshire Police on 20 January 2014, which stated the following: 1979. “CCTV coverage in the yard – this has been brought to the attention of the Estates Manager who will take action on your recommendation.”

Personal Safety Training 1980. The ACPO Guidance on Personal Safety Training was in effect on 6 May 2013. This guidance stated that, as a minimum, forces must ensure that staff receive assessed refresher and development training on an annual basis. 1981. It also noted that forces must ensure that robust systems are in place to monitor the scheduling of training, to ensure that it complies with minimum standards. 1982. The evidence of the subject officers’ training history demonstrates that PC Oates was allowed to go more than a year without personal safety training, which is in breach of the ACPO guidance that personal safety training should be refreshed annually. 1983. The NPIA Personal Safety Training Program provided the required content of the refresher training, however, as Bedfordshire Police were unable to provide any lesson plans for these sessions, it has not been possible to confirm whether the subject officers received this content. 1984. Given that Bedfordshire Police described the refresher training as having no classroom content and amounted to a demonstration of ‘control and restraint’ techniques, it would appear unlikely that the national requirements on content were being met. 1985. On the basis of this evidence it is the investigator’s opinion that Bedfordshire Police may have failed to comply with the national police guidance in relation to the regularity and content of personal safety training or their monitoring of its delivery.

First-aid training 1986. The ACPO guidance in place on 6 May 2013 was the First Aid Learning Programme (FALP), version 1.0. The FALP noted that, to fully comply with the Health and Safety (First Aid) Regulations 1981, police forces should train personnel to the recognised HSE standards of Emergency First Aider at Work (EFAW) and First Aider at Work (FAW) based on a local risk assessment. 1987. The FALP also stated that ACPO endorsed the HSE recommendations in respect of the arrangements for the delivery and annual refresher training for First Aid at Work (FAW) in Policing, and recommended the EFAW standard for basic first-aid training.

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1988. The FALP noted “forces must demonstrate coverage of the national curriculum as defined in the relevant learning descriptor”. 1989. The FALP also noted that forces should have procedures for managing the quality assurance of delivery, which should include processes for monitoring delivery of the first-aid training. 1990. The FALP defined the minimum level of training for officers with direct contact with the public as ‘Module 2: First Aid Skills Police (EFAW)’. For this EFAW qualification to remain valid, annual refresher training was required, and if there was a lapse of more than one year between EFAW training, then re-qualification of the original EFAW was required. This was the standard required for all the subject officers with the exception of PS Withey, because he was trained as a custody sergeant. 1991. The ‘Module 2: First Aid Skills Police (EFAW)’ initial course curriculum included the following: Manage a first aid scene; Assess a casualty; Perform basic life support; Report casualty information; Manage a casualty with spinal injury. 1992. The annual refresher training required included the following core curriculum: Assess a casualty; Perform basic life support; Report casualty information. It also required content to be delivered over a three-year rolling basis, which included: Manage a first aid scene; Manage a casualty with spinal injury. 1993. The FALP ‘Module 4: First Aid at Work Police; Initial and Re-qualification’, which was equivalent to the HSE FAW standard, was used by Bedfordshire Police as the standard of first aid training required for their custody sergeants, and was therefore the standard for PS Withey’s first aid training. 1994. The ‘Module 4: First Aid at Work Police; Initial and Re-qualification’ course curriculum included the following: Manage a first aid scene; Assess a casualty; Manage a casualty with minor injuries; Perform basic life support; Place a casualty in the recovery position; Report casualty information; Manage a casualty with a broken bone (fracture) or dislocation; Manage a casualty with a head injury; Manage a casualty with spinal injury. 1995. The annual refresher content required for the FAW standard was the same as within ‘Module 2: First Aid Skills Police’, for the second and third year. However, in the fourth year the full original training was required to maintain the FAW qualification. 1996. The evidence obtained indicates that Bedfordshire Police had training plans for the EFAW and FAW courses in place at the time of the incident, which were compliant with the ACPO guidance on content. 1997. However, the Bedfordshire Police annual refresher training for these courses was not compliant with the NPIA ‘three year rolling programme’ guidance on content which was in place at the time, and notably it did not contain any input on management of a spinal injury. 1998. Furthermore, the subject officers’ training records and evidence from Bedfordshire Police Training Directorate demonstrate that the subject officers’ first-aid training was not delivered in accordance with the ACPO or HSE

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guidelines on regularity, to the extent that none of the subject officers held valid qualifications for first-aid training to the HSE EFAW or FAW standards. 1999. It is therefore apparent that Bedfordshire Police did not have adequate systems or processes in place to monitor the delivery of their first-aid training, which is also contrary to the ACPO guidelines. 2000. On the basis of this evidence it is the investigator’s opinion that Bedfordshire Police may have failed to comply with the national police guidance in relation to the delivery and content of first-aid training or their monitoring of its delivery, and therefore may also have failed to comply with HSE guidance in respect of first-aid training.

College of Policing Review 2001. In consideration of the training points above, it is noted that, on 29 May 2014, the College of Policing produced a review report for a number of aspects of the training within Bedfordshire Police, including the provision of personal safety training, first-aid training and inclusion of training regarding spinal injuries. This was in part due to the circumstances of the incident involving Mr Cole. 2002. The criticisms raised above are mirrored within the College of Policing review and, as a result of their review, the College of Policing put a number of recommendations to Bedfordshire Police. 2003. The College of Policing is the professional body which sets the national standards for police training and this report would not seek to replace or supersede any of their recommendations regarding the Bedfordshire Police provision of personal safety training and first aid training. It is also not for this report to evaluate the Bedfordshire Police response or adherence to their recommendations. 2004. However, it would be remiss if this report did not include organisational learning recommendations regarding the matters which have come to light during the investigation. These should be considered alongside and in addition to the recommendations from the College of Policing. 2005. A copy of this report will also be sent to the College of Policing for their awareness and consideration. 2006. On 2 December 2015 the IPCC wrote to inform Bedfordshire Police of the above comments regarding the College of Policing review, and stated: 2007. “We would therefore like to issue the following informal learning recommendations to Bedfordshire Police. These should be considered alongside and in addition to the recommendations from the College of Policing: 2008. Bedfordshire Police should take action to ensure that their personal safety training is made compliant with current national police guidance, particularly in respect of its delivery, content and monitoring. 2009. Bedfordshire Police should take action to ensure that their first-aid training is made compliant with current national police guidance, particularly in respect of its delivery, content and monitoring.” 2010. On 11 April 2016 the IPCC wrote a further letter to Bedfordshire Police seeking a response to these informal recommendations.

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2011. On 25 April 2016 the Deputy Chief Constable of Bedfordshire Police provided a response to these informal learning recommendations, which is included as appendix 4.

Post-incident events 2012. On 17 May 2013, the IPCC wrote to Bedfordshire Police stating the following: 2013. “…some concerns have arisen from our initial inquiries, which I think I should inform you of, for you to consider whether there is any quick-time learning that can be gained, and any changes in procedure to be made at this stage…” 2014. “From the information we have gathered so far it appears there was some delay before PIM cover and attendance of PSD was provided in this case.” 2015. “You will of course be aware of the requirements in relation to incidents that involve death or serious injury following police contact to ensure compliance with Article 2. Of particular importance is the ‘golden hour’ and the responsibility of the police to preserve the scene and initial evidence. You will also be aware of the importance of prompt referral to the IPCC of such cases.” 2016. “…I would like to draw your attention to this matter now and as a matter of urgency seek your reassurances as to what processes would be in place to ensure 24 PIM cover and appropriate response from PSD including prompt referral to the IPCC should a similar incident occur.” 2017. This constituted an informal learning recommendation.

Recommendations 2018. As a result of this investigation, the Commissioner may wish to consider the following recommendations for Bedfordshire Police, some of which have been made previously as informal learning recommendations but which the Commissioner may wish to consider formalising:  Bedfordshire Police should take action to ensure that the positioning of CCTV cameras in custody suite yards would allow full coverage of the yard, including consideration of obstructions caused by parked vehicles.  Bedfordshire Police should take action to ensure that their personal safety training is made compliant with current national police guidance, particularly in respect of its delivery, content and monitoring.  Bedfordshire Police should take action to ensure that their first-aid training is made compliant with current national police guidance, particularly in respect of its delivery, content and monitoring.  Bedfordshire Police should ensure that provisions are in place for 24-hour availability of trained Post Incident Managers.  Bedfordshire Police should ensure that provisions are in place for 24-hour availability of trained Family Liaison Officers and contingency arrangements in the event that of delay in deployment of a Family Liaison Officer.

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Other organisations

East of England Ambulance Service (EEAS) 2019. As discussed within findings 117 and 118, the two initial paramedics who attended, Witness 7 and Witness 33, gave evidence that on their attendance they were not provided with any information which would indicate that Mr Cole may have a neck injury. 2020. However, the contemporaneous evidence of the recording of the request for an ambulance and the EEAS Incident Details Log show that the request for an ambulance included a report that Mr Cole had complained of a neck injury. 2021. In this respect, the Commissioner may also wish to consider providing a copy of this report to EEAS for their consideration.

Security Industry Authority 2022. The Security Industry Authority (SIA) is the organisation responsible for regulating the private security industry, which would include those working as door supervision for a nightclub. 2023. The Commissioner may wish to consider sharing this report with the SIA in respect of any concerns about the actions of door staff involved in these events.

Erik Waitt Lead Investigator, IPCC

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Appendix: Map of the area around the nightclub (D683)

Van 1: Crewed by PC Oates, PC Ross and PC Spicer, and used to transport Mr Cole. Van 2: Crewed by PS G, PC A and PC C. The marked locations of the police vans are approximate and not to scale.

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Appendix: Letter from DCC Boutcher 25 April 2016 (D690)

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Appendix: List of subsidiary findings Finding 1: The evidence supports that Mr Cole was not forcibly removed from the stage within the nightclub. Finding 2: The evidence suggests that the nightclub’s door staff used no more than minimal force to eject Mr Cole from the nightclub. Finding 3: The evidence supports that the nightclub’s door staff used no more than minimal force to prevent Mr Cole from re-entering the nightclub in the initial period after his ejection. Finding 4: There is evidence that force was applied to Mr Cole by Witness 24, Witness 11 and Witness 31 to attempt to restrain him in the initial period after his ejection. Finding 5: The evidence supports that there was some form of provocation of Mr Cole from Mr AA, and some form of threat or aggression from Mr Cole. Finding 6: The evidence supports that police assistance and CCTV monitoring was requested by the nightclub’s door staff due to the actions of Mr Cole and his friends. Finding 7: The evidence supports that Mr Cole approached door staff at the entrance of the nightclub with an empty glass bottle held in a manner which was perceived as a threat. Finding 8: The evidence supports that Mr Cole was moved away from the entrance and the bottle was taken from him by his friends, without physical contact from the door staff. Finding 9: The evidence supports that police officers PC Ross, PC Oates and PC Spicer first attended the incident at approximately 1.34am. Finding 10: The evidence supports that Mr Cole was non-compliant and combative on first contact with police officers. Finding 11: The evidence supports that PC Spicer’s initial contact with Mr Cole was momentary and minimal. Finding 12: The evidence shows PC Spicer had no further interaction with Mr Cole until Mr Cole ran towards Mr AA at 1.47am. Finding 13: The evidence supports that the initial response from PC Ross and PC Oates was to instruct Mr Cole’s friends to remove Mr Cole from the area. Finding 14: The evidence supports that Mr Cole was forcibly taken away from the nightclub by Witness 24, Witness 11 and Witness 31, and it cannot be excluded that some of their use of force was around Mr Cole’s neck area. Finding 15: A tribunal could find that PC Oates took proactive, appropriate action in response to complaints against the nightclub’s door staff from Mr Cole’s friends, and notified a senior officer of his concerns. Finding 16: A tribunal could find that PC Kalyan took appropriate action to request CCTV monitoring of Mr Cole and his friends. Finding 17: The evidence shows that PC Kalyan and Inspector Fosbury did not have any direct involvement with Mr Cole on their initial attendance.

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Finding 18: The evidence shows that Mr Cole, Witness 24, Witness 11 and Witness 31 returned to the nightclub at approximately 1.41am, with the intention to speak to Witness 18 to obtain a refund. Finding 19: At approximately 1.45am Mr Cole, Witness 24 and Witness 31 spoke to Witness 18, but she did not agree to refund their entrance fees. Finding 20: The evidence supports that PC Oates and PC Ross approached Mr Cole shortly after his return to the front of the nightclub, but Mr Cole would not engage with them. PC Oates attempted to take hold of Mr Cole but Mr Cole evaded detention. There is no evidence of excessive force being used. Finding 21: The evidence supports that at approximately 1.46am Mr Cole gave his belongings to Witness 32 and Witness 20, which included his mobile phones and identification. Finding 22: The evidence supports that PC Ross decided to arrest Mr Cole for a Section 5 Public Order Act 1986 offence; there is also evidence which supports that she had a reasonable belief that the offence had been committed and that it was necessary to arrest. Finding 23: The evidence supports that PC Oates and PC Ross attempted to arrest Mr Cole between 1.46am and 1.47am. Finding 24: The evidence supports that the force used by PC Ross and PC Oates to try to effect Mr Cole’s arrest amounted to attempts to take hold of his arms. There is no evidence of excessive force being used. Finding 25: The evidence supports that PC Ross and PC Oates were prevented from arresting Mr Cole at this time due to his resistance and the intervention of his friends. Finding 26: There is no evidence of any grounds on which to criticise PC Oates’s request for assistance. Finding 27: The evidence supports that Mr Cole had not sustained the spinal fracture or spinal cord injuries by the time he ran towards the nightclub at approximately 1.47am. Finding 28: The evidence supports that Mr Cole ran towards Mr AA at approximately 1.47am with the apparent intention to assault him. Finding 29: The evidence supports that Mr AA made brief contact with Mr Cole around his chest or bicep area, which amounted to a ‘push’ or part of a technique to deflect Mr Cole’s forward momentum and move him away. Mr AA was entitled to use reasonable force to defend himself and there is insufficient evidence to find that the force used was excessive. Mr Cole did not go to ground as a result of this contact and Mr AA did not have any further contact with Mr Cole. Finding 30: The evidence supports that Mr Cole’s injuries were not caused by his contact with Mr AA. Finding 31: The evidence supports that, after Mr Cole’s initial contact with Mr AA, the next individual who made physical contact with him was Mr BB. Finding 32: The evidence supports that Mr Cole first went to the ground between 01:47:34 and 01:47:42.

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Finding 33: The evidence supports that, immediately after Mr AA pushed or deflected Mr Cole away, Mr BB wrapped his arms around Mr Cole’s waist, upper body or head/shoulder area. Due to this contact or during this contact, Mr BB and Mr Cole both went to the ground. Finding 34: The evidence supports that PC Ross, PC Oates and PC Spicer were in close proximity to Mr Cole at this time and may have had some contact with him, but the force used by Mr BB was the dominant reason for Mr Cole going to ground. Finding 35: The evidence supports that PC Ross’s justification for Mr Cole’s arrest was still made out at the time of his actual restraint and arrest, and therefore an entitlement to use reasonable force to effect Mr Cole’s arrest existed. Finding 36: In the investigator’s opinion, the evidence supports that Mr Cole was initially on the ground for a maximum period of 23 seconds between 01:47:34 to 01:47:57 before he returned to his feet. Finding 37: The evidence supports that PC Ross, PC Oates and Mr BB were involved in Mr Cole’s initial restraint on the ground. Finding 38: The evidence supports that PC Spicer was not involved in the initial restraint of Mr Cole on the ground. Finding 39: The evidence supports that PS Withey had minimal involvement in the initial restraint of Mr Cole on the ground. Finding 40: The evidence supports that PC Kalyan had minimal involvement in the initial restraint of Mr Cole on the ground. Finding 41: The CCTV evidences that Inspector Fosbury was not involved in the initial restraint of Mr Cole on the ground. Finding 42: There is evidence that Mr Cole’s friends Witness 24, Witness 31 and potentially Witness 11 attempted to intervene in Mr Cole’s restraint and arrest. Finding 43: There is evidence that Mr Cole struggled and attempted to resist arrest during the first period of restraint on the ground. Finding 44: There is evidence that Mr BB may have briefly applied some force around Mr Cole’s neck while on the ground. Finding 45: The evidence supports that PC Ross, PC Oates and Mr BB attempted to restrain Mr Cole on the ground while he resisted and his friends intervened, which created a scene of disorder. There is insufficient evidence to establish what force was applied to Mr Cole during the initial restraint on the ground. Finding 46: In the investigator’s opinion there is evidence that Mr Cole may have sustained the spinal fracture before he returned to his feet Finding 47: On the basis of the current evidence and medical expert opinion, a tribunal could not find on the balance of probabilities that Mr Cole had sustained injury to his spinal cord at the time he returned to his feet Finding 48: The spinal fracture to Mr Cole may have been caused by his contact with Mr BB.

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Finding 49: The spinal fracture to Mr Cole may have been caused during his initial restraint on the ground, involving PC Ross and PC Oates. Finding 50: There is evidence that Mr Cole had returned to his feet by 01:47:57, but the evidence is insufficient to establish how this happened. Finding 51: There is evidence that Mr BB was removed from contact with Mr Cole around the time that Mr Cole returned to his feet, and he had no further contact with Mr Cole. Finding 52: The evidence supports that, when Mr Cole returned to his feet and before he went back to the ground, the police officers involved with his restraint were PC Ross, PC Oates, PC Kalyan and Inspector Fosbury. Finding 53: A tribunal could find that Mr Cole could speak, was physically able and continued to be non-compliant and resist arrest while being restrained on his feet by police officers. Finding 54: The evidence supports that Mr Cole went to the ground a second time at approximately 01:48:04. Finding 55: The evidence supports that Mr Cole went to the ground on the second occasion due to force applied by PC Ross, PC Oates and PC Kalyan, while Inspector Fosbury was also in contact with Mr Cole to a lesser degree. Finding 56: There is insufficient evidence for a tribunal to find that the decision to take Mr Cole to the ground was unreasonable. Finding 57: The evidence supports that Mr Cole was taken to the ground on the second occasion in an uncontrolled manner, facing forwards while his arms were held. The police officers in contact with Mr Cole were PC Ross, PC Oates, PC Kalyan and Inspector Fosbury. Mr Cole connected with the ground around his chest and did not hit his head on the ground. Finding 58: There is insufficient evidence available to establish the specific methods applied by the police officers to take Mr Cole to the ground. Finding 59: The evidence supports that, on the second occasion Mr Cole was restrained on the ground, the police officers involved were PC Ross, PC Kalyan and PC Oates. Inspector Fosbury made brief contact with Mr Cole on the ground before he disengaged. Finding 60: The evidence supports that PC Ross, PC Kalyan and PC Oates were all involved in the application of handcuffs to Mr Cole, which were applied to the rear. Finding 61: A tribunal is unlikely to consider the application of handcuffs to Mr Cole during his restraint on the ground to be an excessive use of force in all the circumstances. Finding 62: The evidence supports that one or more police officers knelt on Mr Cole during his restraint on the ground. Finding 63: The evidence is insufficient to establish the exact use of force applied by PC Ross during the restraint of Mr Cole on the ground. However, it is the investigator’s opinion that the evidence is sufficient for a tribunal to be able to find that PC Ross knelt on Mr Cole in a position around his torso while he was face down on the ground.

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Finding 64: PC Ross’s application of a knee to Mr Cole’s torso is individually unlikely to have been the cause of the spinal injuries Mr Cole sustained, but it is possible she contributed to a combination of forces responsible for the spinal injuries Mr Cole sustained. Finding 65: The evidence is insufficient to establish the exact use of force applied by PC Oates during the restraint of Mr Cole on the ground. However, it is the investigator’s opinion that the evidence is sufficient for a tribunal to be able to find that PC Oates knelt on Mr Cole’s upper body and/or applied a forearm across Mr Cole’s neck and/or held Mr Cole’s head in some respect while he was face down on the ground. Finding 66: PC Oates’s application of a knee to Mr Cole’s upper body and/or a forearm or arm on his neck and/or hold of Mr Cole’s head may have caused or contributed to a combination of forces responsible for the spinal injuries Mr Cole sustained. Finding 67: The evidence is insufficient to establish the exact use of force applied by PC Kalyan during the restraint of Mr Cole on the ground. However, it is the investigator’s opinion that the evidence is sufficient for a tribunal to be able to find that PC Kalyan knelt on, or otherwise restrained, Mr Cole’s legs during his restraint on the ground. Finding 68: The evidence supports that PC Kalyan’s restraint of Mr Cole legs did not cause Mr Cole any significant injury. There is insufficient evidence to find that this contributed to a combination of forces responsible for the spinal injuries Mr Cole sustained. Finding 69: The evidence supports that Mr Cole continued to struggle and resist arrest during the second period of restraint on the ground, but stopped struggling when he was successfully handcuffed or shortly beforehand. Finding 70: The evidence supports that Mr Cole was restrained on the ground and handcuffed between 01:48:04 and 01:48:28. Finding 71: The evidence supports that Mr Cole’s friends did not cause any significant interference on the second occasion Mr Cole was restrained on the ground and that they were demonstrably uninvolved at the time Mr Cole was lifted from the ground. Finding 72: The evidence supports that PC Ross, PC Oates and PC Kalyan first lifted Mr Cole from the ground at 01:48:35, before he was lowered again. He was then lifted up at 01:48:52 and moved towards the road. Finding 73: In the investigator’s opinion a tribunal could reject the evidence provided by PC Ross, PC Kalyan and PC Oates of a “volatile, dangerous” scene and find that they were not prevented from performing a welfare check before Mr Cole was lifted from the ground. Finding 74: In the investigator’s opinion, a tribunal could find that PC Ross had sufficient information to enable her to recognise that a welfare check on Mr Cole before he was lifted from the ground was appropriate, and her explanation for the failure to do so is contradicted by the evidence. Finding 75: PC Oates recognised that, before he was lifted up, Mr Cole stopped moving and did not respond verbally or physically to their requests. The evidence supports that PC Oates did not perform a welfare check because he assumed that Mr Cole was being non-compliant and he failed to

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consider or he dismissed any potential injury as the cause. In the investigator’s opinion a tribunal could find that PC Oates had sufficient information to enable him to recognise that a welfare check on Mr Cole before he was lifted from the ground was appropriate, and his explanation for the failure to do so was contradicted by the evidence. Finding 76: In the investigator’s opinion a tribunal could find that PC Kalyan had sufficient information to enable him to recognise that a welfare check on Mr Cole before he was lifted from the ground was appropriate, and his explanation for the failure to do so was contradicted by the evidence. Finding 77: The evidence supports that when lifted from the ground Mr Cole did not move, he did not support his own head and did not support his weight on his feet. Finding 78: Despite the witnesses’ different interpretations of Mr Cole’s condition, a tribunal could find that there were sufficient indicators at this time that the officers could or should have recognised that his condition may be due to injury. Finding 79: In the investigator’s opinion, it is possible the spinal fracture was sustained by Mr Cole during his contact with PC Ross, PC Oates and PC Kalyan when he was taken to the ground at approximately 01:48:04 or while he was restrained on the ground on the second occasion. However, a tribunal would be unable to find that this was more or less likely to be the cause than the contact with Mr BB or the initial period of restraint. Finding 80: In the investigator’s opinion, although it is not possible for a tribunal to establish exactly when the injuries to Mr Cole occurred, a tribunal could find that the spinal cord injury had occurred either before Mr Cole was first lifted from the ground at 01:48:35, or was caused due to Mr Cole being lifted from the ground at that time without spinal precautions. Therefore the spinal fracture must also have occurred by this time. Finding 81: In the investigator’s opinion, a tribunal could find that the injuries to Mr Cole occurred within the parameters of the initial contact from Mr BB (01:47:34 to 01:47:42) and the time that he was lifted from the ground by PC Ross, PC Oates and PC Kalyan at 01:48:35. However, the evidence is insufficient for a tribunal to determine the specific time(s) or cause(s) of the injuries. Consequently, a tribunal could not find any individual responsible for the injuries. Finding 82: The evidence shows Mr Cole was conveyed to the police van by PC Oates, PC Ross and PC Kalyan. Finding 83: In the investigator’s opinion, a tribunal could conclude that Mr Cole was carried to the police van while his legs dragged behind him and his head hung down unsupported; further, that Mr Cole did not walk and did not hold his head up or look around himself at this stage; accordingly that at this stage Mr Cole would have been suffering from neurological deficit caused by injury to his spinal cord. Finding 84: It is the investigator’s opinion that a tribunal could find that at the time Mr Cole was carried across the road PC Oates, PC Ross and PC Kalyan should have recognised that his condition was due to injury, and a tribunal

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could further find that the officers knew that to be the case at the time they gave evidence. Finding 85: The CCTV evidence shows that Mr Cole arrived at the police van at 01:49:07 and was moved inside the police van by 01:53:26. Finding 86: The evidence supports that PC Ross, PC Oates, PC Kalyan and PS Withey were the only police officers directly involved with Mr Cole at the back of the police van. Finding 87: The evidence supports that Mr Cole’s friends did not take any action which interfered with the handling of Mr Cole from 01:49:57 onwards. Finding 88: Once Mr Cole was at the back of the police van, he was largely obscured from the view of CCTV and witnesses due to obstructions. The majority of police officers present were also prevented from observing Mr Cole due to obstructions or distractions. Finding 89: There is no evidence that the subject police officers were aware of the ambulance which approached while Mr Cole was detained at the rear of the police van. Finding 90: There is no evidence that PC E, the officer who directed the ambulance away, was aware of the facts that should have caused concern for Mr Cole’s welfare. Finding 91: The evidence supports that Mr Cole did not stand when he first arrived at the rear of the van. Finding 92: The evidence supports that Mr Cole was lifted up to the back of the van and was leant on the edge of the van facing into the van, but did not support himself on his feet at this time. He was then turned around and placed into a sitting position at the rear of the van. Finding 93: The evidence supports that Mr Cole stated “My neck” or “My neck hurts” one or two times while at the rear of the police van. Finding 94: The evidence shows that Mr Cole did not put his trainer on while at the back of the police van. Finding 95: The evidence supports that PC Ross informed Mr Cole of his arrest at the van. Although he could have been notified sooner, it is the investigator’s opinion a tribunal would be unlikely to find that the delay amounted to a breach of the standards of professional behaviour. Finding 96: The evidence supports that Mr Cole did not have a visible physical injury, but he presented as physically and mentally unresponsive. Finding 97: It is the investigator’s opinion that a tribunal could find that at the time Mr Cole was at the rear of the police van, PC Oates, PC Ross, PC Kalyan and PS Withey should have recognised that his condition was due to injury. A tribunal could also find that these police officers knew that to be the case at the time they gave evidence. Finding 98: A tribunal could find that no-one performed an adequate medical assessment or welfare check on Mr Cole before the decision to take him to custody, or before he was transported away from the scene. Finding 99: The evidence supports that PS Withey made the decision that Mr Cole should be taken to custody and not to hospital. The evidence supports

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that he did not receive or obtain any information to make this decision except for Mr Cole’s comment about his neck and PS Withey’s sight of Mr Cole; further, that PS Withey assumed that Mr Cole was feigning injury and did not carry out or order a welfare check to verify his assumption. Finding 100: The evidence supports that PC Ross, PC Oates and PC Kalyan deferred to the decision-making of the police officers around them and did not take direct responsibility for decisions regarding Mr Cole’s welfare. Finding 101: The evidence supports that PC Ross and PC Oates assumed Mr Cole was non-compliant and/or feigning injury. Finding 102: The evidence indicates that PC Ross and PC Oates moved Mr Cole into the cell of the police van between 01:52:49 and 01:53:14. Finding 103: The evidence supports that Mr Cole was sitting on the floor of the van between the two seats with his back against the perspex or one of the seats. Finding 104: In the investigator’s opinion, a tribunal could find that, once at the police van, Mr Cole did not move his legs at any time or push himself back in the police van; Mr Cole was placed into the cell of the van and had his legs moved for him by the police officers. Finding 105: In the investigator’s opinion, a tribunal could find that Mr Cole’s breathing difficulties would have developed when he was put in the cell of the van, during the journey, or when he was removed from the van and sat at the back of the van in the yard, all without spinal precautions. Finding 106: A tribunal could find that Mr Cole may have attempted to respond to questions during the journey to Greyfriars police station, but was incoherent and did not engage in conversation. Finding 107: In the investigator’s opinion a tribunal could find that Mr Cole did not move his legs during the journey to Greyfriars police station. Finding 108: The evidence supports that Mr Cole did not walk or attempt to walk when removed from the van at Greyfriars police station. Finding 109: A tribunal could find that Mr Cole did not speak while at Greyfriars police station. Finding 110: The evidence supports that Mr Cole’s handcuffs were repositioned from the rear to the front by PC D. Finding 111: The evidence supports that PC Ross was responsible for the decision that the handcuffs should be reapplied to Mr Cole’s front while in the yard at Greyfriars police station. In the investigator’s opinion, PC D’s contact with Mr Cole and the repositioning of his handcuffs would be unlikely to engage any breach of the standards of professional behaviour. Finding 112: The evidence supports that PC Ross did not provide justification for the use of force through continued application of handcuffs to Mr Cole while waiting for an ambulance to attend. Finding 113: In the investigator’s opinion, a tribunal may find that Mr Cole did not move of his own volition while at Greyfriars police station. Finding 114: Around the time that an ambulance was called, Mr Cole made noises indicative of an airway obstruction.

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Finding 115: PC Ross called for an ambulance at approximately 2.02am. Finding 116: The evidence supports that, in the period before the ambulance arrived, Mr Cole did not speak or move, and he was unconscious by the time the paramedics arrived. Finding 117: The evidence supports that PC Ross informed paramedics that Mr Cole was “chatty”, walked to/from the police van and did not show any sign of ill-health until they arrived at Greyfriars police station, at which point he collapsed. A tribunal could find that this was an inaccurate description which was not corrected by PC Oates or PC Spicer. Finding 118: The evidence supports that PC Ross, PC Oates and PC Spicer did not inform the paramedics of a possible neck injury. Finding 119: In the investigator’s opinion, a tribunal could find that the handover information provided to the paramedics and the omission of a potential neck injury affected the paramedics’ treatment of Mr Cole. Finding 120: PC Ross notified custody sergeant PS F of the situation.

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Appendix: Summary of subject officer case to answer decisions

Standard of Professional Behaviour

Orders and Subject officer Instructions / Honesty and Use of Force Duties and Integrity Responsibilities

PC Hannah Ross Misconduct Gross Misconduct Gross Misconduct

PC Nicholas Oates No case to answer Gross Misconduct Gross Misconduct

PC Sanjeev Kalyan No case to answer Gross Misconduct Gross Misconduct

PS Andrew Withey No case to answer Gross Misconduct No case to answer

PC Peter Spicer No case to answer Gross Misconduct Gross Misconduct

Inspector No case to answer No case to answer No case to answer Lee Fosbury

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Addendum to the report – Summary of allegations and final outcomes after gross misconduct hearing

Allegations faced

At the outset, the four officers faced allegations of the following breaches:

PC Hannah Ross Breach 1) Honesty and integrity – PC Ross failed to act with honesty and integrity because she made the following statements to the paramedics and/or her pocket notebook and/or during interview although she knew they were not true: 1. Mr Cole walked to the van. 2. Mr Cole stood at the rear of the van. 3. PC Ross asked Mr Cole if he could move his legs. 4. Mr Cole moved his legs up and down. 5. During the journey to the police station Mr Cole was moving about in the back of the van. 6. Mr Cole spoke to PC Ross throughout the journey to the police station 7. During the journey to the police station Mr Cole lifted his legs up onto a box seat. 8. On arrival at the police station Mr Cole had walked to the back of the van. Breach 2) Use of force – concerning the reapplication of handcuffs at the police station

Breach 3) Duties and responsibilities PC Ross failed to carry out any or any adequate welfare check before Mr Cole was taken to the police station in the police van.

PC Nicholas Oates Breach 1) Honesty and Integrity - namely that: 1. PC Oates failed to correct the inaccurate account that PC Ross gave to paramedics; and 2. in relation to a number of statements made by PC Oates, namely that: a. Mr Cole walked to the van. b. Mr Cole was asked to pull his legs in so that the doors could be shut, c. Mr Cole did pull his legs in as requested. d. When in the back of the van Mr Cole was alert and conscious. Breach 2) Duties and responsibilities PC Oates failed to carry out any or any adequate welfare check before Mr Cole was taken to the police station in the police van.

PC Sanjeev Kalyan Breach 1) Honesty and integrity – PC Kalyan failed to act with honesty and integrity because he made the following statements in his pocket notebook and/or during interview although he knew they were not true: 1. Mr Cole was walked to the van.

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2. Mr Cole was asked if his head was okay. 3. Before Mr Cole got into the van, PC Kalyan heard PC Ross ask him if he could move his legs. 4. In response to PC Ross’s question, Mr Cole moved his legs. 5. PC Kalyan saw Mr Cole put his trainers on at the back of the van. 6. PS Withey was told that Mr Cole had banged his head on the floor. Breach 2) Duties and responsibilities PC Kalyan failed to carry out any or any adequate welfare check before Mr Cole was taken to the police station in the police van.

PS Andrew Withey Breach – Duties and responsibilities 1. PS Withey was aware Mr Cole was complaining of a neck injury. 2. Mr Cole’s presentation was such that it was obvious that he needed to go directly to hospital rather than the police station. 3. PS Withey failed to carry out any or any adequate welfare check or order others to undertake such a check before Mr Cole was taken to the police station in the police van.

At the conclusion of the appropriate authority’s case, representations were made on behalf of PC Oates and PC Ross of no case to answer. As a result, the following allegations were dismissed:

For PC Ross: items 1 and 8 of breach 1. For PC Oates: item 1 of breach 1.

The Panel’s findings (summary)

PC Ross 1) Honesty and Integrity: The Panel found that items 3,4,5 and 7 of the Honesty and Integrity allegation were proved. Particular 6 was not proved on the basis of medical evidence that Mr Cole would have been capable of some speech. Panel found breach amounted to gross misconduct. 2) Duties and responsibilities: Proved, amounting to misconduct. 3) Use of force: Not proved. Another officer provided an account stating that it was in fact he that reapplied handcuffs. Panel found PC Ross may have been mistaken in believing that she reapplied the handcuffs.

PC Oates 1) Honesty and Integrity: Items 2(b) and 2(c) were proved. 2(a) not proved and the Panel did not consider that PC Oates ever stated or inferred that Mr Cole had walked freely or unaided. 2(d) not proved as Mr Cole was conscious in the back of the van.

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Panel found breach amounted to gross misconduct. 2) Duties and responsibilities: Proved, amounting to misconduct.

PC Kalyan 1) Honesty and Integrity: Items 3,4 and 5 were proved. Item 1 not proved and the Panel did not consider that PC Kalyan ever stated or inferred that Mr Cole had walked freely or unaided. Items 2 and 6 not proved. Panel found breach amounted to gross misconduct. 2) Duties and responsibilities: Proved, amounting to misconduct.

PS Withey 1) Duties and responsibilities: Proved, amounting to misconduct.

Sanctions

PC Ross, PC Oates and PC Kalyan dismissed without notice. PS Withey was issued a final written warning.

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