| The Stephen Lawrence Inquiry | |||
CHAPTER TEN FIRST AID 10.1 On the evening of 22 April 1993, Mr & Mrs Conor Taaffe had been to a prayer meeting at their local Catholic church. The church is a short distance north of the point where Stephen fell. They started to walk towards the Well Hall roundabout, and they noticed two young black boys who were running towards them. In his statement Mr Taaffe said that he saw "a couple of young black boys who were jogging along. They seemed to be running. Also at the time I did sense immediately something wrong, something dangerous, something suspicious ....". Mr Taaffe accepted that he did instinctively at first think that an "attack or mugging" might be imminent. Almost instantaneously he overcame that instinctive reaction. 10.2 Mr Taaffe saw that Stephen Lawrence was holding his upper chest with one of his hands, as if he might have been injured in that area. The Taaffes then saw Stephen Lawrence "crash onto the pavement". At once they realised that something very serious had happened, and as soon as they came up to the scene they saw Mr Brooks standing in the middle of the road trying to flag down passing cars. Then they saw him go to the telephone box on the other side of the road, just in front of the church. 10.3 Mr Taaffe remembered that about a week or two before he had seen a television broadcast talking about St John's Ambulance and giving a description of the recovery position. He was bothered that he could not remember the detail of what had been said sufficiently for him to be confident enough to try to put Stephen into the correct position. But his wife almost at once said "Oh no, no Conor, he is in the correct position, he is in the recovery position already". 10.4 As Stephen lay on the pavement Mr Taaffe remembers an involuntary movement of the head to the left and a sound as if Stephen was choking and trying to breathe. Mr Taaffe put his hand on Stephen's back and felt some movement. 10.5 Meanwhile, Mr Brooks had made his telephone call to the emergency services and had kicked the telephone, obviously in total frustration after he had tried to flag down cars which drove by. It should be said at once that Mr Brooks was a victim of this terrible onslaught by these young men. Fortunately he escaped physical injury. He was in great distress and obviously confused and very upset. He has been described as "distraught" and "hysterical", and many other descriptions of his condition have been given in evidence. Mr Taaffe described Mr Brooks as "acting in a desperate and adrenalinated manner". PC Geddis said that he was "very upset, understandably upset". Catherine Avery described him as "distraught and crying". He did give a short account of the matter to Mr & Mrs Taaffe, saying to them that some white boys had got Stephen Lawrence and one of them had had an iron bar. Mr Taaffe's reaction was to think "My God, what did they do with an iron bar to sort of cause these injuries?". He saw quite a lot of blood on the pavement and thought that there may have been a severe internal injury. 10.6 Mr Taaffe has no direct memory of the arrival of PC & Mrs Geddis on the scene, but he does remember a man with a beard joining him and his wife near Stephen. After that the first police car arrived, and in that car were PCs Linda Bethel and Anthony Gleason. Mr Taaffe remembered the police woman immediately coming to the area of Stephen's head. He told PC Bethel what Mr Brooks had said. Mr Taaffe believes that within a minute or two of the arrival of the police Stephen had stopped breathing. PC Bethel put a finger to the front of Stephen's mouth and said that she thought that there was some breathing. Mr Taaffe tried the same test and felt nothing. The other police officer, the male police officer, seemed to be in the background, according to Mr Taaffe. 10.7 When the ambulance came it was evident to Mr Taaffe that Stephen was dead. After Stephen's body was taken away, Mr & Mrs Taaffe said to PC Bethel that they were going to go back to the church to pray for Stephen. Mr Taaffe remembered no large police vehicles at the scene before the ambulance came, and indeed before he left. 10.8 When he came back about an hour later there was a PC standing outside a cordon of yellow plastic tape. Mr Taaffe was not conscious of large numbers of officers or indeed of any team of police officers in action at the scene. 10.9 In his evidence Mr Taaffe remembers that PC Bethel stood up and spoke to Mr Brooks or dealt with Mr Brooks, but he confirmed that PC Bethel was indeed crouching down beside the body of Stephen with himself and his wife until the ambulance came. Mr Taaffe did not recall the presence of PC Geddis and his wife, who were plainly at the scene for a substantial time. He does recall PC Gleason leaving the scene to try to find the ambulance. 10.10 It is of course a common experience that memories of an event such as this vary considerably, and any of those present at the scene may be forgiven for not remembering exactly who was where and at what particular moment. Towards the end of his evidence Mr Taaffe said that it was incorrect to say that either his wife or anybody else cradled Stephen's head. This had been reported in the press, and Mr Taaffe said that he supposed that this was indeed "a loving image, but those are not the facts. She did put her hand on Stephen's head" said Mr Taaffe, "and whispered in his ear 'You are loved, you are loved'." 10.11 A poignant passage in his evidence was that which described his return home when he washed the blood off his hands with some water into a container and poured the water with Stephen's blood in it at the foot of a rose tree. 10.12 Mr Taaffe's conclusion, as set out in his statement, was that "looking back on the incident I feel that neither the police nor ambulance staff can be criticised for their actions at the scene". He also said that he was of the opinion that further First Aid attempts would have been futile, since Stephen needed a surgeon and not First Aid. 10.13 The actions of Mr & Mrs Taaffe deserve nothing but praise. They had no training in emergency First Aid, and their actions and attitude are to be applauded. 10.14 We should say at once that it is the truth that nothing done to Stephen as he lay on the pavement would, in fact, have made any difference, since his loss of blood was extreme. This is confirmed by the doctor who saw Stephen when he was taken to Brook Hospital and by later medical evidence which is available to the Inquiry. That does not mean that steps should not have been taken to follow the rubrics taught to the officers present in their First Aid training. They had no way to know how severe the injuries actually were and they should have performed First Aid in case Stephen's life could have been saved. 10.15 The first police officer on the scene was in fact PC James Geddis. He has almost completed thirty years service in the MPS. He was off duty on the night of 22 April, and with his wife he was going home from a prayer meeting. He drove down Well Hall Road, and his attention was drawn to a body lying on the pavement. He actually drove past but turned round and came back to the scene. 10.16 His immediate reaction was that Stephen Lawrence was in the recovery position. He was lying partly on his right side with one leg up and with one arm extended. One of the reasons why PC Geddis came back was that he had seen Mr Brooks going backwards and forwards across the road and running about waving his arms in the roadway. PC Geddis at once asked Mr Brooks what had happened and in his own words "all I got was that he had been hit with an iron bar and they had gone, and that was it". PC Geddis made a second call at the telephone box where the telephone had been left off the hook by Mr Brooks. PC Geddis told us that he did not know the seriousness of the injury until the ambulance men took Stephen Lawrence onto the stretcher, when he realised how much blood there was underneath. 10.17 There are records in connection with the First Aid courses or refresher training carried out by the police officers involved. PC Geddis' latest certificate expired in June 1993. More will be said about First Aid training later. PC Geddis thought that he could see Stephen's back moving up and down and concluded that he was still breathing, and he also believed that, since Stephen was in the recovery position, he should not be moved. PC Geddis was at the scene when PCs Bethel and Gleason arrived in their panda car. He confirms that Mr Brooks was in a state of "understandable distress". 10.18 PC Geddis was cross-examined on behalf of Mr & Mrs Lawrence by Mr Kamlish. He told the Inquiry that he formed the opinion, when he arrived, that Stephen Lawrence was being looked after and was breathing and was in the recovery position and he felt that it was his duty, if possible, to get information and to ensure that expert help had been summoned to the scene. He felt it best to leave Stephen where he was. The simple fact is that he took no positive step to do anything in connection with Stephen as he lay on the pavement. There was some dispute as to when PC Geddis first saw blood around or near the body. In this connection, Mr Kamlish accused PC Geddis of lying, since the suggestion was that the blood must have been obvious from the start. 10.19 We formed a favourable impression of PC Geddis and we reject the suggestion that he was not speaking the truth. He was after all the Good Samaritan who stopped when he saw that something had happened on the pavement. Once he came to the scene he was effectively on duty since Police Constables have to take action in accordance with their position, even if they are technically off duty. But we feel that it is hard indeed to accuse PC Geddis of negligence or of thoughtlessness. As with other officers we are sure that any deficiency in the actions taken by PC Geddis was caused by lack of training rather than lack of the will to help. He provided his own rug or blanket to cover Stephen. His failure to provide First Aid or to see that it was provided did not arise from bad motives. He assumed that Stephen was being cared for by others, and after making the second telephone call for the ambulance he, like others, relied upon the imminent arrival of the ambulance. 10.20 We should finally mention in this context that PC Geddis, when he was seen by the Kent Police force in 1997, said that he felt shocked by what he had seen and felt that "it was such a waste because I thought he was known to like people in my own family." His own daughter was in fact in the same class as Stephen Lawrence at school. Six to eight weeks after the murder Police Sergeant Peter Solley told Mrs Lawrence about the part played by PC Geddis and his wife at the scene. Mrs Lawrence asked PSgt Solley to pass on to them her thanks for trying to help Stephen at that time. 10.21 We have no hesitation in saying that there was no racist motivation or reluctance in PC Geddis' failure to do anything to Stephen Lawrence. He wrongly thought that the best thing was to leave him where he was in order to allow the paramedics to take over, once the ambulance came. 10.22 Before dealing with the evidence of the other police officers who came to the scene, it should be noted that Mr Brooks' telephone call was made at 22:43. The second telephone call to the emergency services was made at 22:48. The ambulance arrived at the scene at about 22:55. The ambulance arrived at Brook Hospital at 23:05. Dr Patel first saw Stephen Lawrence at 23:07, and he certified that Stephen was dead at 23:17. 10.23 PCs Bethel and Gleason were alerted probably as a result of the first telephone call. They would have taken only minutes to have come from Plumstead Police Station to the scene. They parked their car by the side of the road near to the body of Stephen Lawrence. The probability is that they were at the scene by about 22:50. So that they were probably with Stephen and the others at the scene for only about five minutes before the ambulance arrived. 10.24 PC Bethel at once saw a large amount of blood near Stephen's body, and called her control room asking them to hurry up the arrival of the ambulance. At that stage, PC Bethel said that PC Gleason was going to "head for Stephen Lawrence", and she decided to deal with Mr Brooks. She did look to see what might be done in connection with Stephen. She had been told that Stephen had a head injury, and she also concluded that he was in the recovery position when she arrived. There was no obvious wound to see where the blood was coming from, and she believed that the ambulance would be there within minutes. She told the Inquiry that her understanding of head injuries was that they can bleed "an awful lot more than a normal wound and that doesn't actually suggest that it is incredibly serious". 10.25 Misapprehension as to the nature of the injury is a feature of the evidence of all those who were present. This does not mean that nothing should have been done to try to trace the bleeding. But we believe that PC Bethel's reaction was understandable. Again, as with PC Geddis, the root of the trouble appears to us to have been lack of training rather than any casual approach to what she saw. PC Bethel was trained in First Aid. Her latest certificate was granted on 21 January 1992. If that training had proper content she should have known that it was essential to check at once the source of the bleeding as an elementary first step. 10.26 For part of the time that she was present at the scene she did deal with Mr Brooks. He was walking or moving about the scene and was in a state of extreme distress. She says that she spent quite a lot of time trying to get details from Mr Brooks, and repeatedly asked him questions. All that she could get from him was that the injuries had been inflicted by a group of six white men. He was using strong language, and was very upset and was indicating roundly that he had not called the police and that he was extremely angry that the ambulance had not come first. As we point out in Chapter 4, PC Bethel's assessment of Mr Brooks at the scene is in marked contrast to her later more critical assessment, particularly as given in evidence to the Kent inquiry. 10.27 We accept that PC Bethel did try to feel a pulse in Stephen Lawrence's neck. Catherine Avery saw this being done, from her home next to the scene. Mr Taaffe confirms that she put her fingers in front of Stephen's mouth to see if there was breathing. PC Bethel believed that she felt a faint pulse and that she felt some degree of breathing. It may well be that this was a mistaken conclusion, but she did at least make that effort to see if there was some life left in Stephen. Afterwards, it is evident that she remained close to the body, but, like Mr & Mrs Taaffe, she did nothing to move Stephen or to adjust his position on the ground so that she could see where the blood was coming from. As the ambulance men picked Stephen Lawrence up she did, of course, see how much blood there was. She still hoped and believed that Stephen would recover. 10.28 PC Bethel's last refresher course in First Aid took place in 1992. Very little detail could be gleaned from her or from any of the police officers as to what was actually contained in such a refresher course. It is the opinion of the Inquiry that First Aid training and refresher training of police officers as revealed in this case must have been wholly inadequate. 10.29 Mr Kamlish rigorously cross-examined PC Bethel, and put to her that the first elementary action in First Aid where heavy bleeding is observed is to trace the source of the bleeding and try to staunch the flow. It was her firm brlief that Stephen Lawrence should be left where he was, so she did not obtain a First Aid kit or a torch from the car or turn the lights of the car on to him in order to carry out a closer examination. Towards the end of her cross-examination PC Bethel accepted that she now regrets that she did not look for the injury. But that is said with hindsight, and reveals that PC Bethel was at least prepared to accept now that something else should have been done. That, however, does not mean that her approach to Stephen Lawrence as he lay on the pavement was positively callous or unthinking, even though she took no steps in connection with the bleeding which she had observed. Her inactivity may have been partly caused by her hope that the ambulance woulsd arrive and that professionals would take over. 10.30 There was no indication given to us during her long cross-examination that PC Bethel would have acted differently if the person on the pavement had been white. 10.31 After the ambulance went away, PC Bethel stayed at the scene,
and did duties as directed by her seniors. She cannot herself be blamed for any lack of
direction or initiative. She saw senior officers present, including Chief Superintendent
John Philpott and 10.32 When seen by the Kent Police, PC Bethel was asked about the racist aspects of this case, and she said that this had played no part in her conclusions or in what she had done or failed to do. Her failure to administer positive First Aid was primarily the result of the poor level of training. We believe that if she had thought something needed to be done then she would have done it in order to try to help Stephen Lawrence. 10.33 PC Bethel was further criticised by Mr Macdonald QC on behalf of Mr Brooks. It was suggested that the officer should have asked Mr Brooks if he was injured and that she should have paid more or closer attention to him. There is no doubt that Mr Brooks was in a state of shock and tension and would not have been easy to deal with. There is absolutely no blame to be attributed to him in this regard, because he was a victim and was suffering very considerable stress and distress, both at the scene and thereafter. Mr Macdonald further suggested that PC Bethel was not speaking the truth when she said that Mr Brooks had indicated to her that he had not actually seen the assault on Stephen Lawrence. It is apparent that PC Bethel dealt only briefly with Mr Brooks before turning her attention to Stephen Lawrence. 10.34 PC Gleason also gave evidence. His last refresher course in First Aid appears to have been given in August 1991. He agreed that he arrived at the scene at about 22:50 and in his statement his first description was of "a group of people standing around Stephen Lawrence who was laying on the floor in the recovery position". PC Gleason thought that there was blood around the back, around where the shoulders were. He saw people beside the body, but he did not know who they were. He said that he looked at Stephen Lawrence's head but could find no serious injury to it. He also says that he felt for a pulse and thought that he had found a very weak one. This officer also said that he examined Stephen's body with some care, starting at the head and working downwards. We have to conclude that this was probably not done. He said that there was no evidence to suggest where any wound might have been. Nobody else saw PC Gleason check the body for wounds or injury. Certainly PC Gleason, like the others at the scene, did nothing to administer First Aid by seeking the source of the bleeding and attempting to staunch it. As to the pulse, basic First Aid should teach that the automatic response to failure to detect an adequate pulse at the wrist should be followed by an immediate move upwards to feel for the pulse in the neck. 10.35 Police must not rely upon the immediate arrival of paramedic help to obviate their responsibility to carry out immediate First Aid. The elementary steps to be taken by anyone who has a minimum of training are to check the airways, to check the breathing, and to check the circulation. This is the "ABC" of First Aid. The fact is that PC Gleason, like the others present at the scene, left Stephen where he was, in the mistaken belief that nothing should have been done to move him. Heavy bleeding must be traced as a high priority in a case like this. Police officers ought to have known that. 10.36 PC Gleason was also firmly cross-examined at length by Mr Kamlish. He stuck to his story, namely that he had examined the body of Stephen Lawrence as it lay on the pavement. As we have already indicated, we doubt very much whether this examination took place. This officer like the others said and indicated that he felt at the time that, because the ambulance was on its way, Stephen was best left in the position that he was in. 10.37 It is of some significance that during his time at the scene PC Gleason went in his car, in the hope of expediting the arrival of the ambulance. This action by him was again subject to firm criticism through Mr Kamlish. Whether he should have left the scene or not is doubtful, since radio contact must have been available, but we do not believe that PC Gleason left otherwise than to do what he said that he was doing. He did not find the ambulance and when he came back he took no further steps in connection with Stephen Lawrence, and shortly after that the ambulance came and he accompanied the ambulance to the hospital. 10.38 Any deficiency in what PC Gleason did or failed to do in connection with First Aid was in part attributable to lack of satisfactory training. On the other hand the evidence is that such refresher training as these officers received included training as to the essential need to staunch bleeding. It may well be that PC Gleason was also simply hoping for the immediate arrival of the ambulance. We have to conclude that he did to some extent embellish his evidence by indicating that he had done more than we believe that he did by way of examination at the scene. To that extent his evidence was unsatisfactory. He has perhaps persuaded himself that he did more, in the knowledge that he ought to have done more at the time. There is no indication that he was consciously affected by the fact that Stephen Lawrence was black, and that Mr Brooks was also black and was acting in the way which has been described. 10.39 The last police witness in connection with the First Aid issue, other than professional and expert witnesses was PC Joanne Smith. She was herself called to the scene some time after 22:45. When she got there PCs Bethel and Gleason had already arrived, so that she was there for a shorter time than the other officers. She at once saw that Stephen Lawrence was lying on the pavement covered with a blanket. That blanket had come from the car of PC Geddis, and after the body was covered with the blanket it may be that the blood was less visible to those who came to the scene. PC Smith took no part in the immediate looking after or tending of Stephen Lawrence, but she went to the hospital with Mr Brooks as her passenger. Mr Brooks understandably wanted to go with Stephen in the ambulance, but the paramedics in charge of the ambulance said that that was not possible. All that PC Smith gleaned from Mr Brooks was that he and Stephen had been attacked by some white youths and that Stephen had been hit. She dropped Mr Brooks off at the hospital and collected some scenes of crime tape out of the Area car and took it back to the scene. 10.40 Later she described Mr Brooks as being highly excitable and particularly unco-operative. She found him to have been aggressive and shouting and swearing whilst she drove him to the hospital. He was all the time in a very agitated condition, but she said that he did calm down somewhat as he sat in the car with her. 10.41 In common with many other officers PC Smith made no note of what happened on the night in question. She says that she was not asked to make a note, but that she made a statement later in June 1993. Mr Kamlish challenged PC Smith as to her experience or knowledge of racism in the police force. 10.42 It should be noted that when she left to take Mr Brooks to the hospital she confirmed that none of the Territorial Support Group Units had arrived at the scene. She did not recall them being there at any time whilst Stephen was still at the scene. She did suggest that she may have missed seeing them. Upon her return she confirmed that other Units including the TSG had arrived. 10.43 We do not accept the full thrust of the criticisms of PC Smith advanced by Mr Macdonald in his cross-examination on behalf of Mr Brooks, namely, that she was trying in some way to suggest that he had been "nothing but a bloody nuisance that night". She reported exactly what she had experienced in her short dealings with Mr Brooks at the scene and en route to the hospital. On the other hand it must be said that this officer together with others could and should have shown much more interest in and sympathy for this vital witness both at the scene, where he should have been used to assist in immediate searches for possible perpetrators, and at the hospital where he should have been carefully dealt with as a potential witness and as a victim. Everybody agrees, and the officers themselves agreed, that Mr Brooks was wholly understandably in a state of great distress and agitation. Nobody should blame him for the things that he said at the scene and thereafter. He was a primary victim of the terrible conduct of the young men who killed his friend, and any excitement and stress shown by him is understandable. The virtual abandonment of Mr Brooks at the hospital is to be deplored. Furthermore PC Smith, like PC Bethel, allowed herself to use much more colourful language about Mr Brooks to Kent than she had used in her 1993 statement. We have to say that PC Smith stereotyped Mr Brooks, and failed to treat him as a primary victim. 10.44 Two other witnesses most relevant to the issue of First Aid are, of course, the ambulance men who came to the scene. They are Messrs Geoffrey Mann and Michael Salih. Both of them confirm that Stephen Lawrence was lying in what was "almost the recovery position" when they arrived. They went to check Stephen Lawrence and found no pulse, and no breathing, and they found that his eyes were fixed and dilated. They immediately put Stephen's body in the ambulance and carried out resuscitation en route to the hospital. Both paramedics confirmed that there was a lot of blood in the area of Stephen's chest, and both of them saw Mr Brooks in a distraught state. He tried to get into the ambulance with his friend, but the paramedics rightly did not allow this to take place. 10.45 Both these men, and the doctors later on, confirmed that First Aid would not, in fact, have made any difference to Stephen's condition. It is confirmed by the post mortem findings that the stab wounds inflicted on Stephen Lawrence were fatal. No medical, surgical or First Aid intervention could in the circumstances have saved his life. He must have been dead a short time after he hit the pavement. It is of importance from the police officers' point of view, that when Mr Salih was questioned, he said that he would not have advised anyone to move Stephen Lawrence. Knowing that the report had been of a head injury he believed that somebody in that condition should have been left where he was until professional help was available. This does not detract from the necessity when heavy bleeding is observed to examine the patient in order to try to staunch the blood. But Mr Salih's opinion of the situation as he saw it provides some mitigation to the police officers who failed to do anything in respect of Stephen by way of First Aid. 10.46 Other witnesses who saw Stephen as he lay on the pavement gave evidence to the Inquiry. Miss Catherine Avery and Miss Helen Avery are sisters who lived in the house immediately next to the scene. Miss Helen Avery had been out for the evening with her parents, and her sister was present in the house when the family returned. Both of them confirmed, from their different points of view, that nothing positive had been done in connection with Stephen's body as he lay on the ground. Miss Catherine Avery saw PC Bethel trying to check Stephen's pulse. They saw no other attempts to discover wounds or to take any active step to trace the bleeding. Miss Helen Avery was only 14 years old at the time, and she was amazed that no-one was attending to the body on the floor or trying to stem the flow of blood. She saw that there was a lot of blood and her knowledge of First Aid told her that something ought to have been done. This evidence is revealing, because a 14 year old girl properly instructed in First Aid knew what ought to have been done where heavy bleeding is observed. Yet police officers who were trained or allegedly trained in First Aid did not appreciate that this was an immediate action which ought to have been taken. 10.47 In the context of First Aid it is next necessary to refer to the arrival of the first TSG vehicle. There is much confusion as to the number of the first vehicle to arrive, and as to the names of those who were on the vehicle. That will be dealt with in more detail in the section dealing with the initial response to the murder. It does appear from their evidence, however, that those present included Police Sergeant Nigel Clement, Police Sergeant Andrew Hodges, who was a PC in 1993, and in particular, Inspector Steven Groves. There is, as will appear later, also considerable confusion as to who was on which of the TSG carriers. But both PSgt Clement and Mr Groves, who is an important witness in this case, indicated that they got off one of the carriers very close to the place where Stephen Lawrence's body lay. 10.48 Other officers said that they saw the scene, including the body of Stephen Lawrence on the footpath, either from the inside the carrier or from the roadway just outside it. PSgt Clement said in his original statement that upon attending the scene he saw "a male laying on the pavement near number 318". He said that the man was lying on the pavement close to a large tree, and during his evidence he indicated that the tree must have cast a shadow over the body since he was unable to tell if there was any blood around the body. He says that he saw no blood at that time or indeed at any other time whilst Stephen Lawrence still lay on the pavement. Mr Groves was, of course, the officer in charge of the Unit. PSgt Clement was effectively his second-in-command on immediate arrival at the scene. It is apparent, from cross-examination, that PSgt Clement did not enquire about the state of the casualty on the ground, in particular as to whether he was alive or needed treatment or whether an ambulance was on its way. PSgt Clement played no part in the actions which might have been necessary in respect of First Aid or attention to Stephen Lawrence. Similarly PSgt Hodges, who made a statement on 1 May 1993, told us that there were people attending to Stephen Lawrence. He said that there was nothing that he felt he could do there after he got off the carrier. He agrees that he must have got off the carrier because he went with Mr Groves to the Welcome Inn. He was cross-examined on the basis that he had arrived after the ambulance had left the scene, but he reiterated that he saw a man lying on the floor with others around him. It was apparent, however, that his memory was cloudy, since he had no recollection of seeing PC & Mrs Geddis or Mr & Mrs Taaffe at the scene. 10.49 Mr Groves told the Inquiry that he was on the first carrier to arrive at the scene. He was hideously confused about the other personnel who were with him in that carrier. Simply for example in his statement made on 11 May 1993, he said that the carrier upon which he travelled was driven by PC John Clutterbuck. Further evidence has made it sure that this was not so. Mr Groves did agree that PSgt Clement was with him on arrival. The Inspector was much confused as to the number of the carrier upon which he travelled. The Inspector's evidence will be referred to in more detail in respect of the Initial Response part of this Inquiry (Chapter 11). But the Inspector himself says that when he arrived the ambulance had not yet attended and Stephen Lawrence was lying on the pavement. He told us that he saw Stephen lying near a large plane tree and he also echoed other evidence when he said that he would say that Stephen was in the recovery position. When he got to the scene, Mr Groves said that there were two police officers down on their hands and knees tending to Stephen. He remembered two other people crouched down as well, but he had no idea what any of these people were doing. He says that he asked the officers "Is he breathing?" and "Is he bleeding?" and he asked if they wanted a hand or needed help. He indicated to the Inquiry that he got no reply at all to these queries posed to the officers. He said that he thought that those around Stephen Lawrence were doing what they should have been doing. He said that he could only assume from the position of Stephen's head and what he saw going on that Stephen was still alive. The officers and those around Stephen appeared to be monitoring his condition and from what he could see it looked, he said, as though they were taking a pulse. 10.50 The main point, however, is that it was crystal clear that Mr Groves did nothing to find out properly what the situation was or to check properly what was being done, or to ensure that properly qualified First Aid people were dealing with Stephen Lawrence. He said that the ambulance had been called, and that Stephen was being attended to, and he classified what he had seen going on as First Aid. He said that his conclusion was that if Stephen had still not been breathing the officers would have turned him on his back and performed emergency resuscitation. Since they were not doing that he concluded that all that was necessary or correct was being done. Mr Groves says that he saw no blood when he arrived at the scene. It is possible that the blanket was by that time covering the blood, but Mr Groves made no effort to ensure that the steps being taken by the junior officers present were the correct steps. Indeed, it is likely that if Mr Groves himself had been in the position of the other officers he would have done no more than they did. It is palpable from answers given by Mr Groves that his own training in First Aid was minimal, and that he had been on no courses whatsoever for many years. He seemed to think that it was somehow demeaning that it might be suggested that he should go to a refresher course with junior officers, since he had 27 years service and was capable of acting properly on his own account. Mr Groves had not done any First Aid training since 1985. He can surely be roundly criticised for not finding out who had taken responsibility for First Aid. He simply took it for granted that someone junior was appropriately in charge of Stephen Lawrence. 10.51 The truth is, in a nutshell, that nobody did anything whatsoever for Stephen Lawrence except the small amount of testing to see whether he was still breathing and whether his pulse was beating. Officers who had allegedly been trained and undergone refresher training ought to have realised that the bleeding was such that there should be an immediate investigation in order to decide whence the blood was pouring, in order to try to staunch the flow of blood and if necessary to lift up the legs of the injured man. It is little consolation to Mr & Mrs Lawrence and the Lawrence family that nothing that anybody had done would have made any difference whatsoever. The fact that nothing was done is a source of understandable distress to them, to this day. 10.52 As to the First Aid issue there remains to be considered the expert evidence that was called to assist the Inquiry in respect of measures which ought to have been taken by anybody trained in elementary First Aid at the scene. There were three witnesses who dealt with this area of the case. The most impressive was Mr Graham Cook, Fellow of the Royal College of Surgeons of Edinburgh, and Fellow of the Faculty of Accident and Emergency Medicine. He gave evidence on Day Five. He is a most experienced man and he is at present Director of Accident and Emergency Services at Maidstone Hospital. Furthermore, he is a Medical Consultant to Kent Constabulary and has, for a long time, been involved in the overseeing of First Aid training for police officers and others. His full statement is available as is the transcript of his evidence. But, in essence, he says that First Aid must be based on immediate assessment of the patient. The result of that assessment dictates the necessary activities and measures to be taken. He introduced the letters "ABC" which form the fundamental basis of the initial check which must be made of any patient, namely the checking of the Airway, the Breathing, and the Circulation. He said that haemorrhage control does not require anything more than basic First Aid skills. He indicated that if there had been a blow to the head there could be substantial blood loss, but that would be clearly visible even in poor lighting. From the horrendous injuries suffered by Stephen Lawrence he was sure that there would be very heavy bleeding. He is sure that a properly instructed First Aider would and should have attempted to trace the source of the bleeding in order to take elementary measures to staunch the flow of blood. The right course was to staunch the flow and, said Mr Cook, to raise the legs to put more blood back into the system. Mr Cook asserted repeatedly that this was or should have been elementary to trained First Aiders. There is no doubt that the Inquiry had before it a witness of enormous experience and of practical skill. 10.53 Recommendations will, of course, be made later in this report, but it will be apparent that the Inquiry criticises strongly the training of police officers in First Aid and the lack of any apparently successful or satisfactory refresher training. 10.54 The Inquiry heard two other witnesses in connection with First Aid: Mr David Sadler was until 1997 Branch Training Officer for the Kent Branch of the British Red Cross Society. He is a man of much experience in the field of First Aid. In cross-examination Mr Sadler did effectively agree with Mr Cook that the first priority was to check a casualty's breathing and make sure that there was a pulse and then to go to the bleeding. He did say that he would not want to move the patient once he knew an ambulance was on its way, but later he said that if there was any sign of profuse bleeding then the bleeding point should at once be ascertained, and it should be stemmed by direct pressure. To that extent Mr Sadler accepted the opinion of Mr Cook. His earlier opinion expressed to the Kent inquiry that reasonable steps had been taken by those present was based upon information which omitted reference to the visible blood loss and the possibility that there had been a blow with an iron bar. 10.55 Lastly Police Constable Stephen Hughes gave evidence before the Inquiry. He has been in the MPS since 1975 and he was for many years a First Aid instructor. He was called at the invitation of those representing the Commissioner to help with what the level of First Aid training was in the MPS in 1993. He served from 1989 in No 3 Area Training Unit. He said that from 1984 until 1994 there used to be "an annual week long First Aider seminar". This was apparently discontinued in 1994 because the Force First Aid adviser retired and First Aid training was absorbed by the Occupational Health Branch who saw no need to continue the seminars. Prior to 1994 all uniformed Constables and Sergeants had to have a current First Aid certificate up to their twenty-first year of service. PC Hughes told us that now all officers up to but not including the rank of Inspector are required to have a First Aid certificate which covers them for the last year of service. In 1984 there was a three-day course with about eighteen hours training. That contracted in 1986 to two days ie. twelve hours training. Then from 1987 the course lasted one day and amounted to six hours training. PC Hughes said that it remained thus until the time with which we are concerned. PC Hughes indicated the nature of training which would take place including stress placed upon the importance systematically to search a casualty at skin level for major external blood loss. On finding bleeding students were told to control it by hand if necessary and to complete the search. PC Hughes agreed that if a person is obviously bleeding from the body then plainly the first thing that must be done is to control that bleeding by placing the hand over the wound and applying pressure. In cross-examination PC Hughes indicated that there were refresher courses, but no testing. He also told the Inquiry that one of the reasons for the reduction in length of First Aid courses was simply lack of resources. At one time a doctor examined students after the three-day course, and he had to be paid. There was no requirement in the regulations for a doctor to be involved and for that reason the services of the doctor were dispensed with. The MPS is not registered with St John's Ambulance in connection with First Aid instruction. Certificates come directly from the Health and Safety Executive. 10.56 This evidence reinforced the Inquiry's views as to the lack of satisfactory and proper training in First Aid for officers of all ranks. Not only should officers be properly trained and be given proper refresher training at regular intervals, but it must be made plain that more senior officers need instruction just as much as junior officers. An officer in the position of Mr Groves must be able to ensure that what is being done by his juniors is proper and satisfactory and in accordance with well co-ordinated and directed training. The notion that it may be good enough simply to wait for the ambulance and the paramedics must be exploded. 10.57 The long and the short of it is that front-line police officers must be instructed to "think First Aid". They must be trained properly in basic steps to be taken to recognise and deal with what is discovered. It should be automatic that the Airway, the Breathing and the Circulation are assessed at once. With basic training the staunching of bleeding, the administration of mouth to mouth resuscitation, external cardiac massage and where heavy bleeding is seen, raising the legs to protect circulation should be as much a matter of second nature as it is to dial 999 or to radio for an ambulance. 10.58 The strongest criticism in the area of First Aid must be made against Mr Groves. He received no reply when he asked what was going on, and simply left the scene because he believed that there had been some kind of fight. He was plainly casual and unprofessional in this respect. We are forced to the conclusion that his attitude and his dismissive conduct were contributed to, if not wholly caused, by unwitting but clear racism. He saw a young black man lying injured, and an obviously stressed and agitated young black man on the pavement nearby. It is plain to all of us that he was deflected by what he saw and by his wholly wrong conclusion, and that his whole approach to what had happened was thus undermined by racist stereotyping. We conclude that in this case it must be said that he reacted as he did simply because of what he saw, and that he would not have been similarly dismissive if the two young men involved had been white. 10.59 As to the others involved directly in the allegations as to First Aid we do not infer that their inaction was initiated or caused by overt or unwitting racism. We understand the reactions and strong feelings of Mr & Mrs Lawrence, but we are not persuaded that anybody involved in the immediate attention or lack of attention in connection with First Aid can rightly be accused of anything more than failure to heed such training as was given and of over-reliance upon the imminent arrival of the ambulance and the paramedics. We hope that our recommendations in this field will ensure that such failure and over-reliance do not occur ever again.
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