Transcript of the Hearing 28 October 2013


           1                                        Monday, 28 October 2013

           2   (2.00 pm)

           3   THE ASSISTANT CORONER:  Right, we'll have the jury in then,

           4       please.

           5                  (In the presence of the jury)

           6           Thank you very much, members of the jury.  Thank you

           7       very much for offering to be here at 12 noon.  It may be

           8       that some of you were here, but we were hoping to have

           9       a witness then who is having difficulties being here at

          10       another time.  But as it was that particular witness, in

          11       the end, couldn't even make it at 12 noon so, in the

          12       end, there wasn't quite the urgency that we had so when

          13       we were overtaken by natural disasters, the like of

          14       which no doubt you have been speaking about, it was then

          15       decided it would be safer for us to put the start back

          16       to the usual time.  So I'm sorry if you have been messed

          17       around, but at least we are all here now and ready for

          18       a 2 o'clock start.

          19           And you have a witness, Mr Underwood, who is going

          20       to be?

          21   MR UNDERWOOD:  Dr Glazebrook, please.

          22                  DR WILLIAM GLAZEBROOK (sworn)

          23   THE ASSISTANT CORONER:  Thank you very much.  Do have

          24       a seat, please.  Mr Underwood will ask you some

          25       questions.




           1                    Questions by MR UNDERWOOD

           2   MR UNDERWOOD:  Dr Glazebrook, can you give the jury your

           3       full names, please?

           4   A.  Dr William Glazebrook.

           5   Q.  What are your qualifications?

           6   A.  I have MMBS from Charing Cross and Westminster Medical

           7       School in 1997.  I hold a diploma in immediate medical

           8       care and I'm a fellow of the College of Emergency

           9       Medicine.

          10   Q.  In August 2011, were you employed?

          11   A.  At that time I was employed by Imperial College as an

          12       emergency medicine consultant at Charing Cross Hospital

          13       and I worked for the London Air Ambulance or London

          14       HEMS.

          15   Q.  How did that work?  Was working for the HEMS a part-time

          16       role?

          17   A.  Yes.  So I worked for HEMS as a full-time commitment in

          18       2007 for six months.  After that time I continued

          19       working for them in a kind of locum way.

          20   Q.  Where was HEMS based?

          21   A.  It's based on top of the Royal London Hospital where the

          22       aircraft is.  The operation centre is there as well.

          23   Q.  You say "the aircraft"; was there only one helicopter?

          24   A.  There is only one helicopter.

          25   Q.  That is still the case, is it?




           1   A.  That is still the case.

           2   Q.  What area did and does that helicopter cover?

           3   A.  It covers generally within the M25, including the M25,

           4       and there's a mutual agreement between other aircrafts

           5       around London that they will help in other areas as

           6       well.  So for instance, if the Essex helicopter is being

           7       used in Essex and another job comes into Essex, the

           8       London aircraft will go to that job in Essex as well.

           9   Q.  In 2011, at least, how was it staffed?  How many people

          10       were on board and what did they do?

          11   A.  We have two pilots.  Whenever we fly in an urban

          12       environment there are two pilots to increase the number

          13       of eyes really to look for landings.  In the back of the

          14       aircraft there's a doctor, a HEMS paramedic, and there's

          15       space for one other.  It is often a training doctor or

          16       training paramedic.  On some occasions it's an observer.

          17       On this day it was an observer; she was a registrar of

          18       mine at Charing Cross Hospital.

          19   Q.  As it happened on 4 August then there was you,

          20       a consultant, and a registrar of yours both in the back

          21       of the ambulance?

          22   A.  Yes.

          23   Q.  How is HEMS called upon?  Is it part of the normal 999

          24       service or is there some extra number you can call or

          25       what?




           1   A.  No, it's the 999 and, during the paramedic's time, when

           2       they are up with the aircraft, half of their time is

           3       spent at the Waterloo base listening to 999 calls and

           4       finding the calls that the aircraft would be sent to.

           5       So they are listening in to the 2,000 or 3,000 calls

           6       a day that come into the ambulance service.

           7   Q.  What was the filtration service?  What was it that would

           8       trigger HEMS going out to somebody?

           9   A.  There are different tiers of sending HEMS.  There are

          10       immediate call outs, when the -- it's evident over the

          11       telephone that additional resources will be required.

          12       A second tier would be a call back.  So it sounds like

          13       something relatively serious and the paramedic will call

          14       back that caller and will ask some further questions and

          15       deem whether the aircraft should go or not.  There's

          16       a third tier, which is an immediate, when we are

          17       requested by either the London Ambulance Service

          18       themselves, by the fire brigade or the police service

          19       can request us.

          20   Q.  Was this call-out to Mr Duggan one of those?

          21   A.  This was an immediate call-out as a request from the

          22       police.

          23   Q.  In terms of immediate call outs, what's the normal

          24       expectation among the crew of the air ambulance about

          25       what they're going to be facing?




           1   A.  As in the patients that we go to?

           2   Q.  Yes.

           3   A.  Because there has been some professional eyes put upon

           4       the patient we would expect that the patient would be

           5       needing our services.

           6   Q.  In brutal terms, does that mean that they were in

           7       cardiac arrest?

           8   A.  Yes, but often -- any injury really up to and including

           9       cardiac arrest.

          10   Q.  Let's take the cardiac arrest situation.  That

          11       essentially means somebody's heart has stopped beating,

          12       does it?

          13   A.  Yes.

          14   Q.  What can you do in those circumstances?

          15   A.  The important thing is to work out why the patient's

          16       heart has stopped beating and then to try, as quickly as

          17       possible, to turn that around.

          18   Q.  Let's move to Mr Duggan then.

          19           On 4 August 2011, the day we are talking about, you

          20       were presumably at the base with the helicopter, were

          21       you?

          22   A.  Sir, we were on top of the Royal London Hospital.

          23   THE ASSISTANT CORONER:  Which is where exactly?

          24   A.  Whitechapel Road.

          25   MR UNDERWOOD:  What did you know when the helicopter was




           1       called out about what it was you were going to?

           2   A.  So, we know that we were called out by the police --

           3       what happened -- the call goes through to Waterloo, to

           4       the emergency operations centre of the ambulance

           5       service.  The call will then be transferred to the

           6       helipad.  A telephone goes off there and the paramedic,

           7       the HEMS paramedic sitting at Waterloo, says you've been

           8       called out, they will give the coordinates as to where

           9       the aircraft needs to go to, where the patient is, and

          10       we usually get about a -- one line of what the incident

          11       is.  We found out before we left that it was a police

          12       incident and there had been a shooting and that's all we

          13       knew when we lifted off.

          14   Q.  Did you know that the patient was a police officer or

          15       civilian?

          16   A.  No.

          17   Q.  Were you in fact directed to the right coordinates?

          18   A.  Often in situations like this there can be a little bit

          19       of ... in the heat of the moment, the wrong coordinates

          20       can be put in and in this incident we flew over the

          21       incident to the coordinates we were sent to.  Seeing

          22       that there was no incident there, we turned round and

          23       came back to these coordinates.

          24   Q.  Once you got on the ground, what did you see?

          25   A.  So, when we get over top of the incident, we come down




           1       quite low and do a 360-degree left-sided circle over the

           2       incident so we get a view of the incident over and we

           3       can start making some decisions if we can see what's

           4       going on.  Then we need to -- then the pilots find

           5       somewhere to land.  We landed probably about 50,

           6       75 metres away from the incident and we walked up

           7       a short incline and ... then we found Mr Duggan lying on

           8       the pavement.  There were two or three police officers

           9       and two paramedics, from what I remember, working on him

          10       then.

          11   Q.  At that stage did you know whether he was a policeman or

          12       a civilian?

          13   A.  No.

          14   Q.  From your first glance, what did you see going on apart

          15       from there being people working on him?  What could you

          16       see as injury?

          17   A.  So from -- it's an important thing: as you walk up to

          18       assess the patient and as you are walking towards the

          19       patient you can make quite an assessment by -- there was

          20       no movement and by what was going on to the patient,

          21       what interventions had been done by the professionals

          22       there.

          23           So as we walked up, I noticed that he had an oral

          24       pharyngeal airway, which is a plastic tube, in his mouth

          25       to hold his mouth open so that ventilation and air can




           1       be put into his lungs.  I noticed a police officer was

           2       doing chest compressions, kneeling at the side of him,

           3       and there was some blood on the right side of his chest.

           4       There was a small cannula, which is a little tube, on

           5       the right-hand side of his chest, just below his collar

           6       bone, and there was an Asherman seal, which is a seal

           7       that you put over a wound on the chest to allow air out

           8       and stop air going back into the chest.

           9   Q.  What would a cannula tell you?

          10   A.  The cannula would tell me that the ambulance service

          11       thought that there may be a pneumothorax, which is air

          12       within the chest cavity, compressing down the lung which

          13       can be a cause of cardiac arrest in penetrating trauma

          14       to the chest.

          15   Q.  What happened then?

          16   A.  We -- my registrar -- while we were going to the job, we

          17       had an update that in actual fact there were two

          18       patients, one was in cardiac arrest.  So I initially

          19       sent my registrar to go and see the second patient, to

          20       see what injuries they had and to come back and tell me

          21       what was going on.  And I stayed with Mr Duggan with my

          22       paramedic.

          23           I very quickly made the decision to perform

          24       thoracostomies, which are two holes in the side of the

          25       chest to relieve any blood or relieve any air that may




           1       be causing the cardiac arrest.

           2   Q.  What made you do that?

           3   A.  We have standard operating procedures.  Any patient who

           4       is in confirmed cardiac arrest due to penetrating trauma

           5       to the chest requires these interventions to be done.

           6       These are the causes of cardiac arrest and penetrating

           7       trauma.  And so by immediately trying to relieve that

           8       blood or trying to relieve that air from around his

           9       chest that may be able to reverse the cardiac arrest.

          10   Q.  Right.  If you can spare us too much of the detail, how

          11       does the thoracostomy actually work?

          12   A.  So -- as in the practical procedure of how it's done?

          13   Q.  Please, yes.

          14   A.  With the patient lying prone on their back, we would

          15       lift up both their arms and we would find, between the

          16       fourth and fifth rib, just underneath the armpit, we

          17       would make about a five or six-centimetre incision with

          18       a knife and then, bluntly, dissect between the ribs and

          19       then puncture into the chest wall cavity.  At that

          20       stage, you would hope to have either a large release of

          21       air and the heart to start going or a release of blood

          22       and the heart to start going.

          23   Q.  What happened?

          24   A.  I performed the thoracostomy on the left-hand side.

          25       When I did that, a large amount of blood, very bright




           1       red blood, came out of the left side of the chest.

           2   Q.  What does bright red blood signify?

           3   A.  So that implied to me that this was arterial blood, so

           4       this was blood going from the heart, full of oxygen,

           5       that should be going around to the body, but it was

           6       coming out of the chest so it immediately gave me the

           7       impression that one of the large arteries or the heart

           8       itself had been injured and that a large volume of blood

           9       was in the left side of the chest.

          10   Q.  Was there any value then in doing a right side

          11       thoracostomy?

          12   A.  Yes, because you want to do everything as fast as

          13       possible and so they're done at the same time so the

          14       HEMS paramedic was doing the thoracostomy on the right

          15       side of the chest while I was doing the one on the left.

          16   Q.  This all, if I may say so, sounds rather major.  What

          17       sort of speed was involved here?

          18   A.  It's a decision that you make immediately and it's

          19       a procedure that takes probably less than 30 seconds to

          20       make the holes in the side of the chest.

          21   Q.  You say the hope is that you'll either get air or blood

          22       and then the heart will restart?

          23   A.  Yes.

          24   Q.  What happened here?

          25   A.  So the heart did not restart and we just had a large




           1       amount of blood from the left side of the chest.

           2   Q.  What was your conclusion, if conclusion is the word I'm

           3       looking for, about the bright blood and the lack of

           4       reaction to these two --

           5   A.  So my conclusion at that stage is that this is possibly

           6       going to be a fatal injury.  But the other pathology we

           7       look for inside the chest is blood that has surrounded

           8       the heart and has compressed the heart to stop it from

           9       beating.  So if we've had no return of spontaneous

          10       circulation after performing the two thoracostomies, we

          11       go on to do a thoracotomy, which is joining up the two

          12       holes on the sides of the chest, cutting between the

          13       ribs with a pair of scissors across the sternum, across

          14       the breast bone, and opening the chest up to have a look

          15       at the heart.

          16   Q.  Again, how speedily can you do that?

          17   A.  That takes about one to two minutes.

          18   Q.  Is that what you did?

          19   A.  Yes.

          20   Q.  What did you see there?

          21   A.  At that stage, we saw that the heart was empty and so --

          22       the heart is a muscle, it had no blood in it and it was

          23       about the size of my fist, maybe a little bit larger,

          24       but not moving and very hard, just contracted down to an

          25       empty heart, no blood in the circulation.




           1   Q.  Could you see why that was?

           2   A.  That was because a lot of the blood was in the left side

           3       of the chest.

           4   Q.  Could you see from where it had come?

           5   A.  No.

           6   Q.  So there you were able to see the heart in that denuded

           7       condition and the spent blood; was there anything you

           8       could do?

           9   A.  No.

          10   Q.  In that situation, even in, say, an operating theatre,

          11       if you had been able to have all the facilities

          12       available, would there have been anything you or

          13       a cardiothoracic surgeon could have done?

          14   A.  I'm not a cardiothoracic surgeon, but from my experience

          15       I would suggest that there would have been nothing that

          16       could have been done.

          17   Q.  Do you now know what the cause of the blood letting was?

          18   A.  I've read the pathologist's report.

          19   Q.  Can you help us with that?

          20   A.  So there was a wound to the descending aorta.

          21   Q.  Please tell us what that is.

          22   A.  The aorta is the large artery, blood vessel, that comes

          23       out of the heart, does about a 180-degree turn and then

          24       goes down and supplies the body with blood.  There was

          25       an incision, a wound, to the descending part of the




           1       aorta.

           2   Q.  Do you know how large that was?

           3   A.  I don't know how large that was.

           4   Q.  We'll be hearing from the pathologist, but was that

           5       consistent with what you saw and found?

           6   A.  Yes.

           7   Q.  In the light of what you have learned from the

           8       pathologist's report, do you stay with your conclusion

           9       that nothing could have been done by anyone?

          10   A.  Yes.

          11   Q.  We've heard from various police officers who were

          12       involved in the first aid, one of whom thought he had

          13       found a pulse quite some minutes after the shooting.

          14       Have you any comments on how quickly cardiac arrest

          15       would have set in?

          16   A.  It would have been a few minutes, if not immediate.

          17   MR UNDERWOOD:  Thank you very much, doctor.  If you wait

          18       there, there may be some more questions for you.

          19   THE ASSISTANT CORONER:  Yes.  Mr Thomas?

          20                      Questions by MR THOMAS

          21   MR THOMAS:  Good afternoon.  Just a few questions if I may.

          22       Can you just help me with this: by the time you actually

          23       got to Mark, as we now know him to be, roughly what time

          24       was that?

          25   A.  We were on scene at ... was it 18.30 -- can I refer to




           1       my statement; is that all right?

           2   MR THOMAS:  Please do.

           3   THE ASSISTANT CORONER:  Yes.

           4   A.  So we arrived on the scene at 18.31.

           5   THE ASSISTANT CORONER:  You had been called there when?

           6   A.  So the initial 999 call was at 13 minutes past 6.  We

           7       were activated four minutes later, so we took off four

           8       minutes later, and then we were on scene at 18.31.

           9   MR THOMAS:  And on your evidence, by the time you arrived,

          10       there was no signs of life and you never saw any signs

          11       of life when you were there?

          12   A.  That's correct.

          13   Q.  The injury that Mark had to his descending aorta, how

          14       would you describe that sort of injury in your words,

          15       not mine?

          16   A.  How would I describe?

          17   Q.  That sort of injury and the survivability of that sort

          18       of injury.

          19   A.  I would describe it as a fatal injury.

          20   Q.  Would this be right: that sort of fatal injury is an

          21       injury that's likely to incapacitate relatively quickly;

          22       would that be fair?

          23   A.  Yes.

          24   Q.  If you're unable to assist then say so, but can you give

          25       the court some idea as to how quickly incapacitation




           1       with that sort of injury will take place?

           2   A.  It would be no more than a few seconds.

           3   MR THOMAS:  Thank you.  That's all I ask you.  Thank you

           4       very much.

           5   THE ASSISTANT CORONER:  Thank you.  Yes, it is Mr Stern

           6       I have next.

           7   MR STERN:  No thank you, sir, no questions.

           8   THE ASSISTANT CORONER:  Perhaps I should have Mr Keith next.

           9   MR KEITH:  I have no questions.

          10   THE ASSISTANT CORONER:  Mr Butt?

          11   MR BUTT:  No.

          12   THE ASSISTANT CORONER:  Anyone from there?  Mr Glasson last,

          13       I think.

          14   MR GLASSON:  No thank you, sir.

          15   THE ASSISTANT CORONER:  Back to you Mr Underwood.

          16   MR UNDERWOOD:  In that case, no further questions, thank

          17       you.

          18   THE ASSISTANT CORONER:  I have no questions for you.  Thank

          19       you very much, Dr Glazebrook, for coming and assisting.

          20       You're free now to go.

          21   A.  Thank you.

          22                      (The witness withdrew)

          23   MR UNDERWOOD:  April Barter, please.

          24                    MS APRIL BARTER (affirmed)

          25   THE ASSISTANT CORONER:  Thank you very much.  If you would




           1       like to come forward and have a seat, then we can see

           2       and hear you much clearer.

           3                    Questions by MR UNDERWOOD

           4   MR UNDERWOOD:  Good afternoon, Ms Barter.  As you know, I'm

           5       Underwood.  I'm counsel to the Inquest.  I'll have

           6       questions for you to start with.  Can you give your full

           7       name, please?

           8   A.  April Hannah Barter.

           9   Q.  Are you a paramedic working for the London Ambulance

          10       Service?

          11   A.  I am indeed.

          12   Q.  In August 2011, how long had you been a paramedic?

          13   A.  About a week.

          14   Q.  You were the first one at the scene from the ambulance

          15       service, were you not?

          16   A.  Yes.

          17   Q.  Can you tell us how the call-out went and how your

          18       arrival there went?

          19   A.  I was dispatched via my mobile data terminal, which is

          20       a computer we have in all our vehicles -- we get our

          21       jobs down on it.  I was at the station, which is on

          22       Windmill Road in Edmonton, N18.  I was currently

          23       changing -- doing a shift changeover, so I was due to

          24       start at 6.30.

          25   Q.  When you say a "shift changeover", do you mean you were




           1       not yet on shift?

           2   A.  No, I had not started.  I was due to start at 6.30 and

           3       I took over early from the day turn to enable them to

           4       get off on time, so I was ready then to start by

           5       6 o'clock.

           6   Q.  When the call came in, were you familiar with the area

           7       you were going to?

           8   A.  Yes.

           9   Q.  Were you on your own?

          10   A.  Yes.

          11   Q.  In a car?

          12   A.  Yes, solo responder.

          13   Q.  What happened?

          14   A.  I mobilised immediately from Edmonton station, I made my

          15       way to the call, which was given, I think, as Ferry Lane

          16       at the time, but the location updated on the way to say

          17       it was further down Ferry Lane.  Not towards -- sorry,

          18       beg your pardon, not towards the train station, but

          19       further along, further away from the train station.

          20   Q.  As you approached the area, what did you see?

          21   A.  Heavy, heavy traffic.  The whole of Tottenham Hale,

          22       which has a one-way gyratory system, was completely

          23       gridlocked.  There was a few police cars trying to get

          24       through the traffic and there was a heavy police

          25       presence when I got there.




           1   Q.  Did you have trouble with the traffic?

           2   A.  Initially I did, but then I managed to follow a police

           3       car and I sort of tucked in behind the police car and

           4       managed to make may way to the scene.

           5   Q.  So far as you were concerned as a paramedic, what was

           6       the protocol as you turn up to a scene like this?  Were

           7       you supposed to go to a rendezvous point or what?

           8   A.  The job itself had been given as a police officer shot.

           9       I was told police at the scene.  Normally we would be

          10       given a rendezvous point but because the job had come

          11       from the police itself and as I approached the location,

          12       there was a heavy police presence, I assumed it was safe

          13       to be and I wasn't directed otherwise.

          14   Q.  So did you drive close to where the action was, as it

          15       were?

          16   A.  Yes.  So as I approached Ferry Lane, there was a police

          17       cordon up by the train station, they lifted up the

          18       cordon for me, pointed me straight up the road and

          19       I continued right up to where I was waved down by

          20       a police officer.

          21   Q.  At that stage, how many people did you think needed

          22       attention?

          23   A.  I was told there was multiple patients, so until I got

          24       out of the car I didn't know.  I was just told

          25       "multiple".




           1   Q.  Did you know whether they were police officers or

           2       civilians?

           3   A.  My computer told me that a police officer was shot and

           4       unconscious.

           5   Q.  You say you were waved down by a police officer.  When

           6       you got out of your car, what happened?

           7   A.  I sort of bustled out of my car a little bit, the police

           8       officer opened the door for me, there was a few others

           9       stood around and they were pointing in various

          10       locations.  I said, "Is there multiple patients?", they

          11       said, "Yes, there's two: one's been shot -- it's hit his

          12       radio, but you don't need to see him; the person you

          13       need to see is on the floor", and he pointed behind some

          14       parked cars.

          15   Q.  Did you go behind those parked cars?

          16   A.  Yes, once I've got my equipment out of the back of the

          17       car -- again a police officer helped me do that -- I was

          18       navigated through, I think, three or four parked cars to

          19       the location where the patient was.

          20   Q.  What sort of equipment did you have with you?

          21   A.  I carried my paramedic bag, which is like a personalised

          22       rucksack we all have which has advanced airway tools in

          23       there, it's got tools for IV -- gaining intravenous

          24       access, fluids, drugs.  So I had that bag with me.

          25       I also had an oxygen bag, which has oxygen cylinders,




           1       masks, oral-pharyngeal airways to help with the throat

           2       and other more basic -- advanced manoeuvres and then

           3       also a defibrillator.

           4   Q.  What did you see when you got to where the person who

           5       was unconscious was?

           6   A.  It was, I think, maybe three or four police officers or

           7       people I know to be police officers.  They were in,

           8       I think, armed response -- armed police officer uniform,

           9       the typical boiler suits, and they were performing CPR

          10       at the time.

          11   Q.  Right.  If we could have a look -- and it will come up

          12       on the screen -- at CE22.  Is this a sketch you drew

          13       afterwards?

          14   A.  Yes.

          15   Q.  We've got "before" and "after" against the figures

          16       there.

          17   A.  Yes.

          18   Q.  Is the before photograph where the unconscious person

          19       was?

          20   A.  Yes.

          21   Q.  Again, still at this stage, did you know whether he was

          22       a police officer or not?

          23   A.  No.

          24   Q.  So you describe the police officers there and the person

          25       unconscious.  What were the police officers doing?




           1   A.  CPR.  So one police officer was doing chest

           2       compressions, another police officer was knelt by the

           3       patient's head with like a mask that we use for rescue

           4       breaths and police officer was using that to do like

           5       a 30-to-2 ratio of compressions to ventilation.

           6   Q.  I think it was 6.28 by the time you got to that point,

           7       was it?

           8   A.  I would have to refer to my statement.

           9   Q.  Please do, yes.

          10   A.  (Pause).  Yes, at 6.28 I was on the scene.

          11   Q.  In your opinion, how was the quality of the first aid

          12       being given?

          13   A.  The CPR was exceptional, exceptionally good quality CPR.

          14       It's my role, when I'm first on scene at any patient in

          15       cardiac arrest, to initiate good quality CPR and if

          16       I felt that wasn't effective enough then I would have

          17       taken over from the police officers, but I felt it was

          18       suitable and I let them carry on.

          19   Q.  What was your assessment of the patient?

          20   A.  There was no signs of life.  There was absent pulses.

          21       He was in cardiac arrest.

          22   Q.  You presumably were trained to have a standard reaction

          23       to that, were you?

          24   A.  Yes.  So the first thing I did when I -- once I realised

          25       the patient was in cardiac arrest was I let my control




           1       know he was so they could update HEMS to inform them

           2       that he was in cardiac arrest and then, again, I let the

           3       police carry on with doing the chest compressions while

           4       I got out my oral-pharyngeal airway to put that in his

           5       mouth.  I then opened up my bag-valve mask, connected it

           6       up to oxygen, so I was trying to oxygenate him while the

           7       police were doing their chest compressions.

           8   Q.  What else did you do?

           9   A.  I -- his coat was already cut open and his chest was

          10       already exposed, so I had a quick glance around to see

          11       what injuries I could find.  I knew it had been

          12       a gunshot wound.  I had been informed of that via my

          13       computer on the way there and I was trying to find the

          14       site of the injury.

          15           For traumatic cardiac arrest, the first thing we

          16       need to do is figure out a reversible cause, so for me

          17       the concern was the chest injury.  I could see a wound

          18       over his right chest, so I performed a needle chest

          19       decompression, which is where we put the cannula in

          20       through the chest wall to try and relieve the tension

          21       there.

          22   Q.  Was there an Asherman seal already on the wound?

          23   A.  Yes.

          24   Q.  What was the response to your intervention?

          25   A.  Nothing.  So around the Asherman seal there was quite




           1       a lot of surgical emphysema, which is where you get --

           2       air pockets build up under the skin from the injury.

           3       The first needle I actually put in -- there was so much

           4       resistance, it actually came out again.  The air

           5       pressure was so high, it actually came out and I had to

           6       perform it second time and there was minimal -- no

           7       difference at all.

           8   Q.  What else did you do?

           9   A.  At that point I think my colleague had turned up,

          10       briefly explained the situation to him --

          11   Q.  Is that Mr Brennecke?

          12   A.  Yes.

          13   Q.  Sorry, go on.

          14   A.  I briefly explained the situation to him and at that

          15       point as well we could see that HEMS were overhead.

          16   Q.  Did you do anything else before HEMS got on the ground?

          17   A.  (Pause).  My colleague popped the defibrillator on and

          18       tried to gain some intravenous access, but I stayed on

          19       the patient's airway.

          20   Q.  Did you give a handover to HEMS when they arrived?

          21   A.  (Pause).  I think so, it's ... two years ago, I can't

          22       really recall.

          23   Q.  All right.  Did you see them doing thoracostomies and

          24       the thoracotomy?

          25   A.  Yes.




           1   Q.  Was there any sort of debriefing afterwards?

           2   A.  Very minimal.

           3   MR UNDERWOOD:  Thank you very much.  If you wait there, you

           4       may be asked some more questions.

           5   THE ASSISTANT CORONER:  Yes Mr Thomas.

           6                      Questions by MR THOMAS

           7   MR THOMAS:  Good afternoon.  Just a few questions, if I may.

           8           You told us that you arrived at about 18.28.

           9   A.  Yes.

          10   Q.  On your arrival, you were directed to where the man we

          11       now know to be Mr Duggan was, and that's the man that

          12       you went to see if you could assist?

          13   A.  Yes.

          14   Q.  There were police officers there working on him?

          15   A.  Yes.

          16   Q.  One of the things that you would need to know is what's

          17       wrong with the individual.

          18   A.  Yes.

          19   Q.  Did you ask the police?

          20   A.  At no point did I ask them what had happened.

          21   Q.  No.  I'm not so much referring to what happened before,

          22       but, for instance, you would need to know how many

          23       injuries does he have, things like that.

          24   A.  I was told that he had been shot.

          25   Q.  Did they tell you how many times he had been shot?




           1   A.  No.

           2   Q.  How many injuries did you see?

           3   A.  I only saw one.

           4   Q.  So you were working on the chest injury, the one that

           5       you've described?

           6   A.  Yes.

           7   Q.  The police officers who were with him didn't volunteer

           8       to you that this was a man who had been shot twice?

           9   A.  No.

          10   Q.  All right.  Just help me with this: again, I am just

          11       interested in the timings of this; okay?  Have you got

          12       your notes there?

          13   A.  I have, yes.

          14   Q.  Can you just help us?  I want to get an idea of the

          15       accuracy of your timings; yes?  You say you arrived at

          16       18.28; that's quite a specific time, isn't it?

          17   A.  Yes, it's all documented on our computer systems, so we

          18       have buttons we press when we receive calls.  When we

          19       arrive on scene we press buttons; it is not done from

          20       memory.

          21   Q.  You have answered my question.  The one thing we can be

          22       sure about is your arrival time at 18.28; this is not

          23       something that's done by memory, this is something you

          24       could cross-refer and check with the computer systems?

          25   A.  Yes.




           1   Q.  All right.  That leads me to this question: can you have

           2       a look at page 2 of your statement?

           3   A.  Yes.

           4   Q.  I wonder if we can call that up.  That's at page CS0256.

           5       Can we go to the last paragraph?  Can we just enlarge

           6       the very last paragraph on that page?  This is where you

           7       are, for want of a better expression, trying to get a

           8       history from the police officers; that's right isn't it?

           9   A.  Yes.

          10   Q.  Can I just read out what you say and ask you a question

          11       about it after I have read it.  You say this:

          12           "I asked the police --"

          13           Just pause there.  Those were the officers who were

          14       working on him; correct?

          15   A.  Yes.

          16   Q.  "I asked the police how long he had been in cardiac

          17       arrest and they replied about five minutes before

          18       I arrived."

          19           Yes?

          20   A.  Yes.

          21   Q.  So just looking at that, you are only as good as the

          22       information you were supplied with, but this was the

          23       information you were given; correct?

          24   A.  Yes.

          25   Q.  Just working back.  We know that your time is fairly




           1       accurate, 18.28.  Go back five minutes, that will take

           2       us to about 23 minutes past 6.00 pm.

           3   A.  Yes.

           4   Q.  So the officers were telling you that Mr Duggan had gone

           5       into cardiac arrest -- let's be clear about that, that's

           6       where -- your understanding of that is where the heart

           7       stops and there's effectively little or no sign of life.

           8   A.  Yes, that's correct.

           9   Q.  Have I understood that correctly?

          10   A.  Cardiac arrest is the absence of any heartbeat or

          11       breathing.

          12   Q.  Right.  So the officers were saying to you -- and I just

          13       want to work back with another time that the jury may

          14       have heard -- that this incident or shooting took place

          15       shortly or around about 13 minutes past 6; do you

          16       follow?

          17   A.  Yes.

          18   Q.  So the officers were leading you to believe that it was

          19       only five minutes before you arrived that Mr Duggan went

          20       into cardiac arrest?

          21   A.  That's what they said.

          22   Q.  That's what they said to you?

          23   A.  But in situations under high stress, times can be

          24       completely skewed.

          25   Q.  I understand that.  I'm just looking at -- you don't




           1       know what was going on in their minds?

           2   A.  No.

           3   Q.  Let's not speculate.  This is what they said to you?

           4   A.  Yes.

           5   Q.  Just one final thing I want to ask you about.  Can we go

           6       to page 4 of 5 of your statement, CS0258.  Again, it's

           7       the second to last paragraph, the paragraph that begins:

           8           "The doctor from HEMS ..."

           9           Do you see that?

          10   A.  Yes.

          11   Q.  I just want to ask you about the activity amongst the

          12       people who were there.  You say you certainly remember

          13       there was lots of people, and you describe some of them:

          14           "Lots of people wearing suits talking amongst

          15       themselves ..."

          16           Do you see that?

          17   A.  Yes.

          18   Q.  I fully appreciate that your first and major concern,

          19       your priority, was Mr Duggan.  I accept that.  But from

          20       your observations, there was a lot of discussion amongst

          21       the officers and the men that were there, weren't there?

          22   A.  Someone had been shot, I mean I've -- in previous

          23       experience, any shootings, there's a lot of people at

          24       these events, these scenes.

          25   Q.  Talking amongst themselves about what happened?




           1   A.  (Pause).  Well, in this case, yes.

           2   MR THOMAS:  Yes.  Thank you, that's all I ask you.

           3   THE ASSISTANT CORONER:  I've got you, Mr Keith.

           4   MR KEITH:  No.

           5   THE ASSISTANT CORONER:  Mr Stern?

           6                      Questions by MR STERN

           7   MR STERN:  If I may, please, yes.  I wonder if you could

           8       have a look at CE0310.  It will come up on the screen.

           9       That paramedic vehicle; is that the vehicle you arrived

          10       in.

          11   A.  Yes.

          12   Q.  Did you arrive alone?

          13   A.  Yes.

          14   Q.  Can you see -- it may be you will remember this or maybe

          15       you don't -- there's a man in a white t-shirt by the

          16       wall who is taking a film; do you remember that?

          17   A.  Yes.

          18   Q.  So we have the conversation on that film, the jury

          19       haven't seen it for sensitive reasons, but Mr Thomas,

          20       I'm sure, has seen it, and therefore all the

          21       conversation would be on that film.

          22   A.  Yes.

          23   Q.  You told the jury that the police officers who were

          24       working on Mr Duggan were performing excellent CPR.

          25   A.  Yes.




           1   Q.  Part of the procedure is that there is a handover to

           2       you, is there not?

           3   A.  Usually.

           4   Q.  There was in this case?

           5   A.  I asked what had happened, yes.

           6   Q.  Yes.  And there was a formal handover and various things

           7       were said to you that you may or may not remember.

           8   A.  Yes, no, undoubtedly.

           9   Q.  But we can see them on the film if anybody wants to know

          10       exactly what was said?

          11   A.  Yes.

          12   Q.  The next thing is this: in the time that you were

          13       present with the man that was on the ground, who we now

          14       know to be Mark Duggan, his body remained in the same

          15       position until HEMS arrived?

          16   A.  Until HEMS arrived, yes.

          17   THE ASSISTANT CORONER:  Then he was moved, was he?

          18   A.  Yes.

          19   THE ASSISTANT CORONER:  On your plan, you have two different

          20       positions as to where Mr Duggan was.

          21   A.  Yes, so when HEMS arrived we moved him away from the

          22       wall and down the pavement slightly so they could gain

          23       full access to him.

          24   MR STERN:  I think the doctor, in fact, moved him away from

          25       the railings so that, as you say, there could be access




           1       on all sides to Mark Duggan.  Because he was so close to

           2       the railings somebody couldn't have access that side?

           3   A.  The police officer, I think, was crouched at that side

           4       doing the chest compressions from that side, but HEMS

           5       usually require quite a large space around because they

           6       perform their procedures ...

           7   Q.  You also described about three or four police officers,

           8       you thought, at the time.  One had a face mask and was

           9       doing breathing into Mr Duggan.

          10   A.  Yes.

          11   Q.  One was obviously doing the chest compressions.

          12   A.  Yes.

          13   Q.  There were other officers who were also assisting with

          14       the first aid --

          15   A.  Yes.

          16   Q.  -- obviously in bringing things to those officers and

          17       helping in that regard.

          18   A.  Yes.

          19   Q.  I think the way you summarise it in your statement is

          20       that:

          21           "The police were very cooperative and did everything

          22       that I asked of them."

          23   A.  Yes, absolutely.

          24   MR STERN:  Thank you.  Those are all the questions I have.

          25   THE ASSISTANT CORONER:  Yes, Mr Butt?




           1   MR BUTT:  No thank you, sir.

           2   THE ASSISTANT CORONER:  Mr Glasson?

           3   MR GLASSON:  No thank you, sir.

           4   THE ASSISTANT CORONER:  Mr Underwood?

           5   MR UNDERWOOD:  I have no further questions thank you very

           6       much.

           7   THE ASSISTANT CORONER:  This was your first week, was it, as

           8       a full, independent paramedic?

           9   A.  Yes.

          10   THE ASSISTANT CORONER:  You hadn't even come on duty?

          11   A.  No.

          12   THE ASSISTANT CORONER:  And you had to deal with this.  So

          13       well done to you.

          14   A.  Thank you.

          15   THE ASSISTANT CORONER:  We all appreciate it.  Thank you for

          16       coming along and giving evidence at this point.

          17   A.  Thank you.

          18                      (The witness withdrew)

          19    MR DAVID ARNOLD BRENNECKE (statement read by MR UNDERWOOD)

          20   MR UNDERWOOD:  Sir, the only other medical intervention was,

          21       as we have heard, Mr Brennecke, and he gave a statement

          22       which I'm going to read because nobody has asked for him

          23       to attend.  So I will read that now, if I may, and that

          24       will deal with this in one go.

          25           For our records, it's CS0274 and it's a statement of




           1       David Brennecke of 15 August 2011 and, of course, my

           2       reading it and putting it into the transcript means

           3       nobody need make a note of it.

           4           He says:

           5           "I am David Arnold Brennecke and I am employed by

           6       the London Ambulance Service as a Duty Station Officer

           7       and Paramedic.  I have been employed by the LAS for

           8       21 years.  I have been employed in my current role for

           9       approximately ten years and based at Edmonton Ambulance

          10       Station for five years.  My role involves me acting as

          11       an on-call manager which includes attending any serious

          12       incidents.  This includes attending any police firearms

          13       incident mainly to provide for support for other members

          14       of LAS staff.  I have been asked by the IPCC to make

          15       a statement regarding an incident which I deployed to on

          16       Thursday 4 August 2011.  I was at Edmonton Ambulance

          17       Station when I received a call from our control at

          18       18.21.35 to attend an incident.  I was told that it was

          19       a Police Firearms Incident and that a Police Officer had

          20       been shot.  I was not given a location as such but told

          21       to go to Tottenham Hale tube station.  I drove straight

          22       there on a road which goes north/south and arrived at

          23       the tube station at 18.29 having left at 18.22.

          24       I remember that the traffic was at a standstill but

          25       I managed to park in the station car park.  There was




           1       no one there at the car park which I found unusual.

           2       I then looked up onto Ferry Lane and could see

           3       bystanders and police officers up there.  I walked up

           4       the steps and saw that the road had been cordoned off.

           5       I attracted the attention of an uniformed police officer

           6       at the cordon.  I asked the officer where the incident

           7       was.  The officer told me it was at Ferry Lane.

           8       He asked if I wanted to bring my car up.  I knew that my

           9       colleague's car was already on the scene and as the

          10       traffic was at a standstill I decided not to.  I jumped

          11       over the railings and started to run up the road.

          12       I couldn't see anything up ahead because of the brow of

          13       the hill.  I had not taken anything with me from my car.

          14       When I came over the brow of the hill I could see my

          15       colleague, April Barter's car.  I could also see lots of

          16       police cars, police officers and people.

          17           "To the right of the road behind some cars I could

          18       see a man in plain clothes doing CPR.  I assumed this

          19       man was a plain clothed police officer.  I went over,

          20       took my coat off and went on the floor.  I could see

          21       a gentleman lying on the floor.  I now know that this

          22       gentleman was Mark Duggan.  I was not told who he was

          23       when I arrived and I assumed that he was a plain clothed

          24       police officer.  There were two men who I assumed were

          25       plain clothed police officers who were both making




           1       vigorous attempts to resuscitate the man on the floor

           2       whom I will refer to in my statement as 'the patient'.

           3       I would describe to the two men doing CPR as white, big

           4       set males in civvies.  One man was by the patient's

           5       right side and was doing chest compressions.  The other

           6       man was at the patient's head.  There was a big valve

           7       mask on the patient's face and the second male was

           8       squeezing the bag attached to the face mask to inflate

           9       the patient's lung.  My colleague, April Barter, was

          10       also kneeling by the patient's head.  I think she was by

          11       the patient's right side as I went to the patient's left

          12       side and I remember looking across at her.  She was

          13       about to do a procedure on the patient and I remember

          14       her looking at me and saying something like, 'Thank God

          15       you're here'.  I also remember there was another male

          16       plain clothed police officer who was videoing the whole

          17       event.  I remember that this officer was stood behind

          18       me.  I also remember that the patient was wearing

          19       a 'Puffa' type jacket.  The patient's chest was exposed

          20       as his jacket was open and whatever he was wearing

          21       underneath had been ripped open.  I could see the

          22       patient had a gunshot wound to his upper right side of

          23       his chest just above his nipple.  This was covered by an

          24       'Asherman chest seal'.  This is a round field dressing

          25       which creates a vacuum over the injury and stops the




           1       patient suffering a pneumothorax (collapsed lung).  The

           2       LAS do not carry these [dressings] but I know that the

           3       police firearms teams carry these dressings as I have

           4       attended firearms incidents before.  I assume the

           5       dressing had been put in place by the police officers

           6       before I arrived.  I have been asked if I saw any other

           7       wounds on the patient and confirm that I only saw the

           8       wound in the patient's upper chest.  I did not see any

           9       other wounds including the exit wound.

          10           "I went to the Patient's left side and started to

          11       cut off the left sleeve of his Puffa jacket.  This

          12       caused feathers from his jacket to go everywhere.  I did

          13       this so I could have access to his left anticubital

          14       fossa.  I intended to put a [cannula] in which would

          15       enable me to attach a saline drip.  I could not get

          16       access to the Patient's vein to put the cannula in.  At

          17       this point I remember a uniformed police officer arrived

          18       with a defibrillator machine from April's car.  The

          19       officer gave it to me and I put the pads on the

          20       Patient's chest.  I could not put the right-hand pad on

          21       the patient's upper right chest because of the position

          22       of the wound.  I had to put it further down the right

          23       side of his chest near his armpit.  The defib machine

          24       was not turned on because at this point the HEMS

          25       helicopter team arrived.  I remember they landed near




           1       the traffic lights on Ferry Lane around 100 yards away.

           2       Two doctors arrived one male and one female.  I think

           3       the male [doctor] was more experienced as he seemed to

           4       be in charge.  The first thing the male doctor did was

           5       to move the patient away from the wall, where he was

           6       laid.  There was a lot of blood around the patient so he

           7       was moved to a cleaner area.  The HEMS team also needed

           8       360 degrees access to the patient which was not possible

           9       where he was when I first arrived.  The male doctor took

          10       hold of the Patient's feet and dragged him down the

          11       pavement, approximately 2 feet, to give the HEMS team

          12       full access.

          13           "From the moment the HEMS team arrived we were

          14       working under their instructions.  The first thing the

          15       doctors did was to put chest drains into the Patient's

          16       sides.  The male doctor put the drain into the Patient's

          17       left side.  As he did so a lot of blood 4-5 litres of

          18       blood came out of the drain.  I remember the male doctor

          19       said something like, 'Oh well, that says a lot' or 'That

          20       tells us what's happening'.  April had already put chest

          21       decompression needles (ie two needles) into the

          22       Patient's upper chest, to relieve pressure, before the

          23       doctors arrived.

          24           "The male doctor asked me to assist the female

          25       doctor as she intubated the patient.  The two plain




           1       clothed officers had stepped back from the patient when

           2       the HEMS team arrived, leaving myself, April and the two

           3       doctors to treat the patient.  The male doctor

           4       asked April to put an E-ZIO into the patient's left leg.

           5       This is a procedure which allows a needle to be inserted

           6       into the patient's leg bone so that fluid can be

           7       injected into the patient to keep them hydrated.  The

           8       male doctor was opening up the patient's chest cavity

           9       while the female doctor was intubating the patient.

          10       Once she had finished, I asked the doctor if he wanted

          11       me to put another fluid line into the patient.  He told

          12       me to do this so using the E-ZIO procedure I inserted

          13       another fluid line into the patient's right leg.  At

          14       this point I remember the female doctor saying something

          15       like, 'I'm not getting any chest rise'.  The male doctor

          16       had opened up the patient's chest cavity and said

          17       something like, 'You won't, he's got no lungs left'.

          18           "A little after that, the male doctor said that it

          19       was not beneficial to continue.  I remember he asked to

          20       speak to the Senior Police Officer on the scene and

          21       asked for him to come over.  When the officer arrived

          22       the male doctor told him, 'I think you know where this

          23       is going.  We are not going to carry on with this much

          24       longer'.

          25           "The patient had suffered severe cardiac tamponade




           1       ie he had severe damage to his heart and his heart sack

           2       and his lungs had been traumatically damaged.  The HEMS

           3       doctor explained this.  He pronounced death at 18.41 and

           4       recorded the time of death.

           5           "We had ceased all attempts at resuscitation before

           6       this and then after the doctor pronounced life extinct

           7       we moved away from the Patient's body.  I was approached

           8       by another police officer who told me that another

           9       person had suffered a minor injury from a bullet which

          10       ricocheted off a policeman's radio.  An ambulance had

          11       also turned up whilst we were treating the patient.

          12       I remember that the crew had taken the trolley bed out

          13       and then put it back into the ambulance when the

          14       attempts at resuss were terminated.  The ambulance crew

          15       took the person with the minor injury to hospital.

          16       Before they left we took a blanket from the ambulance to

          17       put over the Patient's body.  We were stopped by

          18       a police officer at the scene who checked with the

          19       senior officer.  Once it had been agreed we could cover

          20       the Patient's body we laid the red blanket over him.

          21           "We left the scene and I arrived back at Edmonton

          22       Ambulance Station at 19.05.  Even when we left the scene

          23       I was still under the impression that the patient was

          24       a police officer.  I didn't know anything to the

          25       contrary until I came into work on the next morning.




           1       Before I left the scene I remember hearing

           2       a conversation between a plain clothed officer and

           3       a firearms officer.  I remember the plain clothed

           4       officer asked the other officer how many bullets had

           5       been discharged.  The SO19 officer said, 'We have

           6       discharged two bullets'.

           7           "There was no mention of the man I now know to be

           8       Mark Duggan discharging a firearm as at this stage

           9       I still thought he was a police officer.

          10           "I would describe the atmosphere as very quiet and

          11       sombre.  I felt this was in line with a police officer

          12       being shot.  I also recall that the area around was

          13       extremely busy with lots of police officers.  There were

          14       also three helicopters in the air that night.  The

          15       police helicopter, HEMS helicopter and a Sky news

          16       helicopter as well.

          17           "I have been asked if any other items of the

          18       Patient's clothing was removed.  Other than the

          19       Patient's jacket we must have removed his trousers to

          20       expose his legs for the E-ZIO procedure.  I cannot

          21       remember doing this.

          22           "I also remember that when the HEMS team arrived the

          23       two police officers who had been doing CPR stepped back

          24       to let the HEMS team in.  The police officer who was

          25       behind me who was videoing the CPR team asked if he




           1       needed to continue filming now that the police were no

           2       longer taking part.  He was told he no longer needed to

           3       film so he stopped and went away.

           4           "I have been asked if I knew the names of any of the

           5       other people involved at the scene.  Other than my

           6       colleague, April Barter I do not know the names of the

           7       police officers or other medical staff at the scene.

           8           "After I returned to the ambulance station I typed

           9       up some notes of the incident.  I have referred to them

          10       and the Patient Report Form during my interview ..."

          11           And he produces those as an exhibit:

          12           "I wish to add that the two officers who were

          13       undertaking CPR were making very good efforts to save

          14       the Patient's life.  I do not think there was anything

          15       else the police could have done to save the Patient's

          16       life before our arrival.  They were doing their best to

          17       save him."

          18           So that's the medical evidence.

          19           Sir, we have, as you know, a rather dislocated day.

          20       Malcolm Nott, who is one of the Crime Scene Managers,

          21       has very kindly agreed to attend today instead of in

          22       about a week's time when he was due to.  I don't know

          23       whether you want to go straight to him or shall we have

          24       a break.

          25   THE ASSISTANT CORONER:  Perhaps we might have our break for




           1       those -- because when you read out evidence they are

           2       actually taking it down and it's taking a little bit of

           3       a strain, so I think we will have a five or ten-minute

           4       break at this stage then have Mr Nott's evidence at the

           5       conclusion of that.  Thank you, Mr Underwood.  Well,

           6       members of the jury, if you would like to leave us for

           7       five or ten minutes, please.

           8           Could we have the cameras off, please?

          12   (2.55 pm)

          13                         (A short break)

          14   (3.08 pm)

          18                  (In the presence of the jury)

          19   THE ASSISTANT CORONER:  Thank you very much.  Yes,

          20       Mr Underwood.

          21   MR UNDERWOOD:  Malcolm Nott then, please.

          22                    MR MALCOLM NOTT (affirmed)

          23   THE ASSISTANT CORONER:  Thank you very much.  Have a seat,

          24       please, would you?  Once you are comfortable -- you have

          25       a file of notes there, I can see.  Please answer the




           1       questions that Mr Underwood will put to you.

           2                    Questions by MR UNDERWOOD

           3   MR UNDERWOOD:  Good afternoon, Mr Nott.  Can you tell us

           4       your full name, please?

           5   A.  My name's Malcolm John Nott and I'm a Crime Scene

           6       Manager with the Metropolitan Police.

           7   Q.  Mr Nott, it's very kind of you to come out of sequence

           8       and help fill our day today.  Let's get this clear: you

           9       were a Crime Scene Manager involved in the aftermath of

          10       Mr Duggan's shooting, but you didn't become involved

          11       until many days after; is that right?

          12   A.  That's correct, yes.

          13   Q.  What I am going to do, if I may, is ruthlessly use your

          14       knowledge of crime scene management generally to give

          15       the jury a picture of what's supposed to happen in the

          16       aftermath of a scene like this so when we do get to the

          17       Crime Scene Managers who were there at the time we can

          18       be shorter with them.

          19           Is crime scene management a particular discipline

          20       within the police force?

          21   A.  Yes.  It is within the Metropolitan Police, yes.

          22   Q.  What's the training?

          23   A.  Various in-house training, various courses.  By and

          24       large it's that type of training, within the Met,

          25       Metropolitan Police, yes.




           1   Q.  How many Crime Scene Managers are there roughly?

           2   A.  At the moment there's about 20, 22.  We cover all of

           3       London, from ...

           4   Q.  Where you have, for example, a fatal shooting, how

           5       quickly would a Crime Scene Manager normally be expected

           6       to be on the scene?

           7   A.  It depends how quickly you're deployed.  Again

           8       travelling is always a problem in London, but typically

           9       within an hour to an hour and a half.

          10   Q.  What's the job?

          11   A.  It's really assessing the forensic aspects of a crime

          12       scene, major crime scene, and then coordinating the

          13       various specialists or specialisms required to examine

          14       that crime scene.

          15   Q.  So we're talking here about forensic scientists are we?

          16   A.  By and large, those are the main people we deploy, yes.

          17   Q.  We have heard about searches called POLSA searches.  Can

          18       you tell us what they are?

          19   A.  We don't really get involved in those.  They're another

          20       aspect of the police.  It's probably outside my

          21       specialism.

          22   Q.  Crime Scene Managers do not bring those on board; would

          23       that be fair?

          24   A.  That's correct, yes.

          25   Q.  Again, we have heard a number of people coming along and




           1       taking charge of the scene or taking charge of aspects

           2       of the scene.  Again, let me take a fatal shooting where

           3       police officers are involved who may have come from two

           4       or three different sections of the police, like Trident

           5       and CO19.  Who has charge of the Crime Scene Managers or

           6       do the Crime Scene Managers have charge of everybody

           7       else?

           8   A.  It really depends on the scene itself.  The Crime Scene

           9       Manager's role is really to take charge of the forensic

          10       aspects of that scene, to interpret them, to report to

          11       the senior officer at the scene and, by and large, work

          12       in conjunction with that senior officer to establish

          13       a strategy for the examination of that scene.

          14   Q.  So here we know, for example, there was a man who had

          15       been shot and killed at the scene.  We know there's

          16       a minicab that he got out of and we know there is a gun

          17       found some distance from him.  Are all of those

          18       important aspects of the crime scene --

          19   A.  Absolutely, yes.

          20   Q.  -- to be preserved?

          21   A.  To be preserved and assessed as is relevant at the time

          22       and photographed and recorded in an appropriate manner.

          23   Q.  Again of course, it wasn't your job on the day to go and

          24       do all of that, but presumably you have been the first

          25       Crime Scene Manager at various scenes, have you?




           1   A.  Many times, yes.

           2   Q.  How do you make sense of it?  Do you get a briefing from

           3       someone when you go?

           4   A.  Usually that's the case.  Initially there will be a

           5       phone call requesting our services and, like any event,

           6       you are not always told the complete truth at the time

           7       only because it's probably not known.  Then you are

           8       deployed to the scene and then, on arrival, by and

           9       large, there's already a senior officer there who has

          10       a fairly good interpretation of what's gone on at that

          11       time.  You would be then talking to them, discuss with

          12       them the scene, look at the various aspects and

          13       priorities within that scene and then come to

          14       a conclusion as to the initial forensic strategy of the

          15       examination of that scene.

          16   Q.  Right.  So the expectation would not be that you go

          17       round interviewing a whole load of people; would that be

          18       fair?

          19   A.  That's correct, yes.

          20   Q.  In terms of paperwork, does the Crime Scene Manager have

          21       a log or notebook or a day book or what?

          22   A.  In the Metropolitan Police we call it a 199.  It's

          23       a crime scene -- it's a log.  Like a CSM log.

          24   Q.  Would, again, in terms of normal practice, when you

          25       attend, as the first Crime Scene Manager at the scene,




           1       and you get this briefing from a senior officer, would

           2       you log that in the log?

           3   A.  That would be included in the contents of that log, yes.

           4   Q.  How would you decide what it is that needs to be done

           5       from there?  Do you have further assessments yourself?

           6   A.  Yes.  You make assessments yourself, usually there's

           7       obvious priorities -- the weather can play a part.

           8       Obviously, if there's a body at the scene, that also

           9       plays a part.  But you balance all these judgments and

          10       then come to a conclusion as to how best to take it

          11       forward.

          12   Q.  Here, do you know that it was Patricia Larrigan who was

          13       the first Crime Scene Manager --

          14   A.  I do now, yes.

          15   Q.  -- and followed, I think, with a handover to

          16       a Mr Cockram?

          17   A.  That's correct, yes.

          18   Q.  Were you the next in the line?

          19   A.  I was, yes.

          20   Q.  Did you read their logs?

          21   A.  Not initially, no, but there is a form that they fill

          22       in -- the first Crime Scene Manager at the scene would

          23       typically fill in a briefing sheet which has the facts

          24       as they know it at the time.  And that forms the start

          25       of what happens in the future after that.




           1   Q.  From that, what did you gather was their strategy?

           2   A.  A strategy had been set.  At my point of intervention,

           3       the scene had already been examined, the vehicles had

           4       been taken away.  That was it at the time.  There was

           5       a strategy to examine -- the vehicle had been taken to

           6       Perivale, which is effectively a police car pound, had

           7       a forensic examination facility, and at that time, that

           8       was the -- that was my -- the strategy to examine that

           9       vehicle.

          10   Q.  By "the vehicle", do you mean the minicab?

          11   A.  The minicab, that's correct.

          12   Q.  I want to ask you a couple of things about that.  Before

          13       we do, can I deal with the gun found in a sock?  You

          14       were aware presumably that that had been found.

          15   A.  I was, yes.

          16   Q.  We know that officers attended late on the 4th to make

          17       that gun safe and the gun was then put in a box and was

          18       duly taken away from the scene.  Do you know whether any

          19       sort of marker was laid about where it had been?

          20   A.  At the scene?

          21   Q.  Yes.

          22   A.  I wasn't aware at the time.  I had only photographs.

          23   Q.  What should be the situation where you've got a gun

          24       found at a scene which is then taken away?  Should there

          25       be some sort of marker on the spot?




           1   A.  Typically -- initially, for any scene ... any major

           2       scene is photographically recorded in a number of ways.

           3       Well, it will always be with still photography and that

           4       can be backed up also with video photography, 3D -- 360

           5       photography.  But then there would usually be a marker

           6       of any significant exhibit -- it might take the form of

           7       a yellow triangle typically with the letters A, B, C, D

           8       marked on them.

           9   Q.  So we would expect to find photography and possibly

          10       a marker from where the gun --

          11   A.  That's the norm, yes.

          12   Q.  Thank you.  Let me deal with a couple of things about

          13       the minicab, if I may.  First of all the box.  Can we

          14       look at CD6457?  It will come up on the screen.  Sorry,

          15       I should start at CD6456.

          16           This is an email exchange between you and

          17       Mr Cockram.  Can I read out first of all your email

          18       which starts at the bottom?  It's one you wrote on

          19       30 August 2011 at 1.36.  You send it to John Orford,

          20       Ms Larrigan, John Cockram, and various others and you

          21       say:

          22           "I have been asked by the IPCC to look into the

          23       following.  Please could you specifically ask everyone

          24       involved if: photographs were taken of the inside of the

          25       Toyota Lucida people carrier in situ at the scene?  Who




           1       was understood to be carrying this out?  When?  Was it

           2       on the paperwork as part of the photography to be

           3       completed?  Who wrote down what photography was

           4       requested-what photography was asked for?  Does anyone

           5       know anything about this at all?  Are there any photos

           6       which capture the internal at all/any of the internal?

           7       If so, please could we have them.  We wish to establish

           8       the position of key exhibits inside the people carrier.

           9       Any information would be much appreciated.

          10       Alternatively, could we please obtain a definitive

          11       answer that this was not done so we that we know this is

          12       the position and we can move forwards with that

          13       understanding.

          14           "There are two main issues.  The first: a bullet was

          15       found by POLSA officers in a plastic bag on the seat in

          16       the rear of the vehicle, but we can find no

          17       documentation or photography at the scene or POLSA notes

          18       that locates this."

          19           The second is:

          20           "A cardboard shoe box was found in the rear of the

          21       vehicle (at Perivale) and photographed there, but is

          22       thought it may have also been on or near the rear seat

          23       of the vehicle at the scene.  Again we can find no

          24       documentation or photographs or POLSA notes that shows

          25       the original position of this.  If any one is able to




           1       help me with this, please let me know ASAP."

           2           Just before we get to the response that you had to

           3       that, can we infer from that that the handover notes and

           4       the scene logs and any other documents you had access to

           5       did not show you what the strategy was for photographing

           6       and what happened about the box?

           7   A.  That came about from a conversation, I think, with

           8       various officers that the box -- there was a box and

           9       obviously, if that had been photographed at the scene,

          10       there was no -- at that time there was no photography

          11       available to me.  Subsequent to that email obviously

          12       there was, but prior to that, no.

          13   Q.  I am not interested whether the photograph was available

          14       to you; I'm interested in whether the strategy as to

          15       what was to be done about photography was available to

          16       you.  Was it?

          17   A.  There was no outright -- around the vehicle itself?

          18   Q.  Yes?

          19   A.  None at all -- not at the time.

          20   Q.  And does it also follow, because of this reference to

          21       the bullet being found by POLSA officers, that you had

          22       no coordination with the POLSA officers; would that be

          23       right?

          24   A.  That's right, yes.

          25   Q.  Is that how it ordinarily is?  You tell us you didn't




           1       control the POLSA officers.

           2   A.  Normally a vehicle is physically examined prior to POLSA

           3       taking over the scene.

           4   THE ASSISTANT CORONER:  By POLSA you mean ...

           5   A.  The police searching -- the police search officers.

           6   THE ASSISTANT CORONER:  Right.

           7   MR UNDERWOOD:  Sorry, just help us with this: you have

           8       a Crime Scene Manager whose job it is to preserve

           9       evidence.

          10   A.  That's right, yes.

          11   Q.  What possible purpose is there for POLSA officers coming

          12       on after that?

          13   A.  It would be after the scene had been thoroughly

          14       examined.  Obviously we would not be taking things

          15       apart, we would not be -- in this situation, the

          16       vehicle -- would not be disassembling the vehicle

          17       looking for items, that would probably be the role of

          18       the POLSA officer.  The Crime Scene Manager would

          19       coordinate the initial strategy of the examination of

          20       the vehicle and that would be the recovery of the

          21       obvious exhibits, the stuff you can see, photography.

          22       And if the box and -- if a Crime Scene Manager had been

          23       involved at the start of the examination of the vehicle,

          24       the box would probably have been recovered.  Anything

          25       inside it would have been recovered forensically,




           1       whether it had DNA potential, fingerprint potential.

           2   Q.  What you are on here is a plastic bag with a bullet in

           3       it; would that not be relevant to the Crime Scene

           4       Manager?

           5   A.  It should be.

           6   Q.  What happens?  You have a Crime Scene Managers managing

           7       the scene, POLSA officers wander along later on and find

           8       something and don't tell you; is that what goes on?

           9   A.  I am not sure what happened in this case.  Again, you

          10       would have to ask the two initial Crime Scene Managers

          11       about that, wouldn't you?

          12   Q.  That's what you were doing here, wasn't it?

          13   THE ASSISTANT CORONER:  That's what you were doing.  In your

          14       email, that's what you were doing, so you are asking

          15       them what exactly was going on.

          16   A.  That's exactly what -- I was asking them exactly that.

          17   MR UNDERWOOD:  Let's see the reply now, shall we?  It's back

          18       on CD6546 and towards the top of the page of course:

          19           "Malcolm, sorry for the late reply, but as you know

          20       I have been a little busy of late and am only now

          21       ploughing my way through the emails!  For what it's

          22       worth, I was briefed that the scene photography had been

          23       completed under Trish's [that's Ms Larrigan]

          24       supervision.  I assumed that this would have included

          25       the inside of the cab.




           1           "I was to supervisor 360 and possibly pole cam (as

           2       you know, I decided to delay this until daylight).  It

           3       does not appear to my notes, but Trish told me that a

           4       flash search of the minicab had taken place prior to me

           5       supervising its removal ..."

           6           She denied that later on, did she not?  Ms Larrigan

           7       said, no, that's not true.

           8   A.  I am not sure.

           9   Q.  "... which, as you know, was also delayed for the above

          10       reason, so any findings should be in Trish's notes."

          11           Did you see her notes?

          12   A.  Afterwards.

          13   Q.  Were there any such records of a flash search in her

          14       notes?

          15   A.  I have not read -- I can't remember actually.  I have

          16       got a copy of them.

          17   Q.  "I recall looking into the cab and I believe I saw a box

          18       on the floor between the two sets of seats.  Wasn't the

          19       cab photographed before it was examined/searched at

          20       Perivale?"

          21           Did you follow that up?

          22   A.  Yes, it was photographed by a Craig Protherow.  I have

          23       a reference number in my notes, yes.

          24   Q.  If we look at CE072.  Is that the photograph, so far as

          25       you're aware, that he's referring to?




           1   A.  That's not taken at Perivale.

           2   Q.  No, that's why --

           3   THE ASSISTANT CORONER:  But Perivale was when you were in

           4       the garage?

           5   A.  Perivale is, effectively, a large garage examination

           6       area.

           7   MR UNDERWOOD:  Sorry, I've taken to you that question at the

           8       end of Mr Cockram's email when he says:

           9           "Wasn't the cab photographed before it was

          10       examined/searched at Perivale?"

          11           So, so far as you were aware, it was not

          12       photographed at the scene; is that right?

          13   A.  As far as I was aware, yes.  Or, if photographs were

          14       done, I was not in possession of any of those

          15       photographs.

          16   Q.  Does it follow that nothing that was available to you

          17       suggested that anybody could believe the box was at all

          18       relevant?

          19   A.  (Pause).  The ... I'm not sure how the relevance of the

          20       box became apparent to me.  It obviously arose in a

          21       conversation, hence my email to people.

          22   Q.  I am not suggesting it's your fault, Mr Nott --

          23   A.  I cannot remember how it --

          24   Q.  I'm asking you whether the information available to you

          25       from crime scene logs of handover notes gave you any




           1       indication about anybody being interested in the box?

           2   A.  None at all, no.

           3   Q.  Were you left much the wiser from this?  There's no

           4       response here about the bullet in the bag and POLSA; did

           5       you --

           6   A.  None at all, no.

           7   Q.  Did anybody ever tell you what POLSA had been up to with

           8       bullets and bags?

           9   A.  Not at all.  Not at that stage, no.

          10   Q.  Did you, in fact, examine the minicab on 9 August?

          11   A.  That was correct, yes, at Perivale.

          12   Q.  If we look at CE62, that's a photograph, it's in our

          13       bundle, jury bundle, at page 21; is that the box?  Can

          14       you recall?

          15   A.  I was not there when that photograph -- I was there, but

          16       I was not standing at the van when the vehicle

          17       photograph was taken, so I'm assuming that is the box

          18       they were talking about.

          19   THE ASSISTANT CORONER:  Who took those photographs?

          20   A.  That was Craig Protherow; he's a photographer.  Again

          21       when I went to Perivale, it's my task to coordinate that

          22       type of examination and one of my questions was for him

          23       to photograph that vehicle.

          24   MR UNDERWOOD:  Were you also coordinating the blood spatter

          25       testing at Perivale that day.




           1   A.  Yes.  At the previous day I had already set up the

           2       meeting at Perivale on the date of the 9th for forensic

           3       scientists to attend and a photographer.

           4   Q.  Was the forensic scientist Andrew Bell?

           5   A.  That's correct.

           6   Q.  There were at least two purposes that we now know of:

           7       one was to photograph the box in the back and anything

           8       else that was relevant; yes?

           9   A.  Yes.

          10   Q.  The other was for Mr Bell to examine the vehicle for

          11       blood spatter; yes?

          12   A.  That's correct, yes.

          13   Q.  Do you know why the vehicle wasn't being examined for

          14       blood spatter?

          15   A.  Because it had been in close proximity to a shooting and

          16       that is what we would do in a vehicle, this one, to get

          17       an understanding as to the position of people -- or try

          18       to get an understanding of the position that people

          19       standing when they are shot or injured in any way.

          20   Q.  You knew this was a fatality, presumably.

          21   A.  Yes.

          22   Q.  You organised Mr Bell seeing that minicab at Perivale.

          23   A.  That's correct, yes.

          24   Q.  Did you know that when that happened the seats had been

          25       turned round?




           1   A.  No.  I had no understanding of that.

           2   Q.  Would that not have been very relevant?

           3   A.  It would have been if somebody had told me, yes -- and

           4       certainly to the forensic scientist who would have

           5       needed to know that information.

           6   Q.  We gather POLSA moved the seats around; did you know

           7       that?

           8   A.  I wasn't aware, no.

           9   THE ASSISTANT CORONER:  Did you not have access to the

          10       photograph that we saw just now of it at the scene?

          11   A.  No, that arrived later.  That was as a result of my

          12       email that you just referred back to when a photographer

          13       came to me and said -- told me about that photograph

          14       existing and that was part of the photograph of a 360

          15       scan, I believe.

          16   THE ASSISTANT CORONER:  You had not realised the seats had

          17       been moved when you are there on 9 August?

          18   MR UNDERWOOD:  So when Mr Bell was looking at the nearside

          19       of the seat for blood he was looking at the wrong side?

          20   A.  He wouldn't have known that either.

          21   THE ASSISTANT CORONER:  He would not have known that either?

          22   MR UNDERWOOD:  Because nobody told you therefore nobody told

          23       him?

          24   A.  No.

          25   Q.  Again, is POLSA supposed to tell people when they do




           1       these things?

           2   A.  They should do.

           3   Q.  Is the Crime Scene Manager there supposed to make

           4       a record of it?

           5   A.  Yes, if you had been told or known about it, it would

           6       have been recorded, yes.

           7   Q.  Did you know the carpets had been taken out of the

           8       vehicle and been put in the boot?

           9   A.  I had no knowledge of that either.

          10   Q.  Again, would that have been relevant to the blood stain?

          11   A.  For the examination carried out by Andrew Bell it would

          12       have been, yes.

          13   THE ASSISTANT CORONER:  Sorry, can you say that again?

          14   A.  For Andrew Bell, the forensic scientist who attended to

          15       look into the blood splatter, that would have been

          16       relevant.

          17   MR UNDERWOOD:  Again let's just be clear, I do not think you

          18       became involved in this until 8 August; is that right?

          19   A.  That's correct, yes.

          20   Q.  For the sake of good order, if we pick this up at

          21       CD4810.  We will see in a moment, when the machine warms

          22       up, "Crime Scene Manager's case note logs, book 199" and

          23       we see CSM is Malcolm Nott, Operation Glasston.  If we

          24       look down bottom left-hand corner, it is book 1.

          25       Towards the right-hand side, towards the bottom:




           1           "Date/time log commenced: 8.8.11."

           2   THE ASSISTANT CORONER:  This is your writing?

           3   A.  That's correct, yes.

           4   THE ASSISTANT CORONER:  There wasn't a log started before

           5       then then?

           6   A.  Not by me, no, but there will have been by the previous

           7       Crime Scene Managers who will each have their own log.

           8       It's not a log that runs from -- is continuous.  Each

           9       one of us has our own log.

          10   MR UNDERWOOD:  Why?

          11   A.  Crime scene -- because the initial Crime Scene Manager

          12       will have her own notes, as will John Cockram who took

          13       over from her.  He'll have his own notes and I will have

          14       my own notes.

          15   Q.  We'll come to it when we do.  If an earlier Crime Scene

          16       Manager had, for example, made a record of the seats

          17       being moved round, if this had been a continuous log you

          18       would have been able to see that, wouldn't you?

          19   A.  Will have been, yes.

          20   Q.  Assuming it was noted there.

          21   A.  If it was noted it would have been -- or it would have

          22       formed part of the initial briefing written by, in this

          23       case, Ms Larrigan.

          24   Q.  From what you tell us, the first two Crime Scene

          25       Managers would not have given you their logs, they just




           1       would have given you a briefing?

           2   A.  That's correct, yes.

           3   MR UNDERWOOD:  Thank you very much.  That's very kind.  If

           4       you wait there, there may be other ...

           5   THE ASSISTANT CORONER:  Yes, Mr Mansfield.

           6                    Questions by MR MANSFIELD

           7   MR MANSFIELD:  Good afternoon.  My name is Michael Mansfield

           8       and I represent the family of Mr Duggan.

           9           I really want to follow through with how a crime

          10       scene should be managed.  There's no question that this

          11       was potentially a crime scene at Ferry Lane, is there?

          12   A.  Not at all, no, it's ... it's a typical crime scene.

          13   THE ASSISTANT CORONER:  Sorry, a typical crime scene?

          14   A.  Typical crime ...

          15   MR MANSFIELD:  In a typical way.  It's extremely important

          16       in crime scene investigation and management that you

          17       preserve the crime scene in situ so far as is humanly

          18       possible.

          19   A.  Absolutely correct, yes.

          20   Q.  Because all sorts of evidential traces can be found at

          21       a crime scene that may be of considerable relevance to

          22       what happened.

          23   A.  Absolutely right, yes.

          24   Q.  So it could be firearms residue, cartridges, if there's

          25       been a firearms incident, fingerprints?  All that




           1       forensic material may be present, some of it unseen to

           2       the human eye.

           3   A.  That's correct, yes.

           4   Q.  I want to deal with the stage -- I appreciate you

           5       weren't on duty; this is just the principle of the

           6       matter.  We know in this case that the shooting itself

           7       was about 6.12 that day, on the 4th.  We also know the

           8       first Crime Scene Manager, Larrigan, who we have had the

           9       name, you know who we're talking about, she didn't get

          10       to the scene until 8.54.  That's nearly three hours

          11       later.  Did you know that?

          12   A.  I wasn't aware, no.

          13   Q.  You weren't aware?  Can I just pause for a moment.  In

          14       relation to what happened in this case, that's the

          15       aftermath, the forensic investigation and the forensic

          16       traces, did anybody have at any stage a kind of

          17       retrospective overview of what had happened here?  Was

          18       anybody given that task that you're aware of?

          19   A.  The two previous Crime Scene Managers -- you would

          20       probably have to direct your questions to them, but as

          21       far as I was concerned I met up with various people at

          22       Emperor State building on the 8th where the forensic

          23       aspects were discussed.

          24   Q.  I am going to come to one or two aspects of it, but

          25       I just wondered if, retrospectively, somebody was given




           1       the task of re-examining what had gone on in this case,

           2       and, in particular, what had gone wrong in this case.

           3       Do you know of anybody who was deputed to do that?

           4   A.  Not at this stage, no.

           5   Q.  All right.  Well, at any stage?

           6   A.  There's a forensic strategy established with the

           7       initial -- or the senior officer -- but I wasn't

           8       involved in that initial strategy.

           9   Q.  When you say "the senior officer", which senior officer?

          10   A.  Whoever takes primacy of the case at the time.

          11   Q.  Who was that in this case; do you know?

          12   A.  At the time the scene was live, I don't know.  My

          13       involvement was -- the first time I was called about it

          14       was when I had a phone call from --

          15   Q.  On the 8th?

          16   A.  On the 8th, exactly, yes.

          17   Q.  I appreciate that.  As far as you know, you don't know

          18       of anybody who has had a retrospective overview of

          19       what's happened in this case.  You don't know who was in

          20       charge before 8.54 on the day?

          21   A.  No.

          22   Q.  Well, leaving aside whoever was in charge, who is

          23       supposed to be in charge once there is a crime scene,

          24       and in this case a shooting incident, which led to

          25       a death?  Who is supposed to be in charge of the scene




           1       before the Crime Scene Managers arrive?

           2   A.  It would be the senior police officer on duty at the

           3       scene at the time.

           4   Q.  Are they trained to deal with crime scenes?  I mean, if

           5       it's a CO19 officer, are they trained to deal with --

           6   A.  Most of them are trained to establish cordons, put in

           7       what they believe to be relevant at the time.  Again,

           8       they can -- they are movable areas, cordons, but they

           9       certainly put in what was relevant, what they believed

          10       to be relevant, and part of their training would be to

          11       preserve evidence.

          12   Q.  Of course, that would involve not interfering with

          13       evidence.

          14   A.  That's correct, yes.

          15   Q.  So for the three-hour period, another senior officer,

          16       not a Crime Scene Manager, would be in charge to ensure

          17       that the scene is preserved?

          18   A.  In this case, yes, those are the hours and times.

          19   Q.  Would that person be expected to keep a record?

          20   A.  A decision log would be kept of some sort.  If it was

          21       a police officer, a duty inspector, I am not sure in

          22       this situation, but they would probably have a decision

          23       log, particularly if there's any significant movements

          24       of items for whatever reason, whether it's to preserve

          25       life or to assist in any way.




           1   Q.  Have you ever seen such an item?

           2   A.  No.  Not in this case I haven't, no.

           3   THE ASSISTANT CORONER:  It would be headed up as a decision

           4       log, would it?

           5   A.  Yes.  I am not quite sure of the book number -- a police

           6       officer would be able to assist you with that -- but

           7       they would have a decision log around significant --

           8   THE ASSISTANT CORONER:  Can I just ask, I don't mean to be

           9       in any way controversial about this, but I just want to

          10       know: a Crime Scene Manager arrives on the scene,

          11       everyone agrees that it is a crime scene, but do you not

          12       have to have in your mind about what is the crime in the

          13       background here?  Does that direct the way you look

          14       after a scene?

          15   A.  Yes, absolutely, it does.  That would form part of the

          16       initial briefing that would take place with that senior

          17       officer when we arrive and that -- if that was the scene

          18       I was going to, that would be recorded into my log.  In

          19       this situation, the scene had already taken place.

          20       I came into this event some time later, but typically,

          21       if I arrived at a scene, a major crime scene, my first

          22       part of my notes would include the briefing I'm given,

          23       the decisions that have been made, any relevant

          24       significant witnesses, movements that have taken place.

          25       But then that would be recorded in my log at the time.




           1   MR MANSFIELD:  Of course, there would be a logical sequence

           2       of investigation because you don't want one set of

           3       people interfering with what might be necessarily

           4       investigated by someone else coming along later.  So you

           5       have to do things in order, don't you?

           6   A.  That's correct, yes.

           7   Q.  What is the order?

           8   A.  Well, in a scene like this, initially, it would be to

           9       photograph and to record the scene.  Provided the

          10       weather conditions are favourable, which I believe they

          11       were in this case, the first act would be certainly to

          12       photograph the scene, to probably video it and then

          13       carry out various other photographic techniques.  The

          14       pole cam was mentioned.

          15   Q.  Would you, in whatever strategy document you're using,

          16       the 199 or whatever book it is, write down the order in

          17       which you have asked for things to be done?

          18   A.  That's correct, yes.

          19   Q.  In this particular case, and again these are questions

          20       I just want your help with because I know you were not

          21       dealing with it, but so the jury may follow, just for

          22       the moment -- we'll hear more details.  The first

          23       photograph, so the jury can have in mind which the first

          24       photograph appears to be, is the photograph the jury

          25       have in their bundle, it's number 20.  It's a little




           1       deceptive, but this is not at Perivale.  It's taken at

           2       the scene and it's a night-time photograph.  You have

           3       seen it since, obviously?

           4   A.  I've seen it, yes.

           5   Q.  This photograph was -- I cannot tell you the precise

           6       time, but I can tell you the window within which it was

           7       taken, in other words 23.50 and 00.25.  So there is

           8       quite a considerable time before this photograph is

           9       taken.

          10           When the photograph is taken, do you expect

          11       a written record of what is depicted in the photograph

          12       to be done by someone else?

          13   A.  No, that wouldn't be the case.  The photographer that

          14       took that photograph would just be recording the scene

          15       photographically.

          16   Q.  Could we have on screen CD257, please?  The jury don't

          17       have this one, but this is a close-up of what is the

          18       floor area of the minicab in the earlier photograph you

          19       have just seen.  It's CD257.  Have you seen this

          20       close-up before?

          21   A.  Not shown like that, but is that not just an enlargement

          22       of that first one?

          23   Q.  It is, yes, an enlargement.  It's a close-up depiction

          24       of what appears to be, at that stage, on the floor.

          25           I am just going to concentrate on the box for the




           1       moment because there comes a stage when you do become

           2       involved.  You start on the 8th and on the 9th we know

           3       that the minicab is at Perivale.  You have just said the

           4       box is in the boot.  Of course, the jury have that

           5       photograph as well, which is the next -- it's 21 in

           6       their bundle.

           7           I want to ask you this: since you were asked to deal

           8       with the box, can you help us as to how the box got from

           9       the floor to the boot?

          10   A.  I've no idea.

          11   Q.  Were you not asked to investigate that?

          12   A.  Not at that time, no.  The time that photograph was --

          13       sorry, that photograph was taken, the box ... there was

          14       no relevance put on the box.  But it became relevant in

          15       later conversations, and that's when I sent the email

          16       which resulted in that first photograph being recovered.

          17   Q.  I appreciate that.  Of course, when you're examining

          18       a scene at the beginning, you don't know what's going to

          19       be relevant, do you?  That's part of the --

          20   A.  Normally, that's the case, yes.  That's the way --

          21   Q.  Therefore, that is one of the prime purposes -- is to

          22       ensure that it is preserved because you don't know what

          23       might be relevant later?

          24   A.  Hence the reason for the photography as well.

          25   Q.  Yes.  You might not have known at the time the




           1       photograph of the box in the boot was taken, but can you

           2       now explain how the box gets from the floor into the

           3       boot?

           4   A.  No idea at all, I'm afraid.  I've got no --

           5   Q.  No idea at all?

           6   A.  -- idea at all.

           7   Q.  Before I just tackle a couple of other things, do you

           8       accept that the handling of this crime scene is far from

           9       perfect, isn't it?

          10   A.  I think it would be fair to say there's a few flaws, and

          11       particularly the issues around the box are certainly one

          12       of them.

          13   Q.  Would it be fair to say that is an English

          14       understatement?

          15   A.  Maybe.

          16   Q.  Maybe, all right.  I am not suggesting that you did,

          17       I just wondered if you can help.  You cannot help about

          18       how the box gets into the boot?

          19           I would like another photograph put up, please.  The

          20       jury don't have this one either, but it's CE0059 and

          21       Mr Underwood has already referred to seats being moved.

          22       It can be split screen by all means.  Thank you very

          23       much.

          24           It's coming up on a split screen so you will see the

          25       one on the night at midnight, roughly speaking.  The one




           1       on the left on the screen is a photograph taken, in

           2       fact, on the 9th, the day that you look at the minicab.

           3       All right?

           4   A.  That's correct, yes.

           5   Q.  Yes.  We can see there, clearly, how the seats have been

           6       moved round and Mr Underwood pointed out that the blood

           7       spatters, if they were in place, would have been on the

           8       far side of this photograph, not on the nearside.  So

           9       once again, as far as you're concerned, you didn't know

          10       they had been moved?

          11   A.  Absolutely no idea at all.  As far as I'm concerned, the

          12       image you see on the left is as I expected the vehicle

          13       to have been lifted from the scene.

          14   Q.  Yes.  I'll come to the lifting of the vehicle in a

          15       moment.  Keep the photographs in mind for a moment, but

          16       go back to the scene.

          17           Is it the Crime Scene Manager who is actually in

          18       overall charge once she gets there at 8.54?  In other

          19       words, whoever comes along, like POLSA officers or

          20       whoever they are, are really under her direction; is

          21       that right?

          22   A.  Yes, that's correct, yes.

          23   Q.  So that she's got to keep a record of what they're

          24       doing?

          25   A.  Yes.  Or the strategy that is set for -- to examine the




           1       vehicle, if that's what they're going to do.

           2   Q.  I think you have said that when you looked at the case

           3       notes here, the manager's log, there wasn't a clear

           4       strategy set out in it that you could see?

           5   A.  Not at the time, no.  I suppose that's a fair comment.

           6   Q.  She won't have written it up -- well, she might have

           7       written it up later, but there was not any

           8       contemporaneous strategy that you could see in the log.

           9           The plastic bag, which became important, because of

          10       its connection with firearms in this case; did you see

          11       a plastic bag at all on the 9th anywhere?

          12   A.  I made no note of it.

          13   Q.  No.

          14   A.  But it would be in any photographs that were taken at

          15       Perivale, if it was there.

          16   Q.  Yes.  Sorry, the photographs have gone, but CE0072,

          17       taken on the night, there appears to be -- I don't know

          18       whether you can help, having looked -- there appears to

          19       be a plastic bag?

          20   THE ASSISTANT CORONER:  You want this one on the 4th or the

          21       one on the 9th?

          22   MR MANSFIELD:  The one on the 4th, not on the 9th.

          23   A.  I've actually got a clearer copy of that, and you are

          24       right, there is behind the seat there is what appears to

          25       be an orange --




           1   THE ASSISTANT CORONER:  You have a clearer copy of that?

           2   A.  Amongst my notes.

           3   MR MANSFIELD:  Can you just point out, having had a clearer

           4       copy, so the jury can see where you mean?  Either on the

           5       big screen --

           6   THE ASSISTANT CORONER:  Take out your clearer copy if you

           7       could.  Slide it out.

           8   A.  It's that (indicates), just that area (indicates).  It's

           9       very grainy obviously because of the enlargement on the

          10       screen.

          11   THE ASSISTANT CORONER:  Can you see that on your clearer

          12       copy?

          13   A.  (Handed).

          14   THE ASSISTANT CORONER:  It is a clearer copy.  It's a much

          15       better copy, isn't it?

          16   MR MANSFIELD:  I wonder if the jury might like to see that.

          17                (Document handed around the jury)

          18   THE ASSISTANT CORONER:  Yes, I think they should.  Make sure

          19       there is nothing else on that.  I think we all ought to

          20       see that.  I wonder if, for a moment, we could pass that

          21       round the jury and make sure we hang onto that.

          22   A.  Just for your information, I believe that was taken from

          23       a still from a 360 scan.  It wasn't a shot of a still

          24       photography of that -- that particular shot you're

          25       looking at now, I believe that was taken as a result of




           1       a 360 scan and it was picked out as a single shot which

           2       probably appears -- probably is the reason why it's

           3       slightly distorted.

           4   THE ASSISTANT CORONER:  What is slightly distorted?  On

           5       our --

           6   A.  That photograph that I am passing around at the moment

           7       -- you're probably best talking to a photographer --

           8       they have a camera that scans 360 degrees -- I know you

           9       can do this thing on iPhones now, but at the time we had

          10       a particular camera that scans 360 degrees, it picks the

          11       scene out 360 but it makes it a two-dimensional image.

          12       That image -- I may be wrong, but I believe that was

          13       captured from that 360-degree --

          14   THE ASSISTANT CORONER:  It's certainly a better one.  It has

          15       a clearer picture of the box too, doesn't it, within

          16       that?  You can see.  I'll let you have a look at that as

          17       soon as the jury have finished looking at it.

          18   MR MANSFIELD:  I do not know if you can help while that is

          19       going round, but I think the photographer's name is

          20       Paul Cowley(?).

          21   A.  That is correct, yes.

          22   Q.  So it's a Paul Cowley who photographed 360.

          23   THE ASSISTANT CORONER:  We will also plunder your files to

          24       see if you have some other good photographs in there

          25       too, Mr Nott.




           1   A.  I'm afraid that's the only one.

           2   THE ASSISTANT CORONER:  Is that the only one, is it?  All

           3       right.

           4           You have that for the moment, Mr Nott, in case you

           5       are asked some more questions about it, but please leave

           6       it behind when you go after this afternoon's evidence.

           7       Thank you very much.

           8   MR MANSFIELD:  I think, if you just have the photograph, it

           9       has just been indicated -- I think it's not visible on

          10       the jury's or my copy, but the carpets are sort of

          11       rucked up there in the back; did you see -- that is

          12       between the two sets of seats --

          13   A.  Just here (indicates).

          14   Q.  Just there.  You are just pointing out there.  On the

          15       original are the carpets, which end up in the boot.

          16   A.  I haven't -- if you showed that on the photograph,

          17       I would know that, yes.  But what you say is correct.

          18       There's a brown coloured -- I'm not sure it's even a car

          19       carpet.  It may well be.  Again the quality of this,

          20       even on this photograph, which you have look the at, is

          21       poor because of the way and means in which it was

          22       captured, but there's a brown carpet type of ... rug or

          23       carpet I'm not sure what.

          24           I'm not -- without knowing what that white item

          25       is ... I wouldn't say, but that brown carpet doesn't




           1       appear in that photograph as far as I can tell.  Unless

           2       that, of course, is the underside of the carpet

           3       (indicates).

           4   THE ASSISTANT CORONER:  The other photograph of 9th --

           5   MR MANSFIELD:  That's one taken on the 9th.

           6   THE ASSISTANT CORONER:  -- shows there's no carpet ...

           7   MR UNDERWOOD:  I think it may well be the evidence of one of

           8       the searchers that they rolled it up and put it in the

           9       boot, so it may be the rolled-up item on the right.

          10   THE ASSISTANT CORONER:  We will try and unroll this

          11       problem -- unravel that now.

          12   MR MANSFIELD:  So thank you for the help on that particular

          13       photograph.

          14           Again, all these items -- that's plastic bag,

          15       carpets, box and so forth, all of which become

          16       increasingly relevant -- emphasise the need at the

          17       beginning to ensure you've got a captured photograph or

          18       image of exactly how it was when that person arrived at

          19       the vehicle, the photographer?

          20   A.  And that's exactly what I said earlier.  That's the

          21       initial act at most major crime scenes.

          22   Q.  I just want to continue with the, if you like, the crime

          23       scene of the minicab itself.  If you're going to, as it

          24       were, seal it up so that you absolutely ensure -- let us

          25       take the two-hour period before the Crime Scene Manager




           1       arrives.  If you want to seal it up before crime scene

           2       get there, is there a method you commonly use to do

           3       that?

           4   A.  Not usually.  The cordons would be in place and if it

           5       was a -- whether it be a vehicle, a house, property,

           6       land, cordons would be put in place and that would be

           7       adequate until a further examination takes place.  But

           8       if you're referring to seals being put over doors, that

           9       may be -- that may happen later on.  That would not

          10       happen initially before a Crime Scene Manager gets

          11       there.

          12   Q.  When would that happen, seals on the doors?

          13   A.  It really depends what stage the vehicle gets taken

          14       away.  Again, in this case, I make no record of any

          15       seals on the doors, there usually -- seals are put on

          16       the doors at the time it's removed from the scene

          17       because that then -- there's always a stage when

          18       a vehicle gets taken away -- whether it be on

          19       a low-loader, whatever means it's taken -- where

          20       effectively it's out of police control for a short time

          21       because of the mere logistics of moving vehicles around

          22       London, so what we would typically do is put seals

          23       usually on the lower part of the doors on the bottom, on

          24       the bonnet, on the boot, just to signify -- so if they

          25       are broken in any way, it gives an indication it's been




           1       tampered with.

           2   Q.  In this particular case, can you help with this: so far

           3       as the vehicle is concerned, would you agree there's

           4       a rather chequered history?  And I am just going to

           5       summarise it to see if you can help, having looked back

           6       at it.  There is an attempt to move it, although it

           7       doesn't actually happen, with a recovery vehicle

           8       entering the scene at just gone midnight; did you know

           9       that?

          10   A.  I do now know, yes.

          11   Q.  Then, it actually doesn't remove the vehicle at that

          12       point.  So we're into the 5 August, the next day.  The

          13       vehicle is moved, isn't it?

          14   A.  My understanding now is that is the case, yes.

          15   Q.  But, having left -- I'll give you a precise time -- it

          16       leaves the scene at 3.20 on the 5th, on a recovery

          17       vehicle, only to be returned less than half an hour

          18       later, about 20 minutes later it comes back again; did

          19       you know that?

          20   A.  I do now know, yes.

          21   Q.  During that passage, that's -- well, the attempt didn't

          22       get as far as moving it, but the successful attempt, in

          23       other words the one at 3.20, does.  Was it sealed then?

          24   A.  It was prior to me getting involved.  I've no knowledge

          25       of it being sealed at that time at all.




           1   Q.  But if it had been moved from the scene, it should have

           2       been, shouldn't it?

           3   A.  It should have had some sort of seals over the doors.

           4   Q.  Right.  In fact, strictly speaking, if the scene

           5       examination hadn't finished, it shouldn't have been

           6       moved, should it?

           7   A.  No.  Can I just add to that, actually?  A lot will

           8       depend on the sort of examination that needs to take

           9       place.  Certainly at the scene a certain amount of work

          10       can be done, but other work, sometimes fingerprint

          11       examination, blood searching, requires specialists like

          12       photography and hence the reason it gets moved to

          13       Perivale because that's an establishment and area where

          14       we have got specialist equipment to use it.  So

          15       a certain amount of the examination of the vehicle would

          16       take place at the scene, hence the reason for the seals,

          17       to then establish the security of the vehicle until it

          18       goes for a further examination at Perivale.

          19   Q.  Can you help: when we talk about seals, is it just

          20       a sort of label that's put across the doors?

          21   A.  Typically it's an exhibit label, which is just a sticky

          22       label.

          23   Q.  Could we just have an example, please?  There we are.

          24       Is that the sort of --

          25   A.  That's exactly right, yes.  That's it, yes.




           1   Q.  That's a close-up of one?

           2   A.  Yes.

           3   Q.  That's the sort of thing that should happen?

           4   A.  Yes.

           5   Q.  Then what should happen is, if anybody breaks the seal,

           6       they have to initial the fact or record the fact they

           7       have broken the seal and put a new one on when they have

           8       finished.

           9   A.  That's generally the case.

          10   Q.  A log of that is kept?

          11   A.  That would be recorded by the person who makes the

          12       examination.

          13   Q.  That's back at Perivale where you're doing a more

          14       detailed examination, but at the scene it's necessary --

          15       back at the scene, as it were -- to have the minivan in

          16       the exact place where it was stopped because you're

          17       looking for the traces that relate to the position of

          18       the vehicle in order, if you can, to ascertain where

          19       people were at various times.

          20   A.  Absolutely right.  There would be absolutely no reason

          21       to move the vehicle, unless it's for safety reasons,

          22       until the examination at least has been undertaken to

          23       a degree where it can then be removed.

          24   Q.  The very removal of the minicab can disturb whatever may

          25       be on the road at that point.




           1   A.  That's always going to be a possibility, yes.

           2   Q.  So if there are casings that relate to firearms that

           3       show where they ended up that, of course, may not be

           4       where they were originally.

           5   A.  That's correct, yes.

           6   Q.  Are you aware of any good reason why you would want to

           7       take a minicab back again once you have moved it?

           8   A.  In all my experience as a Crime Scene Manager I've never

           9       known that to happen before.  And I've been a Crime

          10       Scene Manager for about 12/13 years now.  There would be

          11       no relevance really to take the vehicle back.  It proves

          12       nothing.  It's like restaging the scene; you wouldn't do

          13       it.  It's not something that would be undertaken.  We

          14       would record what was there at the time.  When the

          15       photographer arrives, it's recorded.

          16   Q.  It's basically too late.  Once the stable door is

          17       opened, that's it.

          18   A.  There would be very little reason to take a vehicle

          19       back.  In my opinion, obviously, other people may have

          20       had a different opinion at the time.

          21   MR MANSFIELD:  Right.  Thank you very much.

          22   THE ASSISTANT CORONER:  If you take the vehicle away, that

          23       allows examination in the vehicle, fingerprints, DNA,

          24       looking at the carpet and such like.  But when the

          25       vehicle is at the scene, that enables you to pinpoint,




           1       if you are examining the road or kerb immediately

           2       outside the door for example, so that you can look to

           3       see there whether there are blood spatters or anything

           4       of forensic relevance.

           5   A.  Absolutely right.

           6   THE ASSISTANT CORONER:  Do you know if that was done?

           7   A.  Again, you are probably best to direct those questions

           8       to the two Crime Scene Managers prior -- particularly

           9       the initial one.  But that would be typically what would

          10       be done.  That's the reason why the vehicle is left at

          11       the scene because obviously blood splatter, the position

          12       of casings could all be very relevant to the positioning

          13       of people when shots are fired, when incidents happen.

          14   THE ASSISTANT CORONER:  Thank you, Mr Nott.

          15           Yes, Mr Thomas?

          16                      Questions by MR THOMAS

          17   MR THOMAS:  Just three questions, sir.  Good afternoon.

          18           Can you just confirm this: when you talk about a

          19       crime scene, you can have more than one crime scene,

          20       can't you?

          21   A.  Yes.  When I say "crime scene", I'm talking about the

          22       whole entity effectively, but there's various aspects

          23       within one major crime scene which you can subdivide it.

          24   Q.  You can have several crime scenes within a major crime

          25       scene, as it were?




           1   A.  That's correct, yes.

           2   Q.  So one of the things that the crime scene investigator

           3       needs to have in mind, or Crime Scene Manager needs to

           4       have in mind, is the potential offences.  You would

           5       certainly need to think, well, what are the particular

           6       offences that could be on the face of these instructions

           7       that I've got; is that right?

           8   A.  Yes.

           9   Q.  Can we just go through that exercise on the face of this

          10       case?  Firstly, there's the actual shooting of

          11       Mark Duggan.  That would be something that would be

          12       relevant in terms of --

          13   A.  Yes.

          14   Q.  -- a crime scene.  Secondly, there would be the finding

          15       of the firearm and where that was located; would you

          16       agree?

          17   A.  That's another aspect of it, yes.

          18   Q.  Thirdly -- I'll stop at three for my purposes --

          19       thirdly, there would be the fact that part of this

          20       investigation was the fact that Mark Duggan was said to

          21       have picked up a firearm and had been travelling with

          22       that firearm in the minicab; do you follow?

          23   A.  Yes.

          24   Q.  There would be all sorts of potential forensics relating

          25       to that.




           1   A.  That's correct, yes.

           2   Q.  Right.  So just to assist everybody on this, obviously

           3       the taxi itself would be a crime scene.

           4   A.  Yes.

           5   Q.  Yes.  The position where Mark was, where he is said to

           6       have been shot, that would be a crime scene?

           7   A.  (Nods).

           8   Q.  You are nodding, but nods don't pick up on the

           9       transcript.

          10   A.  Yes.

          11   Q.  And finally, on the grassy green, where it's said that

          12       the gun was found, that would be a crime scene; yes?

          13   A.  Yes.

          14   Q.  That was the first question.  Second question.  You

          15       mentioned the delay that there was in between the Crime

          16       Scene Manager arriving at the scene and what you would

          17       generally expect to find between the Crime Scene Manager

          18       arriving and ... what you said earlier on is you would

          19       expect that a senior officer at the scene would do the

          20       scene preservation.

          21   A.  That's correct, yes.

          22   Q.  Would you agree obvious things in terms of crime

          23       scenario preservation?  We know that the police officers

          24       had cameras and videos.

          25   A.  Mm.




           1   Q.  Because the first aid was videoed, for example.  We

           2       heard one officer, who said that he had a camera -- can

           3       you just help me with this: bearing in mind that a video

           4       was there and there was a camera there, taking

           5       a photograph of, let's say, the taxi.  That's not

           6       invasive, that is not going to disturb the taxi crime

           7       scene as long as you don't go into the taxi; would you

           8       agree?

           9   A.  Yes.  Part of the reason photography is done is because

          10       it's non-invasive, non-destructive.

          11   Q.  Exactly.  As far as you're concerned, a senior manager

          12       who discovers potential significant items such as the

          13       gun or, you know, the taxi that was travelled in with

          14       the gun supposedly in it, can you think of any good

          15       reason, any good reason, why, say, where the gun was

          16       found or the taxi not to have been photographed, bearing

          17       in mind it's non-invasive, can you think of any good

          18       reason?

          19   A.  None at all.  As you said earlier, it's part of a crime

          20       scene and part of the role of the photographer would

          21       be -- the role of the photographer would be to record --

          22       would be to record the crime scene.

          23   Q.  Yes.  Final question.  You mentioned the seals and the

          24       seals can be audited when you put the seals on the

          25       doors.




           1   A.  Yes.

           2   Q.  I mention the word "audit" because it has to be signed

           3       for if the seals are broken.  That has to be signed for

           4       and the record is kept for that; yes?

           5   A.  The seals are numbered.  Again, if you look back at that

           6       photograph, I think you will be able to see they have

           7       a unique reference number on them.

           8   Q.  In other words you can follow the audit trail; do you

           9       follow?

          10   A.  That's right, yes.

          11   Q.  There were no seals on this vehicle, were there?

          12   A.  That's correct, no.

          13   Q.  Knowing what you know, what you now know about this,

          14       that's surprising, isn't it?

          15   A.  It is, yes.

          16   Q.  Can I ask you this --

          17                      (Disruption in court)

          18   THE ASSISTANT CORONER:  Right, Mr Thomas.  Please continue.

          19   MR THOMAS:  Knowing what you know about this and the way

          20       that this particular -- if you were training -- you said

          21       you've been a Crime Scene Manager for some 13 years,

          22       something like that.

          23   A.  Something like that, yes.

          24   Q.  If you were training your junior staff and the way that

          25       this crime scene was managed, would you be happy with




           1       it?

           2   A.  I certainly wouldn't be happy with the fact the door --

           3       the integrity of the vehicle hadn't been recorded in

           4       some way.  And, in this situation, with door seals.

           5   Q.  Well, it's not just the door seals, with the greatest of

           6       respect.  Shall we just run through what Mr Mansfield

           7       went through?  You have the seats being moved around and

           8       nobody telling you about it; yes?

           9   A.  That's correct, yes.

          10   Q.  You've got the box being interfered with, shifted from

          11       one part of the vehicle to another part of the vehicle.

          12   A.  That's correct, yes.

          13   Q.  Then we come onto the door seals; yes?

          14   A.  Mm.

          15   Q.  Then we come onto the fact that, for some reason -- and

          16       there's been no good reason for it that's been presented

          17       for this court yet -- no photographs taken of the

          18       vehicle properly in situ early on; agreed?

          19   A.  That's correct, yes.

          20   Q.  This is shocking, isn't it?

          21   A.  It's far from ideal.

          22   MR THOMAS:  That's all I ask.

          23   THE ASSISTANT CORONER:  Yes, let's see who comes next on my

          24       list.  Right, I've got you Mr Stern, actually.

          25   MR STERN:  No thank you.




           1   THE ASSISTANT CORONER:  Then I have Mr Butt.

           2   MR BUTT:  Thank you, sir.

           3                       Questions by MR BUTT

           4   MR BUTT:  Mr Nott, you were asked if there was any good

           5       reason why senior officers who, for example, discover

           6       the gun or, for example, the taxi wouldn't have it

           7       photographed.  You said you couldn't think of any good

           8       reason why a photographer wouldn't take photos of those

           9       exhibits; yes?

          10   A.  That's correct, yes.

          11   Q.  I am not sure what stage Mr Thomas was talking about,

          12       but if you were being asked about the period before the

          13       Crime Scene Manager attends and before any scene of

          14       crimes officer attends and before any trained search

          15       officer attends; at that stage, the Tactical Firearms

          16       Commander would be in charge of the scene, wouldn't he?

          17   A.  In this case, I would imagine so, yes.

          18   Q.  Yes.  If, for example, a gun was found before any Crime

          19       Scene Manager is there, when all you have are the

          20       Tactical Firearms Commander and the CO19 officers, there

          21       could be a number of other tasks that have to be done

          22       before you begin to think about photographing the gun or

          23       the taxi wouldn't there?

          24   A.  Once a crime scene has developed, effectively it's

          25       locked down and cordons are put in place.  Then the role




           1       of the Crime Scene Manager is to coordinate all the

           2       various aspects that take place afterwards.  There would

           3       be very little reason to do anything I can think of

           4       immediately prior to the arrival of a Crime Scene

           5       Manager and, generally speaking, a Crime Scene Manager

           6       and a photographer, that would be the initial response

           7       to a crime scene whatever it may be -- major crime scene

           8       whatever it may be.  There would be very little reason

           9       to do anything prior to the arrival of a Crime Scene

          10       Manager.

          11   Q.  Absolutely.  Because the Tactical Firearms Commander, in

          12       the minutes after the shooting, is going to be

          13       concerned, as you say, with precisely those points:

          14       putting the cordons in place.

          15   A.  Preserving life is obviously the priority then cordons

          16       in place after that and most police officers, in fact

          17       all police officers, are taught that in various ways.

          18   Q.  So in those very early stages, when the Tactical

          19       Firearms Commander is in charge, all of those are

          20       obviously good reasons that take precedence, for

          21       example, over photographing those items?

          22   A.  Yes.

          23   MR BUTT:  Thank you.

          24   THE ASSISTANT CORONER:  Thank you Mr Butt.  Mr Glasson?

          25   MR GLASSON:  No thank you, sir.




           1   THE ASSISTANT CORONER:  Mr Keith?

           2                      Questions by MR KEITH

           3   MR KEITH:  Mr Nott, you have been asked a number of

           4       questions about the events on 4 August, so may I just

           5       complete the picture through you?  We will no doubt hear

           6       some more from the Crime Scene Manager, Ms Larrigan.

           7           At a scene of this complexity, are there a number of

           8       officers and individuals, entities, who attend the scene

           9       and become involved in its management?

          10   A.  Not really.  The Crime Scene Manager would be overall in

          11       command.  But there may be other people helping him or

          12       her, certainly with the initial examination of the

          13       scene.  And again I go back to it: it may be the

          14       photographer, it may be other scene examiners as well,

          15       but the Crime Scene Manager would be overall in charge

          16       of that.

          17   Q.  You are quite right.  You are looking at it from the

          18       angle, of course, of the crime scene management.  My

          19       question, in fact, was more broadly phrased: at the

          20       scene are there officers from different parts of the

          21       Metropolitan Police, different organisations, all

          22       present and contributing their part to what happens

          23       after a fatal shooting?

          24   A.  Yes, there would be, yes.

          25   Q.  So you just heard from Mr Butt, of course, about the




           1       role of the Tactical Firearms Commander.  There are then

           2       officers who attend by way of post-incident management;

           3       is that right?

           4   A.  Mm.

           5   Q.  The crime scene management?

           6   A.  Mm.

           7   Q.  The scene gets handed over to more and more senior

           8       officers as they arrive.

           9   A.  That's generally the case, yes.

          10   Q.  The Directorate of Professional Standards becomes

          11       involved, that is to say the part of the Metropolitan

          12       Police concerned with investigating?

          13   A.  They did in this case, yes.

          14   Q.  They attended the scene, did they not?

          15   A.  Again I wasn't --

          16   Q.  You don't know?  Don't worry.

          17   A.  I don't know, sir.

          18   Q.  Of course, you have the IPCC.

          19   A.  That's correct, yes.

          20   Q.  Who are the IPCC, Mr Nott?

          21   A.  Independent Police Complaints Commission.

          22   Q.  And did they become involved at such a scene?

          23   A.  Again, I haven't got times -- but I know they did in

          24       this case.

          25   Q.  Yes.  You have been asked about Ms Larrigan's role that




           1       night.  Could you please look at CD483?  It will come up

           2       on the screen.  These are the Crime Scene Manager's case

           3       note log.  If we can just zoom in, please, we can see

           4       there:

           5           "CSM [Crime Scene Manager] Patricia Larrigan; scene,

           6       Ferry Lane; incident, DPS [director of professional

           7       standards], fatal police shooting; victim, Mark Duggan;

           8       SIO, Colin Sparrow, IPCC; DI Suggett, DPS."

           9   A.  Yes.

          10   Q.  When you came to be performing your role on 8 August,

          11       because you had no involvement before then, who did you

          12       regard as the Senior Investigating Officer, the person

          13       in charge of the investigation and ultimately of all the

          14       forensic and everything else?

          15   A.  I think if you refer back to one of the previous slides

          16       you will see the first page of my book 199, which is

          17       representing -- that's Ms Larrigan's version and it was

          18       Colin Sparrow again, IPCC ...

          19   Q.  CD4810, please.

          20   THE ASSISTANT CORONER:  That's yours?

          21   A.  That's mine, sorry.

          22   THE ASSISTANT CORONER:  That's when you're involved on the

          23       8th, 9th and then you are --

          24   A.  Dated the 8th.

          25   THE ASSISTANT CORONER:  Mr Sparrow.




           1   A.  My understanding was Mr Sparrow, IPCC, was the person in

           2       charge.

           3   THE ASSISTANT CORONER:  Why were you involved at all as

           4       a Crime Scene Manager in those days afterwards?

           5   A.  Because -- it's the way the Metropolitan Police works

           6       nowadays.  In an ideal world -- it goes back many

           7       years -- the initial Crime Scene Manager would pick up

           8       a case like this and go all the way through, cradle to

           9       grave effectively.  The system has evolved with some

          10       criticism, in the time since then, and cases like this

          11       do get handed over.  It happens, unfortunately, all the

          12       time.  It's certainly not ideal, in my view, but that's

          13       what happens.  Typically in this situation you've got --

          14       well three Crime Scene Managers involved.

          15   THE ASSISTANT CORONER:  And you take it on into the future,

          16       did you?

          17   A.  Yes, I did.  In this case, yes.

          18   THE ASSISTANT CORONER:  Right the way through to today?

          19   A.  Yes.

          20   MR KEITH:  Each of the Crime Scene Managers had presumably

          21       to fill in a log --

          22   A.  Yes.

          23   Q.  -- and we have seen yours and Ms Larrigan's case note

          24       logs and presumably case scene managers have to go to

          25       bed so there must come some time when there has to be




           1       a handover to a night shift or the next day shift and so

           2       on.

           3   A.  That's the reason that the CSM briefing sheet is

           4       completed.

           5   Q.  So there is a record for whoever takes over when the

           6       shift or the next --

           7   A.  Exactly right, yes.

           8   Q.  -- shift starts?

           9   A.  That's filled in at the earliest opportunity.  Again,

          10       that can -- it can be the next day, mainly because of

          11       the logistics of the way we work.  Initially it would

          12       probably be a verbal handover, in most situations.

          13       Again, that verbal handover would be recorded by whoever

          14       takes that on.

          15   Q.  Picking up that thread and some of the points put to

          16       you, could we look at CD485, please, which just shows us

          17       the early part of the night of the 4 August?  This is an

          18       extract from Ms Larrigan's case notes log.  We can see

          19       then at 19.20, "Call to DI Suggett".  So the Crime Scene

          20       Manager, at that stage, is in, it would seem, contact

          21       with the Director of Professional Standards, the person

          22       who is in charge, in part, of the investigation at that

          23       stage?

          24   A.  That would appear to be part of the notes, yes, that's

          25       correct.




           1   Q.  We can see at the bottom of the page Ms Larrigan herself

           2       attends the scene at 20.54.

           3   A.  Yes.

           4   Q.  So she has been in touch with the relevant people and

           5       coordinating matters from 18.35, but actually goes to

           6       the scene at 8.55 and meets Detective Superintendent,

           7       now Assistant Chief Constable, Mr Cundy of Trident.

           8       And, sir, we've obviously heard about his role and will

           9       hear more in due course.

          10           If you go over the page to CD487, we can see that

          11       she's made, right at the top of the page, an entry

          12       entitled "Scene assessment: initial".  There are

          13       subparagraphs dealing with cordons, scene security, area

          14       around the incident, Ferry Lane; is that part and parcel

          15       of the Crime Scene Manager's role --

          16   A.  That's correct --

          17   Q.  -- to note different areas that need dealing with?

          18   A.  That's correct.  And the reason she refers to it is it

          19       is her initial scene strategy.  That could develop onto

          20       other aspects, but at the time she writes these, that's

          21       what she believes to be the initial priorities.

          22   Q.  At the bottom of the page, we can see:

          23           "IPCC members attend scene."

          24           Mr Mehaffey --

          25   A.  Yes.




           1   Q.  -- is an IPCC investigator.  David Kirkpatrick, also an

           2       IPCC investigator, and a reference there, again, to

           3       Chris Mehaffey and Colin Sparrow of the IPCC whom you

           4       have mentioned being the senior investigator.

           5           Then over the page on CD488, there's a reference

           6       right at the top of the page to a discussion between

           7       them all as to the initial observations and the issues

           8       that arise.  Again we need not take time because

           9       Ms Larrigan will no doubt speak to this in due course,

          10       but since Mr Underwood asked you about these areas, you

          11       can see "issues arising", if you scroll in, please:

          12           "Initial action plan [in the middle of that

          13       screenshot]: recovery of the weapon, recovery of the

          14       radio, removal of the deceased, removal of ballistic

          15       material, cars, positions, [further down the page]

          16       deployments, stills photography, photographer Rankin

          17       ..."

          18           He was one of the photographers, was he not?

          19   A.  That's correct, yes, on the day.

          20   Q.  Then the photography that you've referred to,

          21       "360 degrees, Paul Cowley".  He's the photographer who

          22       took the photography from which we now have the stills

          23       late on that night.

          24   A.  The single still you see later on in the night, that's

          25       correct.




           1   Q.  We have seen one in the jury bundle at page 20.

           2           Then, at 3, "Gun: make safe".  "Forensics" at 4.

           3       "5, recovery of weapon: DC Payne", and so on and so

           4       forth.

           5           So, to the extent that there is an initial

           6       assessment, then an initial action plan and then

           7       a forensic strategy, are those done by the Crime Scene

           8       Manager in isolation or are they done, in your

           9       experience, following and as part of the discussion with

          10       the investigators in charge, namely the IPCC?

          11   A.  Yes, exactly that.  The latter thoughts are exactly

          12       that.  It's done in conjunction with those people that

          13       are present that can give you information that can take

          14       you on to develop the scene.

          15   Q.  CD490, one page further on, please, we see in fact

          16       a heading, do we not "forensic strategy" at point 10.

          17       So are these notes referring to actions, strategy and

          18       discussions with all the relevant people what you would

          19       have expected?

          20   A.  If they had been my notes I would have had something

          21       very similar, yes.  Obviously Ms Larrigan will be able

          22       to enlight [sic] you further as to that.  That forms the

          23       basis of most Crime Scene Managers' logs.

          24   Q.  Then we come forward to your involvement, which

          25       commenced on 8 August, CD4810.  Again, as you pointed




           1       out, the SIO, the Senior Investigating Officer, was

           2       Mr Sparrow.  CD4810.

           3           Over the page, 4811, we can see your first entry in

           4       relation to this case dated 8 August 2011.  You have

           5       told us you were not involved before that date.

           6   A.  No.

           7   Q.  At whose request did you become involved in the scene

           8       management, using that expression loosely?

           9   A.  (Pause).

          10   Q.  If you look at the top line?

          11   A.  "IPCC, Colin Sparrow".  That's Colin Sparrow, the name

          12       next to ...

          13   Q.  You got a call from Colin Sparrow, the IPCC

          14       investigator, and you agreed to meet the people that you

          15       met, including an officer from the Director of

          16       Professional Standards --

          17   A.  At Emperor State Building.  ESB is -- "meeting at ESB"

          18       is Emperor State Building.

          19   Q.  Over the page, page 4812, we can see at 14.00,

          20       2 o'clock, you then went to the forensic service with

          21       Colin Sparrow and Mr Fitzpatrick --

          22   A.  That's right.

          23   Q.  -- again, an IPCC investigator.  And you then carried

          24       out the blood pattern analysis to which you have spoken;

          25       is that right?  If you look further down the page,




           1       "16.30, discussion with Colin Sparrow".

           2   A.  (Pause).

           3   Q.  Then right at the bottom:

           4           "M/V [motor vehicle] minicab to be examined.  EXT re

           5       ..."

           6   A.  "Externally re BPA [blood pattern analysis].  Agree with

           7       Colin Sparrow."

           8           So I had had a conversation with him and that's the

           9       strategy around that vehicle.

          10   Q.  "EXT", what does EXT mean?

          11   A.  Exterior.

          12   Q.  BPA?

          13   A.  Blood pattern analysis.

          14   Q.  Did you examine inside the car on 8 August?

          15   A.  No.

          16   Q.  What was your primary function that day, or rather on

          17       the next day because, I think, you carried out the --

          18   A.  I think you mean the 9th, do you?

          19   Q.  The 9th, you're quite right.  What was your primary

          20       function?

          21   A.  To coordinate the two people to attend who, like my

          22       notes show, the forensic scientist, Andrew Bell, and to

          23       carry out a blood pattern analysis or to examine the

          24       outside of that vehicle and to arrange for the

          25       photographer, Craig Protherow on that particular




           1       incidence, to carry out photography.  I think if you

           2       look at --

           3   Q.  4814, the following page.

           4   A.  The following page, dated 9th, that's the one --

           5   Q.  We can see the reference to Perivale at the top,

           6       Gareth Jones, IPCC.

           7   A.  That was one of the IPCC representatives.

           8   Q.  Mr Bell?

           9   A.  Andrew Bell is forensic scientist and Bill Storey(?) is

          10       one of the crime scene examiners at Perivale.  And the

          11       strategy really around that time is photography, like

          12       I said earlier, it is three-quarters damage, blood

          13       pattern analysis and interior and the forensic

          14       examination to interpret any of the BPA, blood pattern

          15       analysis.  Secure and interpret it.

          16   Q.  The car --

          17   THE ASSISTANT CORONER:  That wasn't just external; that was

          18       internal as well, wasn't it?

          19   A.  Initially, my notes show that was agreed with the IPCC

          20       to be external but ... external agreed with Mr Sparrow.

          21       And I go on to say: no requirement -- on the next page

          22       after that one that you showed --

          23   MR KEITH:  Two thirds of the way down the page.

          24   A.  Page 178, that's 41 -- that's on there: "No requirement

          25       for fingerprints or FDRs", which is Firearms Discharge




           1       Residue.

           2   THE ASSISTANT CORONER:  On the inside?

           3   MR KEITH:  If you look, please, at 179, Mr Nott, this might

           4       help you more, our CD4814 --

           5   A.  Yes, no fingerprint requirement --

           6   Q.  Just pause there, Mr Nott.  Halfway down the page, do

           7       you see: "bio exam"?

           8   A.  Yes.

           9   Q.  Is that the examination by Andrew Bell?

          10   A.  That's correct, yes.

          11   Q.  Underneath that, what two lines are there?

          12   A.  "No fingerprint requirement".  The fact I've bracketed

          13       it means it's been agreed with Gareth Jones and: "No int

          14       DNA requirement"; again, that's been agreed with

          15       Gareth Jones.  And he was an IPCC representative at the

          16       time.

          17   Q.  The function you were carrying out was to attend the

          18       scene, that's to say in Perivale, where the car was, for

          19       the examination to be carried out by Mr Bell?

          20   A.  That's correct, yes.

          21   Q.  But the scope and the nature of any other enquiries was

          22       agreed in advance for (with?) the IPCC and we can see

          23       them there?

          24   A.  Yes.

          25   Q.  Then, on the completion of the bio exam, we can see,




           1       three lines further down: "I looked over vehicle for

           2       ballistic damage, visual light."  What did you mean by

           3       that?

           4   A.  Just using normal light source torches.  We've obviously

           5       got other equipment at our disposal.  For that

           6       examination, a visual examination was all that was

           7       required.

           8   Q.  Photographs were taken, of course.  Can we have CE42,

           9       43 -- just to give you an idea of the range of

          10       photographs -- 46.  They show there the seals that were

          11       on the car when the car came to Perivale; is that right?

          12   A.  That's correct, yes.

          13   Q.  49, 54.  What are those yellow marks on 54?

          14   A.  The yellow marks were put in place by forensic

          15       scientist.

          16   Q.  Mr Bell?

          17   A.  Mr Bell.  Probably to indicate ... areas of possible

          18       blood.  Again, his notes would show that but ...

          19   Q.  57.

          20   A.  Yes.  Again --

          21   Q.  That's a close-up.

          22   A.  It's a close-up of where there's something more than

          23       just a drop of blood, just to show -- that's a scale --

          24       and the letters you see there, AGB/2, would be his

          25       exhibit reference, or so I believe.




           1   Q.  Then at the conclusion of that examination, were the

           2       results handed to the IPCC?  Could you look, please, at

           3       CD6518.  Does that indicate -- it's a note made by

           4       Mr Bell of the exhibits being handed to Mr Jones at

           5       Perivale --

           6   A.  Yes, that's --

           7   Q.  -- on 9 August?

           8   A.  Mr Jones has obviously made -- whatever form those notes

           9       have taken, he's taken possession of --

          10   Q.  We can see Mr Bell --

          11   A.  Sorry, Mr Bell.  And Mr Jones has signed underneath his

          12       notes to show he's received them.

          13   Q.  Where the IPCC are involved in an investigation in this

          14       way, is it usual for decisions, therefore, to be made

          15       about forensics, photographs, ballistics, blood

          16       splatter, moving a car and so on; all to be made with

          17       the assistance of the IPCC or after discussion with

          18       them?

          19   A.  Certainly when they're involved, that would be the case.

          20   Q.  That was the question.  Where they are involved, that is

          21       one of their primary purposes, isn't it?

          22   A.  And any decision -- and action would be in conjunction

          23       with them.

          24   THE ASSISTANT CORONER:  When there's a decision, as in this

          25       case, to allow the vehicle to be returned to the taxi




           1       driver, who takes that decision?

           2   A.  Again, that would be in consultation with the IPCC.

           3   THE ASSISTANT CORONER:  You?

           4   A.  As soon as the forensic aspect is completed -- my

           5       understanding it's been completed -- I will convey that

           6       to the IPCC representative and then they would consult

           7       the SIO or the -- again, the IPCC lead -- and make that

           8       decision then.

           9           It wouldn't be for me to say to return it.

          10       I'd consult other people prior to that.

          11   MR KEITH:  Since you have asked, we will be hearing evidence

          12       in due course from Mr Martin, who is a forensic vehicle

          13       pound officer, who examined the car on the 9th, looking

          14       for valuables or anything that should be put in safe

          15       storage, and then he signed off the release form and the

          16       car was then released to the owner.

          17   THE ASSISTANT CORONER:  It's not so much that.  The earlier

          18       answer, that the Crime Scene Manager exits on right the

          19       way through until today, which I'm afraid I didn't quite

          20       understand.  Other cases have, for example, exhibits

          21       officers who preserve exhibits for courts.

          22           We all know this taxi wasn't preserved and I am just

          23       trying to work out whether Mr Nott can help us about why

          24       we don't have the taxi today, preserved to assist the

          25       jury; can you help us about that or is that for someone




           1       else to answer?

           2   A.  It does vary, sir, in a number of situations.  If the

           3       vehicle -- or if the vehicle is to be returned and it's

           4       somebody's livelihood, it may well be the case that it

           5       is returned to them.  Vehicles do get returned.

           6   THE ASSISTANT CORONER:  Were you aware that I, through my

           7       team, asked for this taxi much earlier on this year?

           8   A.  I wasn't aware of that at all, no.

           9   MR KEITH:  I think we will be hearing more in due course,

          10       sir, about who has the responsibility for determining

          11       such issues.

          12           Do you know, Mr Nott, who took the decision that the

          13       minicab should be moved on 5 August and then for it to

          14       be returned?

          15   A.  At the initial crime scene?  I have absolutely no idea

          16       who made those decisions at all.

          17   Q.  Do you know which organisation made the decision?

          18   A.  My understanding now is it was probably the IPCC who

          19       asked for that to take place.

          20   Q.  Finally, you've been asked questions about the box.

          21       Again, you have been asked a number of different

          22       questions from a number of different angles.  Is this

          23       the position -- could you just please confirm we have

          24       understood the chronology: we have seen in Ms Larrigan's

          25       notes a reference to photography on 4 August.  Was that




           1       Mr Cowley, Paul Cowley; he took photographs -- or rather

           2       examined the minicab photographically and made, I think,

           3       89 photographs that night?  Do you recall?

           4   A.  I believe Paul Cowley did the 360 photography.

           5   Q.  From which stills were taken.

           6   A.  From which this particular still was taken (indicates).

           7       Individual stills, I believe, were taken by somebody

           8       else.  I cannot remember though.

           9   Q.  Mr Rankin?

          10   A.  That's right, yes.

          11   Q.  So in our jury bundle at page 20 we have a still then

          12       from the 360-degree examination recorded on the night of

          13       4 August?

          14   A.  (indicates)  If it looks something like that

          15       (indicates), yes.

          16   Q.  Yes, it does.

          17   THE ASSISTANT CORONER:  There will be other photographs very

          18       similar to that but moved as the machine goes round

          19       360 degrees?

          20   A.  Exactly right, sir, yes, that's exactly what happens.

          21       And that's just taken -- a still from a moving -- well,

          22       a bigger image.

          23   MR KEITH:  That, as recorded in her notes, was part of the

          24       strategy agreed with the IPCC and it was an obvious step

          25       to take, record the scene photographically.




           1   A.  From what I've seen, yes, that's correct, yes.

           2   Q.  Then, of course, there were further more detailed

           3       photographs on 9 August, the ones we have seen,

           4       concerned with the blood pattern analysis on the vehicle

           5       itself?

           6   A.  That's correct, yes.

           7   Q.  As it happens, there was then also aerial photography,

           8       but you were not aware of that, from which we have now

           9       the photograph at page 90 in the jury bundle.  If you

          10       don't know, don't worry, Mr Nott.

          11   A.  No, I wasn't aware of those photographs.

          12   Q.  When you were asked to make enquiries about the box and

          13       the bullet, you contacted, very sensibly, the people who

          14       were concerned with those areas, namely Ms Larrigan,

          15       your predecessor, quarantine manager.  Mr Cockram?

          16   A.  That's correct, yes.

          17   Q.  The second Crime Scene Manager.  No doubt you asked

          18       for, and you examined, all the logs and the case logs

          19       that we've seen?

          20   A.  It was to establish those facts, yes.

          21   MR KEITH:  Thank you very much indeed.  I have no further

          22       questions.

          23   THE ASSISTANT CORONER:  Mr Underwood?

          24                Further questions by MR UNDERWOOD

          25   MR UNDERWOOD:  Just one matter arising out of that.




           1           You told us that the IPCC would be involved, DPS may

           2       be involved and that decisions may be made in

           3       collaboration, if you like, with the Crime Scene

           4       Manager; would that be fair?

           5   A.  Yes, that's -- yes, it's discussion that takes place.

           6   Q.  Let's say you're the Crime Scene Manager at the scene

           7       initially and you got perhaps DPS and certainly IPCC

           8       primacy over this and there are POLSA searchers, and if

           9       those POLSA searchers move seats around, move carpets

          10       around, move boxes about; would you expect the IPCC to

          11       be told of that?

          12   A.  Through the medium of the statement carried out by the

          13       POLSA officers that carried out that task examining that

          14       vehicle.  And, yes, by inference I would say, yes, they

          15       would -- should know about it.

          16   MR UNDERWOOD:  Thank you very much.

          17   THE ASSISTANT CORONER:  We can see -- I don't want to go

          18       through the details of it -- in your report there, on,

          19       I think, 16 August, your meeting with the IPCC at High

          20       Holborn, trying to find out information which can lead

          21       you to better position where the gun was on the grass,

          22       for example.

          23   A.  That's right, yes.

          24   THE ASSISTANT CORONER:  You yourself, operating after the

          25       event, albeit only a few days after the event, didn't




           1       have a clear picture as to exactly where those items

           2       were.

           3   A.  Exactly.  The only photographs I saw didn't actually

           4       identify the position of the firearm.  I was just made

           5       aware of a general shot of a tent and a close-up of

           6       a gun.

           7           The scene -- in most scenes, you would have locating

           8       shots to establish the position of the general area and

           9       then further locating shots taken to establish the gun.

          10           But my understanding at the time, and hence the

          11       concerns I raised, was there was no initial -- no

          12       photographs that I was aware of that actually identified

          13       the position of the gun in respect of the rest of the

          14       scene.

          15   MR UNDERWOOD:  Sorry, to follow up on that, if I may.

          16   THE ASSISTANT CORONER:  Yes.

          17   MR UNDERWOOD:  We've got, in our jury bundle -- there's

          18       a jury bundle in front of you there -- behind

          19       divider 1 --

          20   THE ASSISTANT CORONER:  There's a bigger map there.  Have

          21       a look behind that, behind divider 1.

          22   MR UNDERWOOD:  At about page 12, there should be a fold-out

          23       A3 plan of the scene.

          24   A.  Yes.

          25   Q.  We know that this was taken from a laser survey scan of




           1       5 August, so after the gun had been removed from the

           2       scene.  What we see there, pretty much directly below

           3       the BMW, there's "body", "wall", "plant pot".  We are

           4       given to understand the plant pot represents where the

           5       gun was found; have you been able to bottom that out?

           6   A.  The only photograph I remember seeing showed the corner

           7       of a piece of concrete, I believe, which ... my

           8       understanding -- I haven't been to the scene -- it was

           9       close to that plant pot.

          10           But, like I said, I remember seeing a photograph

          11       with a big tent up and then a photograph which didn't

          12       actually identify the gun in situ which -- in the method

          13       I would have preferred to have seen it recorded.

          14   Q.  What I'm wondering is whether you can help the jury with

          15       this: when the person came to do the laser survey,

          16       whether he was pointed to the plant pot by a Crime Scene

          17       Manager and told, "Trust us, that's where the gun was",

          18       or what.  Do you know?

          19   A.  I have no idea, no.  I have no idea how that came about.

          20   THE ASSISTANT CORONER:  Have you seen that before, that

          21       plan?

          22   A.  Not this one, no.

          23   THE ASSISTANT CORONER:  You haven't?

          24   A.  No.

          25   THE ASSISTANT CORONER:  Thank you very much, Mr Nott.




           1       I would like to give you a copy of that plan to take

           2       away with you, I'm sure we have a spare one or two.  In

           3       exchange, would you leave that much better photograph

           4       behind.

           5   MR UNDERWOOD:  It's remarkable how useful that large map is.

           6   THE ASSISTANT CORONER:  It is, isn't it?  I had noticed

           7       that.  Leave it there on the top, Mr Nott, that's fine,

           8       but you can certainly take away your other notes.  Thank

           9       you for not only coming in and helping us, Mr Nott, but

          10       also doing so at short notice.  Thank you very much for

          11       that.  Very useful.

          12           Thank you, members of the jury, for sitting a little

          13       bit later today but we have been able to complete those

          14       witnesses, so that does complete our work for today.

          15           I will ask for the cameras to be off and then you

          16       are able now to leave us.  10.30 tomorrow morning,

          17       please, all right.

          22   (4.39 pm)

          23        (The Inquest adjourned until 10.30 am on Tuesday,

          24                        29 October 2013)

               DR WILLIAM GLAZEBROOK (sworn) ........................1





                   Questions by MR UNDERWOOD ........................2
                   Questions by MR THOMAS ..........................13
               MS APRIL BARTER (affirmed) ..........................15
                   Questions by MR UNDERWOOD .......................16
                   Questions by MR THOMAS ..........................24
                   Questions by MR STERN ...........................29
               MR DAVID ARNOLD BRENNECKE (statement ................32
           8             read by MR UNDERWOOD)

           9   MR MALCOLM NOTT (affirmed) ..........................42

          10       Questions by MR UNDERWOOD .......................43

          11       Questions by MR MANSFIELD .......................61

          12       Questions by MR THOMAS ..........................81

          13       Questions by MR BUTT ............................87

          14       Questions by MR KEITH ...........................89

          15       Further questions by MR UNDERWOOD ..............106