Investigations into the circumstances surrounding the death, on 17 March 2003 of a man who was crushed when gates at Strabane Police Station closed on him has found no evidence to suggest any police officer was to blame.
It concluded that at some point ' an unauthorized, unknown individual' had carried out work on the gates, which prevented their safety mechanism from working.
The Police Ombudsman investigated the issue of any possible police misconduct, which might have contributed to the man's death, while the Health and Safety Executive considered the issues surrounding the safety of the gates.
The Police Ombudsman, Mrs. Nuala O'Loan, found no evidence to link any individual police officer to the problems with the gate. She said the officers on duty that night did not bear responsibility for the death but said that the PSNI as an organization was guilty of corporate failure in their duty to maintain the gates so that they operated safely, a failure, which had terrible consequences.
The investigation established a series of major electrical problems with the gates -
- the gates were fitted with four safety strips on the rubber edges, which were designed to prevent them closing when there was anything between them. The strips were last certified as working correctly in May 2002. At some stage the strips were disabled.
- the gates continued to move for about six inches after the open/close buttons were released;
- the person who pressed the button could not see the gates opening or closing and had to rely on a monitor;
- the gates had an ongoing problem of oil leaking from the hydraulic system and there was an emergency cut-off switch located near the gates, but access to it would have been difficult because it was blocked by a trailer containing sand used to cover the oil spillages from the gates;
- the lighting was poor around the gates and the operator was therefore unable to see clearly what was going on; at night he relied on the sound of the gates closing together to let him know that they were shut.
THE ACCIDENT
The man died from injuries he received in the early hours of March 17 2003 when he was caught in the electronic gates at the vehicle entrance to the station as they closed on him. He had been among a crowd of between 15 and 20 people, some of whom chased a man towards Strabane Police Station, where outside its gates they kicked him, punched him on the head and threatened to kill him.
Seeing the attack, a police officer rushed to the station gates, which were opened for him, and confronted the crowd. When they refused to stop the attack, the officer tried to grab the victim and pull him into the base to safety. Several men kept hitting the man as the police officer tried to pull him inside. The officer managed to get the intended victim inside the gates but at least two other men got in too. A civilian employee pressed a button to close the gates. He could not see what was happening as the gates closed.
One of the men tried to run back through the gates but was caught between them as they began to close. The police officer, seeing what had happened, shouted to his colleague to open the gates again and banged on the safety mechanism on the gates four or five times with his fist to stop them closing. Because the safety mechanism had been disabled the gates continued to close and the man was crushed by the gates. Police officers at the scene gave first aid but he died shortly afterwards in hospital from his injuries.
Police Ombudsman investigators were called immediately to the scene, which had been cordoned off. The area was forensically examined and CCTV in and near the police station was seized. Statements were taken from police officers involved and from people who had been in the crowd. The people in the crowd had been drinking and there were discrepancies in their accounts of what happened, the order in which it happened and in the timing of events. Paperwork completed by various contractors who had worked on the gates was examined.
THE GATES
In August 2002 an engineer, who had been asked to look at reports of a 'faulty button', was told that the safety edges of the gates were not working, and he found additional wiring in the gates' control panel, which appeared to have the effect of bypassing their safety edges. The man said he was not qualified to deal with this and assumed that someone else was carrying out work on this part of the gates. He could not recall if he told anyone about what he found. He did however record it on his job sheet.
In November 2002 a police officer reported the problem with the gates to the PSNI civilian employee responsible for arranging work to be done on the gates. An engineering company was contacted the following day, but claim it was only requested to do work on the pedestrian gate, not the main gate. There are no records to prove or disprove this.
In January 2003 another engineer working on the gates also noted this problem in his reports on two separate occasions, but said he did not have the material or expertise to fix the problem. He reported the matter to the PSNI. The PSNI Estates Officer notified the maintenance company on the first occasion and was told that the response time would be five days. The engineer attended eight days later but again could not repair the fault and states that he recorded this in his repair sheet.
CONCLUSION
There is no evidence or any suggestion that the work, which caused the failure of the safety mechanisms on the gates, was carried out by a police officer.
There was clear failure by the PSNI to ensure that the gates had an operational safety mechanism. The Police Ombudsman concluded, "no portion of blame can or should be attributed to any one individual officer." The Health and Safety Executive for Northern Ireland's investigation was unable to identify which individual or individuals were responsible for bypassing the sensors. It is still considering what if any charges should brought against the PSNI corporately.
The Police Ombudsman concluded that the fault had been identified in August 2002. It was reported to the PSNI on a number of occasions, and while the contractors were notified on a number of occasions the gates were not fixed.
"Ultimately, no one took responsibility for ensuring that the critical work to rectify the situation was done. There clearly was a corporate failure by PSNI in that they did not have adequate systems to ensure that the gates were made safe.
"The two people on duty were confronted with a situation on the night in question which required quick thinking and a positive response. Their actions did not reflect any degree of human error. They have quite simply been let down by a failure within PSNI, as an organization, to properly manage and maintain vital electrical equipment.
The actions of the other police officers that night who gave first aid and tried to save the man's life were swift and professional," said Mrs. O'Loan.
The Police Ombudsman has made a series of 16 recommendations designed to ensure that the gates at the Strabane station are made safe and that there are no similar problems at other stations. The Police Ombudsman also recommended a more stringent system for overseeing the work of subcontractors brought in to do work in police stations.