Independent Office for Police Conduct (IOPC - formerly IPCC)
Printable version

National review of policing a person who is believed to have swallowed items recommended following death of Edir Da Costa

Learning recommendations focussed on how to handle situations where people are suspected to have swallowed items have been issued to the Metropolitan Police (MPS) and College of Policing (CoP) following the death of Edir Frederico Da Costa.

During our investigation, the Independent Office of Police Conduct (IOPC) identified a lack of guidance for police officers on the use of CS Spray when a person was suspected of having an item in their mouth, as well as noting inconsistencies in the guidance provided to officers about how to conduct mouth searches.

We have also made a recommendation to the MPS regarding monitoring of emergency life support training.

The IOPC launched an investigation in June 2017 following the death of Mr Da Costa. We published the findings of that investigation in October 2018 and have continued to work with the CoP and MPS.

We requested the CoP carry out work on the use of CS spray when a person is suspected to have items in their mouth. We noted there is no single agreed medical position on the subject.

A review was conducted by the Medical Director of Forensic Healthcare Services MPS Detention. He concluded that an incapacitant spray is more likely to cause coughing that might lead to expulsion of an object in a person’s mouth rather than a gasp that could see the item slip down into the throat and cause a blockage.

We also made a learning recommendation to MPS that they monitor whether officers have received up to date Emergency Life Support (ELS) training.

The MPS provided assurances that all officers have been reminded it is their personal responsibility to make sure their ELS training is up to date and this will be reviewed as part of their annual performance and development reviews. Noncompliance will be monitored and raised with managers monthly.

In the early stages of our investigation we also informally recommended that guidance to officers about how to conduct a mouth search be made consistent nationally.

MPS suspended the use of mouth searches as a result and requested a medical review be undertaken. The CoP has amended their guidance as a result of the medical review to incorporate its findings.

IOPC Regional Director Sal Naseem recently said:

“The death of Mr Da Costa is a tragedy and my sympathies are with all involved. It is critical we share the insights we gain from our investigations and consider what can be done to prevent such incidents from occurring in the future.

“In this case, we made recommendations to better support decision making and practice by officers and to encourage work to be done to provide clarity around an area of policing at national level. The response from the MPS and the CoP has been hugely positive and demonstrates the type of systemic change which can be achieved through the learning we identified and, importantly, a collegiate approach. The fact Mr Da Costa sadly died in this incident demonstrates the huge dangers in trying to conceal items in this way from police and the potentially fatal consequences.”

We have also published our final report and rationale summary


Channel website:

Original article link:

Share this article

Latest News from
Independent Office for Police Conduct (IOPC - formerly IPCC)

Secure cloud collaboration, view the short video demonstration here