CIEH Training 19 September 2017 Newport Pseudomonas Outbreak 2015
Blue Voodoo / Sun Tattoo / Flesh Wound Blue Voodoo Tattoo opened at 92 Commercial Street in 2013 Moved to 83 Commercial Street in February 2014 Registered by John Cochran for tattooing and cosmetic piercing
Skin Piercing Practitioners John Cochran Registered for tattooing and cosmetic piercing CW- Cosmetic Piercing Registered for cosmetic piercing Offered 2 piercings for 10 Apprentices Several Apprentices carrying out duties at premises No skin piercing activities None registered with NCC
Referral from Public Health November 2014 Wales ENT specialist informed Health Protection Team of increase in cases being admitted to Royal Gwent Hospital for infected piercings- all had been admitted for Pseudomonas infections 4 females had been admitted in October/November 2014 Linked to the same premises- Blue Voodoo, Newport Case finding exercise undertaken
Post Piercing Infections Case Age Date of Date of Date of Site of Piercing onset admission piercing Case 1 17 04.08.14 11.08.14 20.08.14 Helix and Anti-Helix LA of residence Newport Case 2 16 27.10.14 29.10.14 11.11.14 Helix Newport Case 3 18 13.11.14 (approx.) Case 4* 15 02.08.14 07.08.14 (approx.) Female 1** 15 10.05.14 14.05.14 (approx.) 21.11.14 28/11/14 Scaffolding & Neck Blaenau Gwent 12.08.14 Helix Newport 19.05.14 Nipple Newport Female 2*** 17 18.10.14 24.10.14 31.10.14 Tragus Newport Female 3**** * Case 4 came forward following press release in May 2015 ** No swab results were available to confirm whether it was/was not a Pseudomonas species infection *** Female 2 would not co-operate with NCC s investigation **** Female 3 could not be contacted by the HPT following hospital discharge
Ear Piercing Locations
Case Photos
Case Photos
Case Photos
Case Witness Statements In depth witness statements required Including descriptions of everyone involved in piercing Aftercare advice given and what they actually did Experience of having piercings in the past Photographs Hospital Treatment Victim Impact Statements Access to medical records Statements also provided by parents for some cases
Investigation of Cases Site visit undertaken: Inadequate sterilisation Use of ultrasonic cleaners inadequate Using re-usable metal equipment etc, etc, etc Prohibition Notice Served
Collection of Evidence Customer consent forms: Approximately 1000 forms No suitable copying facilities on site Sections 20(2)(k) and 20(2)(m)- Notice to Identify Original Documents taken into possession for copying
Who was in control? John Cochran Registered premises as Blue Voodoo then changed name of premises to Sun Tattoo Studio Previously registered in Brighton and Paignton/Torquay areas CW Operated cosmetic piercing element of business- Flesh Wound John Weston Paying business rates for premises Named as tenant on tenancy agreement for 83 Commercial Street During visit informed by John Cochran that John Weston was not involved in business
CW- Cosmetic Piercer Following service of PN, in December 2014 informed that cosmetic piercing no longer taking place at premises On follow up visit Officers were informed that CW had moved to Bristol and had nothing to do with the business No forwarding address provided
Who is John Cochran? Informed us that he was closing shop and leaving area Would not provide home address details- lived in a campervan Suspicions that John Cochran was John Weston What next??
PACE Code G Police can arrest if requirements of Code G are met: Elements of Arrest under Section 24 PACE Person s involvement or suspected involvement or attempted involvement in the commission of a criminal offence AND Reasonable grounds for believing that the person s arrest is necessary BOTH ELEMENTS MUST BE SATISFIED
PACE Code G Criteria for believing arrest is necessary in this case: Person was suspected of involvement in a criminal offence To enable the name of the person in question to be ascertained (JC only) To ascertain the person s address. Also, grounds to doubt an address given when previously requested To allow the prompt and effective investigation of the offence. Unless the person is arrested and taken into custody the investigation of the offence would be frustrated, unreasonably delayed or otherwise hindered. Also, unlikely that the person would voluntarily attend interview To prevent any prosecution for the offence being hindered by the disappearance of the person in question
Friday 13 th..unlucky for some Gwent Police satisfied that criteria for arrest was met Officer from Gwent Police arrested both John and CW. On arrest, John provided name John Weston Conveyed to Newport Central Police Station and put in cell Assessed at Station to determine whether they could be interviewed Appropriate Adult Interviewed under caution by NCC Officers Released on bail with conditions and had to sign weekly at Newport Central Police Station Questioned two further times under caution at the police station
And we still don t know his name.. Under caution confirmed he changed name from John Weston to John Cochran 3 years ago, but no evidence at this stage At a later date a change of name deed poll record was submitted to show change of name from John Western to John Cochran.where did Western come from?? Denied carrying out any cosmetic piercing at 83 Commercial Street
Identity of John Cochran / Weston / Western Case 2 gave description of person who carried out her piercing: The man was older I think he looked over 50. He was wearing glasses, had tattoos on his arms and neck. He had short hair which was receding on the top. He was average build and had a goatee. Case 2 consent form obtained from premises named John as carrying out piercing When put to him in interview, John continued to deny carrying out any cosmetic piercings
Identity Parade Image of John Cochran taken by Gwent Police Worked with South Wales Police Identification Unit, Cardiff Bay Parade compiled using international database - approx 40,000 images System retrieved 9 images for Witness to use to identify defendant Resulted in positive identification of John Cochran/Weston Identification Unit provided Witness Statements for entire process
Information for Identity Parade Very detailed description in form of witness statement of Defendant Include: Time of day Lighting levels Weather conditions Description of person, including: age, height, build, skin colour, hair style and colour, distinguishing features etc
CW- Cosmetic Piercer Appropriate Adult required during interviews Needed to consider this throughout interviews- regular breaks, signs of distress/triggers Change in circumstances throughout investigation Social Services
Appropriate Adult Role of an AA Safeguard providing independent support to detainees who are: Aged under 17, or Vulnerable Adults (mental illness, learning disabilities, brain injuries etc) They are NOT simply an observer. Their role is to assist the interviewee to ensure that they understand what is happening during the interview and investigative stages. In particular, they should: Support, advise and assist the interviewee; Ensure that the police/ interviewer acts fairly and respect the rights of the detainee Help communication between the interviewee, the police and others The AA is NOT there to provide legal advice
Interviewing at Police Station Officer needs to have User Name for the system. At Newport we needed to log on via a laptop in the interview room All interviews were video recorded- no tapes, CD s etc. Need to obtain copies of discs from Central Office to enable transcript to be done Interview script will need amending to fit with Police station interview Present case to Custody Sergeant- they will decide whether to bail
Charging of Defendants Planning on charging at Police Station following final interview, however, need to check scheme of delegation Also, difficult to get offences put onto police database
Court Case Originally pleaded not guilty at Magistrates Court Case scheduled for 3 week trial at Crown Court Appointment of Experts- Body Piercing & Epidemiologist Special Measures- evidence from Belfast via video link and separate room for under 18 case
Court Hearing John Weston agreed to plead guilty on basis that charges against CW were dropped. Agreed to present no evidence in CW case following advice from Counsel Sentenced to: 16weeks custodial, suspended for 2 years 150hours unpaid work Curfew of 18:30-06:30 to reduce liberty (covered Christmas & New Year period) Registration with Newport CC revoked
Operation Seren Public Health Wales, Aneurin Bevan University Health Board and Newport City Council Offered Hep A, Hep B and HIV tests to persons who had received treatments at 83 Commercial Street 841 people in total tested
Operation Seren- the cost Total cost of locating and testing individuals was 240,159 Equivalent to: 35 Hip Replacement Operations 16,666 Carbon Monoxide Alarms 8 Full Time EHO s for 1 year
Technical Report Operation Seren Report