Findings from investigation into the death of Miranda Stevenson’s death in custody

On 30 May 2015 at around 3am, Surrey Police arrested Ms Stevenson for entering premises which were subject to a closure order and was taken to Guildford Police station and she remained in police custody.

During the morning she became unwell and was seen by a health care professional (HCP). At lunchtime she had deteriorated and after a further assessment she was taken to hospital for medical treatment at 1.31pm.

By the early evening the hospital staff had assessed her as being clinically stable and she returned to police custody. At approximately 9.24pm, she was charged with the offence of breaching a closure order, but was denied bail and was informed that she would remain in police custody for another two nights and would attend court on 1 June.

Throughout her detention, numerous welfare checks were recorded on the police custody record by police staff and police officers. At around 7.25am on 1 June, sadly Ms Stevenson was found deceased in her cell.

The incident was referred to us by Surrey Police as a death or serious injury matter and we started our independent investigation. During the investigation we focused on the actions from three custody sergeants and six designated detention officers (DDOs) whose care Ms Stevenson was in whilst in custody. All nine officers and staff members were notified that their actions and conduct was under investigation. We interviewed the police officers under misconduct and criminal caution, and they provided prepared statements. Staff were also interviewed under a disciplinary caution.

In our investigation we reviewed the custody site CCTV, examined relevant policies procedures and legislation to establish whether officers and DDO’s had complied with them. We also reviewed the processes, responsibilities and custody roles within Surrey Police as well as looking at the training officers received to conduct custody roles.

The evidence showed that Ms Stevenson was initially placed on 30-minute general observation welfare check. The welfare checks were recorded on the custody record. Ms Stevenson was checked every 30 minutes by a number of different DDO’s. The checks varied in how they were carried out, with some via the cell door spy-hole only, some via opening the cell door, others via opening the cell door hatch. The length of time the checks were conducted for were also varied – some taking only a few seconds.

At 8.41am on 30 May the Health Care Professional (HCP) examined Ms Stevenson and provided her medication as she was suffering symptoms of an acute opiate withdrawal. Ms Stevenson asked to see the HCP again after a few hours as she had been experiencing stomach cramps. At that stage the custody sergeant decided Ms Stevenson was to remain on general observation 30-minute welfare checks and also stipulated she be monitored on CCTV from the bridge.

The HCP stated he examined Ms Stevenson for the second time at 11.20am in her cell and at that point he referred her to the hospital. The custody record showed from that point onwards Ms Stevenson was placed on constant observations. The CCTV footage showed Ms Stevenson was constantly observed until she was escorted to hospital a couple of hours later.

Ms Stevenson returned from hospital at approximately 6pm. On her return the custody sergeant consulted with the HCP. CCTV footage showed that the HCP assessed Ms Stevenson at 6.18pm and recorded on the custody record that she was “normal and stable”. It was decided that Ms Stevenson was fit for detention and placed onto 30-minute general observation welfare checks with additional CCTV monitoring.

At approximately 9.40pm the HCP examined Ms Stevenson and recorded that she was in withdrawal. He prescribed medication for alcohol and opiate withdrawal and a medical review was set for 4am the following morning. At that time she was asleep and the advice was to not wake her from the HCP. When she was awake, he stated he would complete his review then.

At 7.52am an HCP examined the woman and gave her further medication for alcohol withdrawal. She was further seen by an HCP again at 5.15pm and again given medication.

On her second day in custody, Ms Stevenson’s care plan was updated and showed she had been taken off CCTV observations as there was another high-risk detainee who required a higher observation level. It was judged that she remained a medium risk and remained on 30 minute general observation welfare checks, and throughout the day she was checked by several different DDOs with the same variation of method and duration as the day before.

At approximately 7.17pm, the CCTV footage confirmed that one of the custody sergeants conducted a visit to the cell. He explained that he watched the woman’s elbow to discern any movement. He clattered the hatch to see if she re-positioned herself as a result of the noise. He confirmed he saw her move. The CCTV footage confirmed the custody sergeant appeared to look through both the spy hole and the hatch.

Several DDOs and a custody sergeant made checks throughout the evening and the night. They all recorded that woman was asleep and breathing. The evidence indicated that majority of these checks were made using the spyhole, rather than the cell door hatch.

The CCTV footage indicated that Ms Stevenson stopped breathing at approximately 7.30pm. This indication was confirmed by two pathologists who viewed the CCTV footage.

At 7.15am the next morning, the HCP and a DDO went to the cell to provide medication to Ms Stevenson. They found her unresponsive with no signs of life. A post-mortem identified the probable cause of death as sudden death during alcohol and drug withdrawal.

The IOPC investigation found shortcomings in Surrey Police’s training in relation to how staff and officers were supposed to carry out cell checks. The use of spyhole checks had incorrectly been trained when national guidance stated they should not be used.

The Police Authorised Professional Practice (APP) custody guidance states that staff conducting a welfare check through the cell spy hole is not acceptable. The guidance does not set out the length of time a welfare check should be conducted for, however it is the responsibility of the person conducting the check to ensure they are satisfied they can record accurate observations.

On the evidence available, the IOPC determined that one custody sergeant and six DDOs had a case to answer for gross misconduct in that they failed to carry out welfare checks in line with the guidance and failed to identify that Ms Stevenson was deceased for approximately 12 hours.

All the evidence gathered was sent to the Crown Prosecution Service (CPS) to consider possible criminal charges. In January 2018 the CPS decided there was no criminal case to answer. The woman’s family exercised their right to review and in the autumn of 2018 the CPS decided there would be no further action.

Surrey Police reviewed the IOPC report and they agreed with the recommendation that the six DDOs should face disciplinary hearings. There was not agreement in relation to the custody sergeant who eventually attended a misconduct meeting.

At the disciplinary hearings the cases against the DDOs were found to be proven. Three DDOs received final written warnings, the other three DDOs had left the force before the hearings took place.

At the misconduct meeting, the case against the custody sergeant was found to be proven and she was given management advice. This sanction remained after an appeal process.

The inquest into Ms Stevenson’s death took place in early 2020. The inquest verdict recorded that the cause of death was related to alcohol and/or drugs.