Man dies in custody - Avon and Somerset Police, December 2014

On 28 December 2014, Avon and Somerset Police arrested a man for being drunk and disorderly. They took him to Bridgwater custody suite, where he was taken into a holding cell escorted by three officers.

While in the holding cell, the man began being verbally aggressive and moving around the cell. Officers attempted to sit him down on a bench within the cell. The man fell backwards and slid down toward the floor, banging his head on the wall and the bench. He displayed symptoms of fitting and unconsciousness, resulting in the officers placing him in the recovery position where he remained for ten minutes. The officers did not request any medical assistance.

While the man was in the recovery position, a custody sergeant and custody detention officer entered the cell, and, believing the man to be drunk and being looked after by the three officers, they left. The man remained in the cell for approximately thirty minutes and, following a staff handover, he was then booked into custody by the oncoming custody sergeant.

The officers did not inform the custody sergeant that the man had hit his head, showed signs of fitting or unconsciousness or that he had been in the recovery position while in the holding cell. During the booking in process, the man became verbally aggressive and the custody sergeant requested he was taken to his cell.

CCTV shows what appears to be a struggle between the man and the escorting officers on the way to the cell, resulting in the man being taken to the floor and incapacitant spray being used on him. The man was then carried to a cell and, after being searched by the officers, he was left there alone, unrestrained and face down.

Shortly afterwards, the man became unwell again. An ambulance was called and the man was taken to hospital. The hospital doctor was not informed about him hitting his head, signs of fitting, unconsciousness or that incapacitant spray had been used on him. The man had a pseudo seizure at the hospital and complained of chest pain. Medical tests were conducted, including an ECG, but he was deemed fit to be detained and returned to custody.

On 29 December 2014 the man was interviewed, charged for offences and remanded in police custody to attend court the following morning. That evening, the man complained that he did not feel well. He was seen by a healthcare professional and then returned to his cell. The light within his cell was switched off. Via infra-red CCTV the man can be seen falling off his bed, landing face down onto the floor where he remained for over 3 hours. The custody detention officer recorded that he had conducted welfare checks on the man. However, during this time the custody detention officer could not see within the cell and he did not enter.

On 30 December 2014 at 3am, a custody sergeant conducted a review of the man’s detention. He did not view the cell via CCTV or enter the man’s cell and recorded that the man made no representations as part of the review. The man’s cell was entered around 30 minutes after the review and he was found dead. Cardiopulmonary resuscitation was started and an ambulance called but there were no signs of life.

It was later established that the man had died of a pulmonary embolism.

Our Investigators obtained accounts from the sixty staff involved, which included healthcare professionals, police officers, police staff, hospital staff, and independent witnesses at the scene of his arrest and expert evidence from a cardiologist professional.

We reviewed CCTV from Bridgwater custody for the full time he was in detention, as well as CCTV from the hospital and place of arrest.

Investigators considered relevant national and local policies and procedures.

A referral was made to Crown Prosecution Service 17 June 2016 and no charging decision was authorised.

The investigation concluded that the standards of the three escorting officers, three police sergeants and one member of police staff fell below the expected standards of behaviour.

Three misconduct hearings and a misconduct meeting were concluded by Avon and Somerset Police on 22 September 2017. The outcomes were as follows:

• The custody detention officer was found guilty of misconduct and received a 24-month written warning.
• Three escorting officers were found guilty of misconduct and received no further action.
• One police sergeant was found guilty of misconduct and received a 12-month written warning.
• Another police sergeant was found not guilty of misconduct; no further action was taken.
• One police sergeant was dealt with by way of unsatisfactory performance and was not required to attend a misconduct meeting.

We waited until completion of the inquest, which took place in July 2018, in order to publish our findings.