Adverse incident in custody - Hampshire Constabulary, March 2018

On 18 and 19 March 2018, a man detained by Hampshire Constabulary at Portsmouth Central custody suite made multiple attempts to self-harm by tying items of clothing round his neck. The last attempt resulted in him being found unresponsive by custody staff, who then managed to rouse him.

During our investigation we considered the custody CCTV, custody record log, and written responses from two members of custody staff and a witness.

The evidence confirmed that the man’s observation level was reduced from level three to level one by the police sergeant at approximately 10.24pm as a result of the man having calmed down and fallen asleep. In view of the man’s well documented history of self-harm in custody and attempts to self-harm when arrested, we were of the opinion that level one observation was not appropriate, and not in keeping with the force’s procedure. Following the man attempting to self-harm on multiple occasions, there was no custody officer review of the risk to the man and no increase to his level of observation.

Evidence also indicated that the police sergeant failed to keep the custody record appropriately updated and may not have fully assessed and reviewed the ongoing risk to the man, which is against policy/guidance. However, as the man was in a CCTV cell and checked every 30 minutes overnight, we were of the opinion that this wasn’t so serious as to amount to misconduct, and that the officer’s performance issues could be dealt with by means of management action. The same officer also left some items of clothing in the man’s cell that could be used as ligature. There is no set policy regarding retention of clothing by detainees, and we were of the view that this could also be dealt with by way of management action.

Evidence also indicated that a detention officer did not inform the custody sergeant that the man had attempted to self-harm. This had already been dealt with by the force through management action soon after the incident.

After reviewing our report the force agreed that the performance of both officers had been unsatisfactory and that they would receive (or had received) management action.