Man dies on way to custody - Thames Valley Police, November 2017
On 24 November 2017, Thames Valley Police was called to a disturbance in Oxford where a man had allegedly assaulted two people and was in possession of a knife.
Officers spent several hours searching for him. At one point they stopped and searched the man they were looking for, however, they did not believe it was the right person at that time and let him go.
Officers later located the man again and arrested him for assault and possession of a bladed article. The man resisted arrest and officers used force to restrain him. Officers placed him in the back of a police van and took him to a police station.
En route to the station, the man became unresponsive. The officers pulled over, took the man out of the van, called an ambulance and began first aid. The ambulance arrived and took the man to hospital, where he subsequently died.
Our investigators attended post-incident procedures and seized or secured evidence from the officers involved in the incident.
During the investigation, our investigators interviewed the officers involved in the search, arrest, restraint, transport and first aid given to the man. They obtained and analysed various evidence, including video footage, witness statements, medical records, radio transmissions, expert reports and relevant policies/legislation.
Investigators found indications that five officers might have behaved in a manner which could have breached the police Standards of Professional Behaviour and may have a case to answer for misconduct. Four were interviewed regarding the allegation that they may have failed in their duty to safeguard the man’s welfare. A fifth officer provided a written response to the allegation that they failed to be diligent in their duty to appropriately supervise the officers concerned and protect the integrity of the evidence-gathering processes after the incident.
Evidence indicated that two of the officers suspected that the man may have put something in his mouth and asked him whether that was the case, and to open his mouth. We were of the opinion that, at that point, the officers should have either conducted a search of the man’s mouth or, if he was unco-operative/resistant to that, then conveyed him to hospital as soon as possible – rather than take him to a police station in a police van.
Based on the evidence available, we were of the opinion that both officers may have a case to answer for misconduct. We recommended that one of them receive management action and that the other one, who had assumed a ‘lead role’ during the incident, should attend a misconduct meeting.
We were also of the opinion that the fifth officer’s decisions to allow the officers to travel together, without explicitly explaining the non -conferring rules, and to allow one of the officers to switch off their body-worn video before the post-incident procedure were inappropriate and did not follow guidance. We were of the view that the officer may be considered to have a case for misconduct, and that this could best be addressed through management action.
Based on the evidence available we found no indication that that the other two police officer may have behaved in a manner that would justify the bringing of disciplinary proceedings.
The medical expert who analysed the first aid provided to the man by officers identified a number of areas for improvement for Thames Valley Police, such as the early use of defibrillators, airway management and cardiopulmonary resuscitation. We included these in our report to the force.
We identified some areas of learning for the force and made some recommendations (see below).
We completed our investigation in December 2018.
After reviewing our report, and a further exchange of correspondence, Thames Valley Police agreed that two officers would receive management action, and another one would attend a misconduct meeting.
At the meeting, held in June 2019, an independent panel found misconduct to be not proven. The panel chair believed that the officer had an ‘honestly held’ belief that the man didn’t have anything in his mouth, and that officer had carried out an ongoing risk assessment. No further action was taken against the officer.
At the inquest into the man’s death, held in summer 2019, the jury delivered a narrative conclusion stating that the man had died as a result of cardiorespiratory arrest caused by intoxication from alcohol, cocaine and morphine.
IOPC reference
Recommendations
Information about a previous drug-related incident involved the same individual as this case had not been put on his Police National Computer (PNC) record. While it did not materially affect this case, awareness of this information could potentially have affected the police response to his behaviour. This type of information could also have material bearing on cases in future with other individuals. The IOPC recommends that Thames Valley Police (TVP) update their policy/guidance to clarify when drug-related incidents should be updated on to an individual’s PNC record.
Do you accept the recommendation?
Yes
Accepted action:
In March 2016 [a man] had presented to hospital in Oxford reporting that he had ingested heroin and cocaine; he absconded from hospital, which was reported to the police who brought him back and arrested him. [The man] refused a further scan, stating that he had vomited up the drugs. Following medical opinion that he no longer had drugs in his body, he was de-arrested. This did not lead to a warning marker being placed on PNC and therefore this information was not provided to the arresting officers in November 2017. During the March 2016 incident [the man] was never taken to a police custody suite. The application of PNC warning markers has mainly been the responsibility of Custody Officers, however increasingly individuals are dealt with by police without passing through custody (for example those detained under the Mental Health Act). TVP has issued updated guidance to all officers reminding them that, where a person is not brought into custody but they identify information that would assist in managing risk to the individual, the wider public and police officers they must ensure appropriate Warning Markers or Operational Information are applied on PNC. The process to achieve this has been amended to make it less bureaucratic. We will bring these recommendations to the attention of Force Evidence Manager, Learning & Development Department & PIM Co-ordinator (DCI) to undertake further learning distribution (amendments to policy, CPD events, supervisory training etc.) where necessary.
Officers in this case were not separated and were permitted to turn off their body-worn video (BWV) for the journey to the police station for the post incident procedure. This means that there is no record of any discussion that may have taken place during this time. The IOPC recommends that Thames Valley Police (TVP) update their policy/guidance to reflect the statutory guidance issued recently by the IOPC to ensure that where key policing witnesses are not separated, alternative measures are taken to ensure demonstrable integrity of their evidence and a transparent process.
Do you accept the recommendation?
Yes
Accepted action:
In March 2018, Thames Valley Police issued the following broadcast to officers and staff; Post Incident Procedure (PIP) – Body Worn Video (BWV) usage Thursday 22 March 2018, 8:51am This Post Incident Procedure (PIP) is an established response to the action or perceived inaction of the police resulting in the death of, or serious injury to, another, has revealed failings in command or has unduly placed an officer or member of the public in danger. There is a positive obligation to ensure that all activity relating to the recording of accounts is transparent, auditable and capable of withstanding scrutiny. You are reminded that, where possible, those who may be considered or identified as Key Police Witnesses (KPW) should not confer in the post incident phase and where practicable, be separated or be accompanied by an officer(s) not directly involved in the incident until they arrive at the designated PIP venue. Those who are in possession of Body Worn Video (BWV) should continue to record all post incident activity until they arrive at the designated PIP venue; if the initial incident was not captured, they should start recording at their earliest opportunity. Any escorting officer(s) in possession of BWV should start recording from their initial interaction with the KPWs through to handover at the designated PIP venue Thames Valley Police has now issued new operational guidance that specifically addresses the recommendations.
Evidence in this case suggests that all officers could have benefited from more comprehensive and clear advice regarding conferring and the use of body-worn videos. The IOPC recommends that Thames Valley Police (TVP) considers how it can ensure that first line supervisors are able to give effective and appropriate instructions to officers immediately following a death or serious injury and that their role and responsibilities in this process are clear.
Do you accept the recommendation?
Yes
Accepted action:
In March 2018, Thames Valley Police issued the following broadcast to officers and staff; Post Incident Procedure (PIP) – Body Worn Video (BWV) usage Thursday 22 March 2018, 8:51am This Post Incident Procedure (PIP) is an established response to the action or perceived inaction of the police resulting in the death of, or serious injury to, another, has revealed failings in command or has unduly placed an officer or member of the public in danger. There is a positive obligation to ensure that all activity relating to the recording of accounts is transparent, auditable and capable of withstanding scrutiny. You are reminded that, where possible, those who may be considered or identified as Key Police Witnesses (KPW) should not confer in the post incident phase and where practicable, be separated or be accompanied by an officer(s) not directly involved in the incident until they arrive at the designated PIP venue. Those who are in possession of Body Worn Video (BWV) should continue to record all post incident activity until they arrive at the designated PIP venue; if the initial incident was not captured, they should start recording at their earliest opportunity. Any escorting officer(s) in possession of BWV should start recording from their initial interaction with the KPWs through to handover at the designated PIP venue Thames Valley Police has now issued new operational guidance that specifically addresses the recommendations.