Death of man following custody – Warwickshire Police, October 2018

On 5 October 2018 Warwickshire Police arrested a man as he had been recalled to prison. The man was taken into custody at Leamington Spa police station where he remained until the evening of 7 October. On that evening the man became seriously ill in his cell and was taken to hospital. A CT scan was performed which revealed that the man had suffered a bleed to his brain. Sadly, the man did not recover and died in hospital on 8 October 2018.

We commenced an investigation following a referral from the police force. Our investigators conducted a detailed investigation which included examining CCTV footage from the custody suite, obtaining accounts from police officers and staff, and liaising with HM Coroner’s Office. The investigation considered risk assessments and the level of care afforded during the man’s period in custody, taking into account relevant force and national policies on detention.

Our investigation found that the grounds for arrest were reasonable, and that risk assessments and observation checks on the man were carried out regularly and in accordance with policies. The custody desk CCTV during the booking-in process and later the cell CCTV did not show the man displaying any visible signs that medical intervention was required, until the evening of 7 October when he became unwell. The man was seen by a healthcare professional on two occasions while in custody for the prescription and administering of methadone. We found no evidence to suggest any use of force, or that the actions of any police officer or member of police staff had contributed to the man’s death.

It was documented that the man had been a drug user and had had underlying health issues for a number of years. A post mortem found that he had died from a brain haemorrhage. At an inquest held in March 2020 a finding was returned that the man’s death was by natural causes.

At the end of our investigation in October 2019, we raised some points of organisational learning for Warwickshire Police, which the force accepted. These included ensuring where CCTV exists that staff handovers take place within sight and sound of a camera and microphone, and that staff are reminded of the importance of recording all actions on the custody log in respect of movement requests for detainees from custody to prison.

During the investigation, there was no indication any police officer had behaved in a manner that would justify the bringing of disciplinary proceedings, or had committed a criminal offence.