Adverse incident in custody - Hampshire Constabulary, July 2017

On 15 July 2017 at 2am a man was brought in to custody by Hampshire Constabulary. Following the booking in process, which included input from a healthcare professional (HCP), the man was placed on the highest observation level – close proximity constant observations – due to his demeanour and admission to having recently consumed controlled drugs.

At approximately 7am on 15 July it was recorded that, after speaking to the HCP, the man’s observation level was reduced to Level 1 with 30-minute checks.

At 9.36pm on 16 July the man pressed the cell buzzer and spoke to staff on the custody desk. He informed them he had just tried to kill himself. A custody sergeant arrived in his cell and found him with a ligature around his neck. The man was immediately put back on the highest level of observations, and it was recorded that the man had made the ligature by ripping his t-shirt. The man remained in this t-shirt.

At 11.45pm an entry in the custody record stated a verbal handover had been given to all custody staff for the following shift and that the man had now been put on the next level down of observations, which was constant observations via CCTV.

At 1.10am on 17 July the man was found unconscious during routine cell checks with a ligature wrapped around his neck. The ligature again was made from ripped parts of his t-shirt. The custody sergeant retrospectively entered in the custody record the man’s observation level had been changed to the lowest level and had been found with the ligature before the custody record and care plan had been updated.

During the investigation, our investigators obtained CCTV footage and statements from several officers and staff who worked in custody on the two days. We reviewed compliance with local and national policies.

During the investigation we found an indication that two custody sergeants may have breached the standards of professional behaviour.

Based on the evidence available we found no indication that any person serving with the police may have behaved in a manner that would justify the bringing of disciplinary proceedings, or committed a criminal offence. However, evidence appeared to indicate that the second custody sergeant had not reviewed important and valuable information, which may have changed their assessment of the man’s risk level and therefore his observation level. We were of the opinion that this would be best addressed through management advice.

After reviewing our report Hampshire Constabulary agreed that the second custody sergeant would receive management action focused on the decision-making and risk assessment process surrounding custody observation levels.

Our investigation also highlighted areas for improvement for the force in their local policy in relation to removing clothing and providing anti-rip replacement clothing for detainees who express suicidal thoughts.