Death in custody – Kent Police, June 2021
In July 2021, a woman died in the custody suite at Tonbridge police station in Kent.
Our investigation, which began following a mandatory referral from the force, looked at the contact Kent Police had with the woman following her arrest on 23 July and during her subsequent detention at Tonbridge station until the following day, when she was found unresponsive in her cell by a custody staff member.
We also examined the level of care she received in custody and whether this was in line with local force policy and national guidance.
During the investigation we obtained accounts from custody staff and officers who had contact with the woman. Custody records, body worn video footage and CCTV footage were reviewed. A pathologist’s report was provided, which included toxicology results. Local and national police policies and guidance around care of detainees were also reviewed.
Our investigation found that when she was processed at the station, officers recorded that she was under the influence of “alcohol/substance”. She also alleged that she had been assaulted but did not initially state she had any injuries.
Between 10pm on 23 July and 12.57pm on 24 July, when the woman was found unresponsive in her cell, at least 35 observation checks by custody staff were recorded on the custody log, many of which were brief checks through the spy hole.
On the morning of 24 July, the woman spoke with a custody nurse and she was given paracetamol after complaining of a headache and saying she felt hot. After being found unresponsiveness during a cell check, custody officers immediately provided CPR and requested an ambulance. Paramedics arrived and provided first aid at the custody suite however she was sadly pronounced deceased shortly before 2pm.
An inquest in November 2023, concluded that the woman died as a result of a serious infection and while she gave contradictory reports of her condition, her death was probably contributed to by the absence of medical intervention at least five hours prior to her death.
In August 2021, during the early stages of our investigation, we issued Kent Police with a learning recommendation that the force should take urgent steps to ensure custody staff adhere to the College of Policing’s authorised professional practice (APP) relating to Detention and Custody. In particular, we highlighted the levels of observation and cell checks for those who are under the influence of alcohol and drugs.
We also said the force needed to remind custody staff that welfare checks through spyholes are not an acceptable welfare check and recommended that the force review whether current monitoring systems were sufficient to ensure that custody staff were adhering to the APP. The force agreed with our learning recommendation and advised they would take steps to implement it.
We concluded our investigation in July 2022 and determined that a custody officer – a police sergeant – had a case to answer for misconduct for the observation level they set the woman when she was booked into custody. Following an appeal, the misconduct finding was overturned and the officer was instead referred to the reflective practice review process (RPRP).
We also found performance issues for three officers - relating to the standard of cell checks or reviews they completed and their risk assessment of the woman – and performance issues for another officer and a detention officer, relating to how they assessed, reported or recorded information the woman disclosed to them. These officers underwent RPRP.