Death in custody – Metropolitan Police Service, September 2021
We began an independent investigation in September 2021 after we were notified by the Metropolitan Police Service (MPS) of a man who became unresponsive in custody and died that evening.
We established that at approximately 5.40pm on 4 September, two MPS officers were conducting proactive patrols in plain clothes in Leyton. They stopped a man and one of the officers searched him on suspicion of drug possession. He was handcuffed to the front and the officer found a small package containing a white substance and subsequently arrested him on suspicion of possessing a class A drug.
When putting the man into the back of a police van an officer noticed he put his hand in his pocket. The officer then searched the man inside the police van but didn’t find anything. The officer did not notice the man putting his hand to his mouth during this search. After the van doors were closed, the van CCTV footage showed that a bulge appeared in the man’s cheek.
The officer didn’t see this during the journey to Leyton Custody Centre.
After arriving at the custody centre, officers noticed that the man had something in his mouth and asked him to open it. When the officers saw something, they instructed him to spit it out.
Officers took the man down to the floor where he became unresponsive and the London Ambulance Service was called, while officers provided CPR.
The man was pronounced dead at the custody suite shortly after 8pm.
Our investigation looked at the police interaction with the man prior to his death including his search and arrest, the actions of officers and custody staff during and after his transport to custody and whether their actions were in line with local and national policies.
As part of our investigation, we reviewed police body worn footage as well as CCTV footage from the police van and custody suite. We obtained and reviewed statements from the police officers involved and reviewed relevant police policies, training and guidance.
A post-mortem report identified that he died due to an obstruction in his airway. A large amount of blue plastic material, which contained packages of cocaine and a by-product of heroin, was found in the man’s windpipe.
At the conclusion of our investigation in November 2022, we decided that the officer who searched the man inside the custody van should face a misconduct meeting for breaching the police standards of professional behaviour of duties and responsibilities. This related to their failure to adequately search the man following his arrest and for failing to properly monitor him during his transport to custody.
A misconduct meeting which was held by the force, decided that there would not be a disciplinary outcome for the officer but instead they would go through the reflective practice review process (RPRP) to consider opportunities for learning.
An officer reflecting on their actions is a formal process reflected in legislation. The reflective practice review process consists of a fact-finding stage and a discussion stage, followed by the production of a reflective review development report. The discussion must include:
• a discussion of the practice requiring improvement and related circumstances that have been identified, and
• the identification of key lessons to be learnt by the participating officer, line management or police force concerned, to address the matter and prevent a reoccurrence of the matter.
We also found that two officers based in the MPS’ Directorate of Professional Standards should go through the same process for their mishandling of exhibits. One officer stored a water bottle in the same bag as the man’s phones, which leaked and damaged the phones. The other officer incorrectly stored biological samples following the post-mortem examination which affected the ability to analyse them.
In January 2024, an inquest determined that the man died as a result of foreign body airway obstruction.
An inquest jury found that failings in both police searches of the man probably caused or contributed to his death. They described both searches as “incomplete and unsatisfactory.” They also found that the police monitoring of the man on his way to the custody suite in the police van probably caused or contributed to his death and said there was a “missed opportunity” to see the package in the man’s mouth. They concluded that there were failings in the actions of officers in the custody suite, namely a lack of leadership and poor communication, and that this possibly caused or contributed to his death.
The inquest jury also found that the man’s own actions contributed to his death, by failing to mention the package during the search, putting the item in his mouth in the van and keeping it hidden in his mouth at the custody suite.
We carefully considered whether there were any learning opportunities arising from the investigation. We make learning recommendations to improve policing and public confidence in the police complaints system and prevent a recurrence of similar incidents.
We carefully considered whether there were any organisational learning opportunities arising from the investigation. We make learning recommendations to improve policing and public confidence in the police complaints system and prevent a recurrence of similar incidents.
In this case, the investigation has not identified any learning.