Investigation into police contact before death - Devon and Cornwall Police, July 2021
Our investigation found that Devon and Cornwall Police officers treated a woman in custody, who died soon after in hospital, in line with policies and procedures.
A woman became unwell in a cell at Charles Cross custody suite in Plymouth at around 4.30pm on 3 July 2020. CPR was administered by custody staff and a healthcare practitioner. She was taken to hospital, where she died the following morning. The woman had been arrested at an address in Weston Mill Road and taken into custody at around 1.30pm on 3 July.
A small plastic bag containing traces of white powder was later found by hospital staff secreted internally on her person. A post mortem concluded that she had died due to the effects of cocaine.
At the end of a four-day inquest in Plymouth in spring 2024, a jury returned a narrative conclusion. Issuing our findings has awaited the end of the inquest.
We began our investigation following a mandatory referral from Devon and Cornwall Police. We looked at the level of care provided during the period of detention, including the thoroughness of searches and checks carried out. Investigators reviewed CCTV and body-worn video footage of the arrest and time in police custody as well as relevant police documentation. We also obtained witness statements from officers and staff who interacted with the woman and the paramedics who treated her.
Our investigation found no evidence that she was either under the influence of drugs or that she had concealed any item internally at the booking in stage. This was supported by our review of CCTV footage. She was strip-searched on her arrival in custody with a negative result. The evidence indicates that officers conducted an appropriate and thorough visual inspection during the strip-search. Police personnel stated they had asked the woman whether she had any weapons or drugs on her and she had replied not.
We found it reasonable for custody staff to place the woman under Level 1 observations requiring a cell visit every 30 minutes. The evidence shows that staff checked on her at regular intervals. A detention officer noticed that she appeared to be experiencing a seizure when reviewing the CCTV feeds around four minutes after their previous visit to the cell. An ambulance was called promptly, and a healthcare professional attended swiftly to assist in providing treatment. Following the arrival of the Ambulance Service, police officers and staff helped carry out CPR. A detention officer further assisted by performing chest compressions during the journey to hospital.
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. In this case, the investigation has identified learning.
IOPC reference
Recommendations
The IOPC recommends that Devon and Cornwall Police ensure that the time a check is conducted on a prisoner is recorded on the custody record in addition to the computer generated time shown when the update is added.
The detention officers at Charles Cross custody suite are allocated specific roles on a daily basis and one will be assigned to conducting checks on prisoners in detention. A Detention Officer who submitted a statement in relation to this investigation has explained that having completed all of the cell visits, they return to the main office to update the electronic detention logs for each person detained. The time on the log is recorded as the time the entry is made on the log and not the time the check was conducted.
Comparison between custody records and CCTV has shown that this results in a time discrepancy and it can appear from the custody record that the time between visits sometimes exceeds the minimum requirements which in this case were every 30 minutes.
The Detention and Custody Authorised Professional Practice (APP) states that the Custody Officer is responsible for managing the supervision levels of each detainee and they will need an accurate record to fulfil this responsibility. The APP also states that forces should put in place audit and inspection regimes of custody records that ensure (amongst other things) that notes are contemporaneous, or recorded as soon as possible. The actual time the visit took place will be required to meet this responsibility.
Do you accept the recommendation?
Yes
Accepted action:
DCI Lou Costin has changed roles and I am now Performing the role of the Appropriate Authority for Devon and Cornwall police.
I formally accept the recommendation.
Supt Ryan Doyle as the head of the custody department has provided the following response:
“The discrepancy between time of cell visit and the time it is shown on Unifi is caused by an inability in the system to change the actual time of visit, and so the time will always show the when the update was added.
Whilst we use Unifi there are three options: custody staff return to the custody desk to update after each individual visit; custody staff are issued with tablets/devices that allow updates to be added whilst away from the desk; custody staff are asked to record the actual time of visit in the free text.
Option 1 creates inefficiencies by increasing the time it takes to complete visits, and cause delays to these.
Option 2 requires investment which would be short-sighted as we are changing to the Niche custody system in Spring 2022.
As a result I will ensure that staff are briefed to follow Option 3. This will be an interim measure for the remaining lifespan of Unifi, and I will investigate how this issue can be avoided when we move to Niche.”
Further to this I will ensure that this action is formally recorded on the force Pentana system. This will ensure the action is allocated an owner and auditable should there be a further request to check progress when the Niche system is introduced in 2022.
Kind Regards
DCI Kevin TILL
20/07/21