Man died while in police custody – Nottinghamshire Police, June 2017
In June 2017, a man was arrested in a park off Sandy Lane, Mansfield on suspicion of a drugs offence shortly after 8pm. He was taken to Mansfield Police Station where he was later found unresponsive in his cell after a routine check the following morning. Paramedics attended and he was sadly pronounced dead at 5:13am that day.
We investigated the circumstances surrounding the man’s death, the medical care and treatment he received, and the decisions made by custody officers and staff when conducting checks and whether they were in accordance with local and national policies. We examined evidence, which included custody suite CCTV footage, custody records along with medical reports. We also interviewed police officers and staff to obtain their accounts.
The evidence obtained indicated the care which had been provided may have fallen below the required standard in the monitoring of their state during their detention.
Our investigation concluded in December 2019.
We waited for all associated proceedings to be finalised before publishing our findings.
We found that a healthcare professional had a case to answer for misconduct for failing to properly assess the man’s condition and for a failure to recognise the immediate need to send the man to hospital for treatment. As the individual no longer works for Nottinghamshire Police, having been a contractor at the time of the incident, no disciplinary action could be taken. Information was passed to the Health and Care Professions Council.
We found a detention officer had a case to answer for misconduct for failing to carry out checks on the man to a sufficient standard and for failing to identify that his condition had deteriorated. Following a misconduct meeting held by the force in June 2020, misconduct was found proven in respect of not conducting thorough checks on the man but not proven in respect of her having not recognised or acted upon his deterioration. The meeting also found misconduct proven in the making of false entries on the custody record. The outcome was management action.
We also concluded a second detention officer had no case to answer for misconduct but found performance issues over the sufficiency of a welfare check and custody record entry.
An inquest concluded in February 2022 and recorded an outcome of ‘drug-related death’. The inquest jury also commented that poor communication within the multi-disciplinary team led to a missed opportunity in recognising deterioration and seeking further medical help.
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 found learning for the force around better inputting of information on custody records to help with the care of detainees. We progressed these areas of organisational learning under Paragraph 28A, Schedule 3, Police Reform Act 2002.
IOPC reference
Recommendations
The IOPC recommends that Nottinghamshire Police amends its custody assessment process to include a specific question about whether the detainee has any allergies. Where a detainee has indicated they have an allergy this information should be visible to all custody staff so that they can ensure that the detainee is only provided with appropriate items of food or drink.
This follows a case where a detained person declared to the custody healthcare professional an allergy, and where they were later provided food which contained the food they were allergic to. Their initial assessment when arriving in custody stated they had no special dietary requirements. The current question that Nottinghamshire Police use relating to dietary requirements as part of its custody assessment process does not make clear that the detainee is also required to share allergy information at this point of their assessment.
Do you accept the recommendation?
Yes
Accepted action:
Nottinghamshire Police have accepted this recommendation. An additional question is now asked at the point of booking in by the duty custody Sgt of a detained person.
A mandatory question in relation to allergies is now asked :
‘Do you have any food allergies that need to be considered whilst you are in custody? If yes, give details.’
If the detained person answers ‘yes’ confirming a food allergy this is now highlighted on the electronic custody record. This is visible to all staff responsible for a detainees’ welfare in care whilst they are in the custody suite.
In addition the custody kitchen areas also now display all food available with detailed contents highlighting food suitable for those with particular allergies / vegan / Halal etc.
Nottinghamshire Custody engaged with the learning and Development Department for custody training regarding this recommendation and ensured that this was implemented into future custody courses for new joiners and the annual training day for all current employees within the custody facility.
To ensure that the learning was delivered immediately the communications of the learning was delivered direct to individuals through team briefings by the Pace Inspectors. It was additionally incorporated into the custody monthly newsletter.
The learning was further delivered to the healthcare professionals employed by our service provider.
In addition the policy regarding custody procedural has been amended to reflect the specific need of asking the direct question in relation to allergies.
The IOPC recommends that Nottinghamshire Police remove the option of a drop-down menu when entering cell observation entries onto the custody log, or otherwise introduce a prompt to the system which reminds detention officers of the need to input further information once an option on the drop-down menu has been selected.
This follows an incident where entries recorded on the custody record for a detained person provided inadequate information, in addition to several incorrect entries being recorded. Custody staff explained these errors as being a result of the use of drop-down menus when entering information onto the custody record. Whilst there is a time factor in typing entries rather than using a drop-down menu system, the value in considering a detainee’s welfare more thoroughly in order to construct a custody log entry, in addition to the added clarity and detail provided in a more specific record, outweighs the convenience of a quicker approach.
Do you accept the recommendation?
Yes
Accepted action:
Nottinghamshire Police accepts the recommendation to introduce a prompt which reminds detention officers of the need to input further information once an option has been selected.
We have reviewed all of the drop down boxes and wording contained within them to ensure that prompts are clear for detention officers to include more detailed information on their visits.
We have reviewed our drop down menus on cell visits and made the following changes;
1.When conducting a visit to a detainee who is awake the detention officer will be required to include the following:
- Time of visit
- Record details of the interaction and / or activity
- Answer yes / no if there are any changes in detainee’s condition and if so record what those are.
Nottinghamshire Custody engaged with the learning and Development department for custody training regarding this recommendation and ensured that this was implemented into future custody courses for new joiners and the annual training day for all current employees within the custody facility.
The learning was delivered immediately through team briefings by the Pace Inspectors. It was additionally incorporated into the custody monthly newsletter.