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Case 2.11 | Bulletin 6 – General
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Death of a man in custody

Death by overdose on the premises of a police station raising issues about
• Rousing of detainees
• Inspection of custody records
• Transportation of detainees
• CCTV coverage in custody suites

Overview of incident
Mr M, a man in his fifties, was suffering from alcohol and medication dependency. He had threatened to kill himself and been admitted to hospital for psychiatric assessment several times. In September 2006 Mr M went into an off-licence, picked up a couple of bottles of sherry and walked out with them. The proprietor of the shop followed him, took the bottles from him and led him back to the shop. Once inside, Mr M became agitated and aggressive and there was a scuffle. Mr M then ran to the rear of the shop and locked himself into a toilet cubicle. The proprietor called the police. A few minutes later four police officers arrived at the premises. The proprietor told them Mr M had referred to having a knife. After failing to persuade Mr M to leave the toilet cubicle he was forcibly removed by a police officer and he was struggling and fighting so much the officers had to use handcuffs and leg straps to restrain him. They thought he was drunk. Mr M was arrested for theft and criminal damage. By this time a police van had arrived and Mr M had calmed down enough to be able to walk to the police van. Mr M was placed on the floor in the rear of the van by the four officers, still in handcuffs and leg restraints. No officer accompanied him in the rear compartment and the driver could not see Mr M unless he stopped and looked behind him. It was a breach of Force policy for there to be no officer escorting Mr M inside the van to monitor his welfare. There was no CCTV coverage of the custody complex to which Mr M was taken. On arrival, Mr M was escorted by two officers who attempted to sit him on a bench, but he was sliding off and appeared to be deliberately uncooperative. One of the officers suggested to the Custody Officer taking Mr M directly to the designated drunk cell. The Custody Officer agreed and Mr M was assessed as being drunk and taken to the ‘drunk’ cell. The officer who had driven the van recognised Mr M as someone he had dealt with before during an incident which resulted in Mr M being admitted to hospital for a psychiatric assessment, but he did not tell the Custody Officer this. Independent Police Complaints Commission. All Rights Reserved. Mr M’s property was documented and his restraints were removed. Half hourly visits were arranged on the basis he was under the influence of alcohol. The first visit was shortly before noon when Mr M was sleeping on his back. Believing he was drunk, the officer checking placed him in the recovery position. He told the Custody Officer he had done this and it was entered on the custody record. He had told Mr M what he was going to do and he had grunted in return. The officer wrote on the record that Mr M was ‘very intoxicated and hardly woke up.’ The officer did not ask Mr M questions designed to assess whether he was intoxicated. The custody sergeant made subsequent checks at three twenty minute intervals. On these visits he did not go into the cell, looking at Mr M through the observation hatch, but he could hear Mr M snoring loudly and could see he was breathing. He concluded that Mr M was sleeping off the effects of the alcohol. When he next visited he noticed that there was blood on the mattress and that Mr M was clearly unwell. An ambulance was called, officers and then paramedics attempted resuscitation, but were unable to revive him. Mr M was pronounced dead early that afternoon. After his death, empty boxes of medication labelled paracetamol, Amitriptyline and Propranolol were found at Mr M’s flat. A post mortem suggested that he had died from an overdose of paracetamol, Propranolol and Amitriptyline. No alcohol was detected. Type of investigation
Recommendations

Local recommendations

Finding 1
Code C of the Police and Criminal Evidence Act 1984 provides that a detainee that appears to be drunk must be roused every half hour. For these purposes rousing requires the officer to go into the cell and put a series of questions and commands on the basis of which the need for medical help, and the possibility that a person who is drowsy and smells of alcohol may suffer from other conditions, can be assessed.
Recommendation

2.
The Force should ensure that all staff put into practice the provisions of Code C in relation to the rousing of detainees, are aware of the requirements and their responsibilities and have practical guidance on implementing them.
Finding 2

3.
Code C requires that the response to these question and commands is recorded.
Recommendation

4.
In order to ensure that Custody Officers are complying with the requirements of Code C and in particular with paragraph 9.15(f) and Annex H, it is recommended that the Force Independent Police Complaints Commission. All Rights Reserved. review its procedures to ensure that the custody records relating to such detainees are regularly inspected. This is in line with the guidance in ACPO guidance on ‘Safer Detention and Handling of Persons in Police Custody’ (2006).
Finding 3

5.
Force policy was for there to be an officer escorting Mr M inside the van to monitor his welfare.
Recommendation

6.
The Force should ensure that all staff likely to be involved in the transportation of the prisoners receive appropriate training in relation to the risks associated with the transportation of vulnerable and restrained detainees.
Finding 4

7.
Because of the absence of CCTV coverage, the investigation depended solely on interviews with the police officers and staff and examination of custody records. CCTV coverage could have done a lot to alleviate the concerns of the family on how Mr M was treated.
Recommendation

8.
The Force should establish as soon as practicable a policy for the provision of CCTV in custody suites in accordance with chapter 122 of the Guidance on the Safer Detention and Handling of Persons in Police Custody (2006). Force response
The Force accepted the recommendations which would be progressed through an action plan. If you need more information about this case, please email [email protected]
Independent Police Complaints Commission. All Rights Reserved.

Source: http://www.ipcc.gov.uk/sites/default/files/Documents/%5BNPM%5D%20LtL%20Bulletin%206%20-%20Case%202.11.pdf