Investigation concludes into death of man in Thames Valley Police custody

An investigation into the care and attention given by Thames Valley Police (TVP) to a man who died in custody in 2021 found no evidence that police contributed to his death.

Jon Green, aged 49, died in custody in the Abingdon police station after he was found unresponsive in his cell shortly after 1am on 26 June 2021.

An inquest, which concluded on 5 December 2022, determined that the 49-year-old man’s death was due to liver disease.

Our investigation began following a mandatory referral from the force and we sent investigators to the custody suite and to the police post incident procedures where the officers involved provided their accounts.

We established that Mr Green was arrested at around 5.30pm on 25 June on an outstanding warrant.

He stated to officers that he was feeling unwell and put this down to having withdrawals from alcohol and opiates.

He was detained by TVP at Abingdon custody suite where he was examined by a health care professional (HCP) who provided medication for his withdrawal symptoms.

Custody records show that from shortly after 7pm, officers regularly observed Mr Green’s condition with checks made approximately every 30 minutes. During one check, after noticing vomit on the floor of Mr Green’s cell, an officer notified the HCP who checked on Mr Green, however this was not recorded in the custody record and the officer didn’t notify their supervisor that Mr Green had been sick.

Shortly after 1am Mr Green was found unresponsive in his cell. Officers and staff present immediately attempted CPR and an ambulance was requested, however he was sadly pronounced dead at the scene.

Our investigation, which concluded in May 2022, found no evidence that police caused or contributed to Mr Green’s death and there was no indication any officer had behaved in a manner that would justify bringing disciplinary proceedings or had committed a criminal offence.

We did identify potential performance issues regarding the conduct of two detention officers including around inadequate communication on the custody record and for not clearing vomit from the cell floor. We understand the force are addressing this through unsatisfactory performance procedures.

Our investigation also identified a number of learnings, with which we are consulting with the force, including around handover of information to custody staff; and the quality of welfare checks. We will also be consulting nationally on recommendations relating to the observation of those under the influence of alcohol and guidance for dealing with detainees withdrawing from drugs and alcohol.

As part of our investigation we conducted a detailed scene examination and obtained witness statements from a number of police officers, detention officers and medical advisors. CCTV footage and audio recordings were analysed and we obtained medical experts’ reports.