Updated guidance around drug related incidents and a reminder about the importance of preserving the integrity of evidence following deaths in custody have been issued to Thames Valley Police officers following an investigation by the Independent Office for Police (IOPC) into the circumstances surrounding the death of Nuno Cardoso.
We concluded our investigation in December 2018 and passed our report and findings to TVP’s professional standards department and the Coroner. The report and findings were also shared with Mr Cardoso’s family.
As a result of evidence gathered during our investigation into Mr Cardoso’s death, on Friday 24 November 2017, we made three formal recommendations which TVP has accepted.
They are:
• Update policy and guidance to clarify when drug-related incidents should be placed on to an individual’s Police National Computer record
• Update policy and guidance to reflect the statutory guidance issued by the IOPC in January regarding separating key police witnesses and preserving the integrity of the investigation
• Consideration given to ensuring appropriate and effective instructions are provided to officers immediately following a death or serious injury regarding conferring and securing the best evidence available.
IOPC Regional Director Sarah Green said:
“The outcome of this incident is tragic and I offer my condolences to the family and many friends of Nuno Cardoso and all those affected by the events on 24 November 2017.
“Our investigation was assisted by Body Worn Video and it is clear that the officers faced a challenging set of circumstances and encountered resistance during the incident.
“Our investigation has identified learning for the police which will improve policing practices. We have made three formal recommendations which I am pleased Thames Valley Police has accepted.”
At his inquest on 17 July, a jury delivered a narrative conclusion stating that Mr Cardoso died as a result of cardiorespiratory arrest caused by intoxication from alcohol, cocaine and morphine.
In addition to identifying learning, we formally recommended to TVP that one officer, a PC, had a case to answer for misconduct for allegedly breaching the standards of professional behaviour in relation to duties and responsibilities by taking Mr Cardoso to custody without taking further steps to confirm whether he was concealing something in his mouth. The force accepted our recommendation. At a misconduct meeting held in June the case against the officer was not proven.
Our investigation began following a referral from TVP after Mr Cardoso had been arrested at a halls of residence for students in the Headington area of Oxford.
Officers from TVP attended the Dunstan Road area after receiving reports of a disturbance shortly after 2am. They searched the area and shortly before 5am Mr Cardoso, 25, who was originally from London and studying at college in the area, was arrested.
Mr Cardoso was restrained by officers and placed in the back of a police van on way to custody when officers reported that he become unwell. Officers stopped the van and administered CPR. Additional officers arrived at the scene with a defibrillator and provided further medical assistance. Mr Cardoso was then taken by ambulance to the John Radcliffe Hospital where he died later that day.
Our investigation focused on the actions and decisions of the police officers, the circumstances surrounding the decision to arrest Mr Cardoso, the force used by officers during his, arrest and the care afforded to Mr Cardoso prior to the arrival of paramedics.
Over the course of our investigation we interviewed the officers involved in the search, restraint, arrest and transportation of Mr Cardoso, obtained statements and interviewed witnesses. We also obtained and analysed medical records, radio transmissions, expert reports and the relevant policies and legislation.
Our investigation was greatly assisted by Body Worn Video footage of the incident, which captured Mr Cardoso’s restraint, arrest and medical assistance provided by the officers.
Publication of our findings has awaited the end of his inquest.
Ends
An act of parliament that provides the core framework of police powers to combat crime and provide codes of practice for the exercise of these powers.
Leads and manages the development of the police service in England, Wales and Northern Ireland.
The body that represents the interests of all police constables, sergeants, and inspectors.
Deals with someone’s inability or failure to perform to a satisfactory level, but without breaching the Standards of Professional Behaviour.
Focuses on putting an issue right and preventing it from happening again by encouraging those involved to reflect on their actions and learn. It is not a disciplinary process or a disciplinary outcome.
Department within a police force that deals with complaints and conduct matters.
Refers to lower-level misconduct or performance-related issues, which are dealt with in a proportionate and constructive manner.
This means doing what is appropriate in the circumstances, taking into account the facts and the context in which the complaint has been raised, within the framework of legislation and guidance.
The average is calculated using the individual results of the forces in that most similar force group.
An investigation carried out by IOPC staff.
Carried out by the police under their own direction and control. The IOPC sets the terms of reference and receives the investigation report when it is complete. Complainants have a right of appeal following a supervised investigation (unless it is an investigation into a direction and control matter).
This act sets out how the police complaints system operates.
How a police force is run, for example policing standards or policing policy.
An investigation carried out by the police under the direction and control of the IOPC.
The organisation that is responsible for assessing how to deal with a complaint. For example – whether it can be handled locally or reaches the criteria for referral to the IOPC. The appropriate authority may be the chief officer of the police force or the PCC for the force. If a complaint investigation finds that someone has a case to answer for misconduct, the appropriate authority is responsible for arranging any misconduct proceedings. If you make a complaint, the appropriate authority for your case will contact you.
An intelligence-led agency with law enforcement powers, it is also responsible for reducing the harm that is caused to people and communities by serious organised crime.
Policing bodies include police and crime commissioners, the Common Council for the City of London, or the Mayor's Office for Policing and Crime.
Investigations carried out entirely by the police. Complainants have a right of appeal following a local investigation (unless it is an investigation into a direction and control matter).
IOPC guidance to the police service and police authorities on the handling of complaints.
A complaint or recordable conduct matter that doesn’t need to be referred to the IOPC, but where the seriousness or circumstances justifies referral.
Parameters within which an investigation is conducted.
A person is adversely affected if he or she suffers any form of loss or damage, distress or inconvenience, if he or she is put in danger or is otherwise unduly put at risk of being adversely affected.
This is where a manager deals with the way someone has behaved. It can include: showing the police officer or member of staff how their behaviour fell short of expectations set out in the Standards of Professional Behaviour; identifying expectations for future conduct; or addressing any underlying causes of misconduct.
This could be the Police and Crime Commissioner, the Common Council for the City of London, or the Mayor's Office for Policing and Crime.
A flexible process for dealing with complaints that can be adapted to the needs of the complainant. It may involve, for example, providing information and an explanation, an apology, or a meeting between the complainant and the officer involved.
A flexible process for dealing with complaints that can be adapted to the needs of the complainant. It may involve, for example, providing information and an explanation, an apology, or a meeting between the complainant and the officer involved.
A breach of standards of professional behaviour by police officers or staff so serious it could justify their dismissal.
A matter where no complaint has been received, but where there is an indication that a person serving with the police may have committed a criminal offence or behaved in a manner that would justify disciplinary proceedings.
Disapplication means that a police force may handle a complaint in whatever way it thinks fit, including not dealing with it under complaints legislation. This may only happen in certain circumstances where the complaint fits one or more of the grounds for disapplication set out in law.
The ending of an ongoing investigation into a complaint, conduct matter or DSI matter. An investigation may only be discontinued if it meets one or more of the grounds for discontinuance set out in law.
Quarter 1 covers 1 April - 30 June
Quarter 2 covers 1 April - 30 September
Quarter 3 covers 1 April - 31 December
Quarter 4 covers the full financial year (1 April - 31 March).
You can request a review/appeal if you’re not satisfied with how your complaint has been handled.
Used to house anyone who has been detained.
Complainants have the right to appeal to the IOPC if a police force did not record their complaint or notify the correct police force if it was made originally to the wrong force.
The purpose of an investigation is to establish the facts behind a complaint, conduct matter, or DSI matter and reach conclusions. An investigator looks into matters and produces a report that sets out and analyses the evidence. There are three types of investigations: local, directed and independent.
The ending of an ongoing investigation into a complaint, conduct matter or DSI matter. An investigation may only be discontinued if it meets one or more of the grounds for discontinuance set out in law.
The type of behaviour being complained about. A single complaint case can have one or many allegations attached.
A person who makes a complaint about the conduct of someone serving with the police.
The ending of an ongoing investigation into a complaint, conduct matter or DSI matter. An investigation may only be discontinued if it meets one or more of the grounds for discontinuance set out in law.
List of officers and staff who have been dismissed from policing, or would have been if they had not retired or resigned.
The type of behaviour being complained about. A single complaint case can have one or many allegations attached.
Disapplication means that a police force may handle a complaint in whatever way it thinks fit, including not dealing with it under complaints legislation. This may only happen in certain circumstances where the complaint fits one or more of the grounds for disapplication set out in law.
An independent judicial officer, the coroner enquires into deaths reported to him/her.
A breach of the Standards of Professional Behaviour that would justify at least a written warning.
No further action may be taken with regard to a complaint if the complainant decides to retract their allegation(s).
A record is made of a complaint, giving it formal status as a complaint under the Police Reform Act 2002.
This is a format where information is written in plain English and short sentences.
The IOPC must be notified about specific types of complaint or incidents to be able to decide how they should be dealt with.
No further action may be taken with regard to a complaint if the complainant decides to retract their allegation(s).
Casework involves assessing appeals. Casework staff also have a role in overseeing the police complaints system to help ensure police forces handle complaints in the best possible way.
Disapplication means that a police force may handle a complaint in whatever way it thinks fit, including not dealing with it under complaints legislation. This may only happen in certain circumstances where the complaint fits one or more of the grounds for disapplication set out in law.
Conduct includes acts, omissions, statements and decisions (whether actual, alleged or inferred). For example: language used and the manner or tone of communications.
You can request a review/appeal if you’re not satisfied with how your complaint has been handled.
You can request a review/appeal if you’re not satisfied with how your complaint has been handled.