Police contact in custody investigated after woman dies – West Yorkshire Police, January 2018

West Yorkshire Police received an emergency call from a man reporting that his partner had assaulted him. The call was graded as a priority one emergency.

The man’s partner was arrested on suspicion of assault, and she was taken to custody. She was placed on level two observations which meant she would be checked on and woken up every half hour. The woman told custody staff that she thought she may be pregnant.

The woman was seen by a healthcare professional about an hour after arriving in custody. She was sent to hospital to be checked over, where her pregnancy was confirmed. She returned to custody and was placed on level one observations which meant she would be checked on every half hour but not roused. The woman was reviewed by an inspector, offered breakfast and had her photographs and fingerprints taken.

The woman was found unresponsive in her cell later that day. She was given immediate first aid by custody staff, and an ambulance was called. The woman sadly died after arriving at hospital.

We received a death or serious injury referral from the force and decided to independently investigate the contact between the woman and the police. We examined whether cell checks were conducted appropriately and in-line with guidance, the response of officers to any concerns identified in the woman’s cell, and to concerns raised by other detainees about the woman.

Our investigators viewed body worn video footage of the woman’s arrest, the CCTV footage from custody, and reviewed calls and radio transmissions. We obtained witness accounts, and accounts under caution from police staff and officers. The evidence we obtained was analysed against legislation, policies and guidance.

The evidence gathered by our investigation did suggest that one officer may have failed in their duties to carry out a cell visit. Following this missed visit, the woman was found in her cell and later died. We considered whether this would amount to a criminal offence, but we decided that there was not enough evidence to refer the matter to the Crown Prosecution Service.

We concluded there was no indication that a person serving with the police behaved in a manner to justify disciplinary proceedings. The woman’s death was not foreseeable, and there was no evidence to suggest her death could have been prevented. We did make some recommendations around accurately recording cell checks and conducting them as scheduled in good time, which should be dealt with at a local level using formal performance procedures.

We recommended that a detention officer should receive a full de-brief on the incident and be placed on an action plan so that he be fully aware of his roles and responsibilities while on duty.

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 did not find any organisational learning in this case.