Care in custody examined after man dies – Merseyside Police, March 2023

Two police officers on uniformed patrol in an unmarked police car noticed a man running towards an area known for drug activity. The officers drove down the street to try to cut the man off.

The officers approached the man, who was now joined by two other people, one of whom was holding a bag suspected to contain drugs. A short pursuit began on foot, and the officers took the man holding the bag to the ground. The man was arrested, handcuffed and taken to police custody.

The man’s detention was authorised, and he was searched, including visual and physical pat downs and the use of a metal detector hand wand. He was not strip searched as the arresting officer had told custody staff that drugs had already been found. The custody sergeant assessed the man and placed him on a rest period until the morning.

That morning, the man was seen by a Health Care Professional (HCP), who noted that the man’s level of substance intoxication would indicate he had self-medicated in custody, or had substances on him in the cell. A strip search was completed, and the man was placed on a further rest period of four hours. He was interviewed after this time.

A detention officer conducted a routine check/observation later that afternoon and saw that the man was lying on the floor of his cell. The detention officer entered the cell, followed by two other detention officers and an HCP. The HCP tended to the man and an ambulance was called. The man was taken to hospital where he died.

We received a death or serious injury referral from the force and decided to independently investigate the man’s detention, arrest, transportation and handover to custody; the initial and ongoing risk assessments completed in custody; the level of care given; the strip search; and the medical attention he received. We also examined whether the response, actions and decisions made by the police were in line with local and national policies and guidance.

Our investigators went to the custody suite and completed house-to-house enquiries in the area where the man was arrested. We analysed and compared CCTV footage from the arrest and the custody suite, police officers’ body worn video footage, and documentation from the custody suite. We obtained accounts from key policing witnesses and the HCP responsible for the man’s care while he was in police custody.

We concluded there was no indication that an officer serving with the police had committed a criminal offence or behaved in a manner to justify disciplinary proceedings. However, we found that the HCP who had visited the man in custody had behaved in a manner to justify disciplinary proceedings.

We recommended that three officers would benefit from individual line management with regards to their performance, including the importance of rousal checks to observe someone in custody, and the importance of retaining written handover notes.

We found that the HCP had a case to answer for misconduct with regards to not equating their suspicions that the man had ingested drugs in his cell with a medical emergency, and for failing to confront the man about whether he had consumed or inserted drugs or warn him about the effects of this.

We shared our report with the force, who agreed. We decided that disciplinary proceedings should be brought against the HCP and that they should take the form of a misconduct meeting.

The HCP was a contracted staff member and under the agreement between their employer and the force, Merseyside Police accepted a misconduct meeting would not go ahead.

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 recommended that Merseyside Police make sure that its custody suites have level three cell check capabilities, which should be used when detainees have high-risk warning markers such as self-harm, suicide, and swallowing or regurgitating drugs. Level three capabilities enable staff to provide the correct care to detainees, in line with College of Policing Authorised Professional Practice.

The custody suite underwent a pre-planned refurbishment in April 2023. Part of this included the installation of level three CCTV and appropriate monitoring stations, and maintenance to the intercom and buzzer systems.