Police contact and custody procedures examined after vulnerable man dies – Northumbria Police, December 2022
A man made a succession of calls to the police reporting that there were people in his house, he was locked inside the bathroom, and he needed the police to attend.
Officers went to the man’s home and saw him climb out of a window. The man walked down the road, shouting, knocking on doors and threatening the occupants. He said he did not believe the officers were real police officers.
Officers noticed the man was holding something in his hand, which they identified as a machete. They followed the man and asked him to stop and put the machete down, but the man did not follow these instructions. One of the officers used their Taser to try to stop the man but this was unsuccessful and the man continued walking down the road shouting. A police dog was deployed, and another officer used their Taser. This was successful and the man was handcuffed, arrested and taken to custody. The man’s wife telephoned the custody office and reported that the man had been in a drug induced psychosis for the past seven months.
A standard search was authorised and conducted in custody. Nothing was found on the man. A risk assessment was completed by the custody sergeant, and a strip search was authorised. No items were found during the search.
The man was seen by a healthcare professional (HCP) who assessed his fitness for interview. The HCP noted that the man was very emotional throughout the assessment and told the HCP that he was scared and wanted to kill himself but could not say how he would do this. A referral was sent to the mental health nurse.
The man also told the HCP that he had some pain in his foot. He was advised to go to hospital if the pain persisted when released from custody.
The man was interviewed in police custody and charged with four offences. He was transported to court and remanded to prison. On the way to prison, the man was taken to a hospital to have his foot checked. In the hospital, the man asked to go to the toilet and on return to the hospital room he placed white powder in a clear outer packaging into his mouth. The man started shaking, and while medical professionals tried to treat him, he sadly died.
We received a death or serious injury referral from the force and decided to independently investigate police contact with the man before his death. We considered the circumstances surrounding the reports that led officers to arrest the man, the procedures carried out by officers when arresting and searching him, and his transportation to the police station.
We examined custody booking procedures and risk assessments, and the extent to which officers were aware of the issues surrounding the man, including previous warning markers. We examined the thoroughness of the searches made, including the nature and extent of the strip search. We also considered whether the police may have caused or contributed to the man’s death.
Our investigators obtained and reviewed police officers’ body worn video footage and footage from the custody suite. We took statements from officers, sergeants, the detention officer and mental health practitioners. We reviewed the incident log, the man’s custody log, and expert reports on toxicology, medical intervention and forensics. These were analysed and compared against relevant policies and procedures.
We concluded there was no indication that a person serving with the police committed a criminal offence or behaved in a manner to justify disciplinary proceedings.
We did recommend that a detention officer and a police sergeant would benefit from the reflective practice review process (RPRP). This process allows officers to learn from and reflect on what could have been done better.
We recommended that the detention officer should take note of available guidance on strip searches, particularly that detainees should not be asked to squat, nor should they make any physical contact with them. We recommended that the police sergeant consider the importance of recording full rationales when authorising strip searches, particularly if they do not follow normal procedures.
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 are in the process of considering learning around local policies and procedures regarding Prisoner Escort and Custody Systems and digital Person Escort Records.