Man died while in police custody – Nottinghamshire Police, June 2017

In June 2017, a man was arrested in a park off Sandy Lane, Mansfield on suspicion of a drugs offence shortly after 8pm. He was taken to Mansfield Police Station where he was later found unresponsive in his cell after a routine check the following morning. Paramedics attended and he was sadly pronounced dead at 5:13am that day.

We investigated the circumstances surrounding the man’s death, the medical care and treatment he received, and the decisions made by custody officers and staff when conducting checks and whether they were in accordance with local and national policies. We examined evidence, which included custody suite CCTV footage, custody records along with medical reports. We also interviewed police officers and staff to obtain their accounts.

The evidence obtained indicated the care which had been provided may have fallen below the required standard in the monitoring of their state during their detention.

Our investigation concluded in December 2019.

We waited for all associated proceedings to be finalised before publishing our findings.

We found that a healthcare professional had a case to answer for misconduct for failing to properly assess the man’s condition and for a failure to recognise the immediate need to send the man to hospital for treatment. As the individual no longer works for Nottinghamshire Police, having been a contractor at the time of the incident, no disciplinary action could be taken. Information was passed to the Health and Care Professions Council.

We found a detention officer had a case to answer for misconduct for failing to carry out checks on the man to a sufficient standard and for failing to identify that his condition had deteriorated. Following a misconduct meeting held by the force in June 2020, misconduct was found proven in respect of not conducting thorough checks on the man but not proven in respect of her having not recognised or acted upon his deterioration. The meeting also found misconduct proven in the making of false entries on the custody record. The outcome was management action.

We also concluded a second detention officer had no case to answer for misconduct but found performance issues over the sufficiency of a welfare check and custody record entry.An inquest concluded in February 2022 and recorded an outcome of ‘drug-related death’. The inquest jury also commented that poor communication within the multi-disciplinary team led to a missed opportunity in recognising deterioration and seeking further medical help.

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 found learning for the force around better inputting of information on custody records to help with the care of detainees. We progressed these areas of organisational learning under Paragraph 28A, Schedule 3, Police Reform Act 2002.