Watchdogs have ruled that Suffolk Police ‘failed to take appropriate care’ of a father-of-three who died after being detained in a police cell - as an inquest jury concluded he received ‘inadequate care’.
The Independent Police Complaints Commission found the level of care given to Robert Peter Edwards, of Culford Road, Fornham St Martin , who was a known methadone and alcohol user, at Bury St Edmunds Police Station ‘fell below an acceptable standard’.
Meanwhile an inquest jury concluded that Mr Edwards ‘could not have been deemed fit for detention - subsequently signs of deterioration were missed’.
Mr Edwards was arrested on suspicion of assault on May 20 2011 and was taken to Bury Police Station, where he was assessed as fit to remain in custody.
The 55-year-old, who had a history of alcohol and drug problems as well as depression and alcohol fits, was later found unconscious in a police cell and died at West Suffolk Hospital on May 25.
The cause of death was aspiration to the lungs, hypoxia to the brain and a combination of alcohol and methadone.
Following a referral from Suffolk Police, the IPCC began an independent investigation which concluded in December that year but the body has waited until the end of the inquest to reveal its findings.
The findings included that:
n ‘Although an early decision for Mr Edwards to be medically assessed by a health care professional was correct, overall the care given to Mr Edwards in custody fell below an acceptable standard and in particular there was a failure to conduct rousing checks properly and to respond sufficiently promptly when Mr Edwards’ condition deteriorated.’
n ‘There was a lack of clarity as to who had lead responsibility for the care of Mr Edwards following a shift handover between custody sergeants.’
The investigation found that a detention officer Barry Brackenborough had a case to answer for gross misconduct for failing to rouse Mr Edwards on more than one occasion.
The detention officer resigned from Suffolk Police ahead of disciplinary proceedings. A misconduct panel, held in his absence, found the case proven and indicated that had Mr Brackenborough not resigned, he would have been dismissed.
Police constable Alison Huntley was found to have a case to answer for misconduct for failing to rouse Mr Edwards adequately on one occasion. She accepted a written warning following a misconduct meeting. A case to answer against Sergeant Jason Francis was found not proven at a misconduct hearing and no action resulted.
IPCC Commissioner Sarah Green said: “My sympathies again go to those close to Mr Edwards at this difficult time. Our investigation found that Suffolk Constabulary failed to take appropriate care of Mr Edwards, who was in a vulnerable state due to his intoxication, and did not properly carry out rousing checks on him as needed. When Mr Edwards’s condition deteriorated, this was not identified and responded to sufficiently promptly.
“The Constabulary has however responded positively to the IPCC investigation. Since the date of Mr Edwards’ death, Suffolk has replaced all of its custody suites including Bury St Edmunds with new purpose built Prisoner Investigation Centres, and introduced new policies which clarify who is responsible for the welfare of detainees and what this responsibility entails.” In their conclusions the inquest jury answered a series of questions.
When asked if a nurse conducted an adequate assessment of his fitness to be detained and whether the nurse was correct in assessing him as being fit to be detained, the jury answered ‘no’.
Asked if checks carried out on Mr Edwards by officers while he was detained were acted on appropriately, they said ‘no’.
They agreed with a doctor that ‘as a general principle earlier referral to the hospital would have increased his chance of survival’.
Suffolk Coroner Dr Peter Dean said the inquest had heard ‘significant issues raised about the approach to care in custody’ but issues had been addressed locally with ‘significant changes within the custody suites across Suffolk’.
He said he would be writing to ‘someone senior in the police service nationally’ to prevent future fatalities.
Dr Dean added: “It’s important to ensure the system in place for looking after people who maybe intoxicated does need to be made clear to those officers charged with a very difficult job. The issues clearly have been addressed locally, there are maybe issues in other areas.”
Supt Kim Warner, of Suffolk Police, said: “Our thoughts and sympathies remain with Mr Edwards’ family at what must be a difficult time and we hope that the conclusion of the inquest can bring them some closure in relation to his death.
“We have taken this incident extremely seriously and have been determined to learn lessons from it. When someone comes into police custody, we have a duty of care for that person. Many individuals who come into custody are vulnerable and our officers and staff must ensure that the correct procedures are carried out.
“Officers and staff who work in our custody suites are given extensive training in rousing procedures, in line with national guidelines. This was no different at the time of Mr Edwards’ death, however in this particular case the training was not put into practise and procedures not followed correctly.”
For more details see Friday’s Bury Free Press.