Mr Lloyd Edward Butler (Deceased)

Transcription

1 Mr Lloyd Edward Butler (Deceased) Investigation into the circumstances of Mr Butler s death on 4 August 2010 whilst in custody of West Midlands Police Independent Investigation Final Report

2 Introduction... 3 Terms of Reference... 3 Subjects to the investigation... 4 Chronological summary of events Policies and Procedures Licensing Act Police and Criminal Evidence Act (PACE) PACE Codes of Practice Code C West Midlands Police Safer Detention and Handling of Persons in Custody Composite Policy The Prompt Card Aide Memoir Training Operational Officer Training Custody Officer Training DEO Training Expert Opinions Responses to allegations Conclusions Version 0.1 Page 2 of 67

3 Introduction 1. On 4 August 2010 at approximately 12pm Mr Lloyd Edward Butler was arrested by West Midlands Police on the grounds of being drunk and incapable. He was taken to Stechford custody and placed into a camera monitored cell. He was placed on a care regime which required him to be constantly monitored by CCTV and to be roused at least every 30 minutes. 2. Approximately 3.15pm on the same day was visited in his cell by a nurse who requested an ambulance. Medical treatment was provided to and he was transferred to the Heartlands Hospital in Birmingham but was subsequently pronounced deceased. 3. The incident was referred to the IPCC by West Midlands Police and was declared to be an independent investigation. Terms of Reference 4. To investigate the circumstances of the death of and his attendance at Stechford Police Station on 4 August 2010 including: a) the circumstances and lawfulness of the arrest of outside 16 Thaxted Road, Tile Cross, Birmingham. b) his transfer to Stechford Police Station and the authorisation of his detention. c) the care and treatment received by from employees of West Midlands Police, force medical examiner and the paramedics following his arrest and his subsequent arrival at Stechford Police Station. d) the medication previously prescribed to and his general medical condition prior to his arrest and detention. 5. To assist in fulfilling the state s investigative obligation arising under Art. 2 ECHR by ensuring as far as possible that: Version 0.1 Page 3 of 67

4 a) the full facts are brought to light and any lessons from the death are learned (this will include collecting and analysing forensic evidence); b) the investigation is independent on a practical as well as an institutional level. 6. Where it appears at any stage during the investigation following a DSI matter referral that any person whose conduct is in question may have committed a crime or disciplinary offence, to make a submission setting out the details to the Commissioner. 7. To consider and report on whether any criminal or disciplinary offence may have been committed by any police officer or member of police staff involved in the incident, and whether relevant local and national policies/guidelines were complied with. 8. To consider and report on whether there is any: a) learning for any individual police officer or member of police staff; or b) organisational learning for the police service (see Annex), including: 1) Whether any change in police policy or practice would help to prevent a recurrence of the event, incident or conduct investigated. 2) Whether the incident highlights any good practice that should be disseminated. Subjects to the investigation Version 0.1 Page 4 of 67

5 9. PC A was involved in s arrest. It was alleged that she knew or should have known that he should have been taken to hospital following his arrest yet she failed to do so, contrary to West Midlands Police Safer Detention Policy. A Regulation 14A Notice was served on PC A on 10 September 2010 which set out that if the allegations were proven, would amount to Misconduct. 10. PC B was involved in s arrest and the same allegations were made against PC B as for PC A. 11. A Regulation 14A Notice was served on PC B on 3 September 2010 which set out if proven, would amount to Misconduct. 12. PC C attended the scene of arrest of and was present when Mr Butler was escorted from a police van to custody. The same allegations were made against PC C as for PC A. 13. A Regulation 14A Notice was served on 3 September 2010 which set out if proven, would amount to Misconduct. 14. Acting PS D was involved in s arrest and transportation to custody. The same allegations were made against A/PS D as for PC A. 15. A Regulation 14A Notice was served on 3 September 2010 and set out if proven, would amount to Misconduct. 16. PC E was at the scene of arrest. The same allegations were made against PC E as for PC A. 17. A Regulation 14A Notice was served on 3 September 2010 which set out if proven, would amount to Misconduct. 18. PC F was at the scene of the arrest. The same allegations were made against PC F as for PC A. 19. A Regulation 14A Notice was served on 3 September 2010 which set out if proven, would amount to Misconduct. 20. PC G attended the scene of arrest and was present when was escorted from a police van to custody. The same allegations were Version 0.1 Page 5 of 67

6 made against PC G as for PC A. 21. A Regulation 14A Notice was served on 3 September 2010 which set out if proven, would amount to Misconduct. 22. PC 2151 Dean Woodcock was involved in s arrest, escorting him into Stechford custody and was involved in caring for him whilst in custody. It was alleged that : Due to the condition of i.e. that he was drunk and incapable, he knew or should have known that he should have been taken to hospital following his arrest and continued to be aware of that during his transport to, and stay in custody, yet failed to ensure he was. He failed to constantly observe him despite being aware that he was required to do so. He failed to rouse him in accordance with the care plan devised for him. He failed to ensure that the care afforded to him was adequate. 23. A Regulation 14A Notice was served on PC Woodcock on 17 August 2010 and set out if proven, would amount to Gross Misconduct. 24. Following a review of CCTV footage from Stechford custody it was alleged that PC Woodcock: Used and/or was party to language and comments, more particularly with regard to Mr Butler, which were inappropriate. 25. As a result a further Regulation 14A Notice was served on 11 November 2010 and set out if proven, would amount to Gross Misconduct. 26. PS 5708 Mark Albutt was one of two Custody Officers on duty from Mr Lloyd Butler s arrival in custody until approximately 3pm. PS Albutt booked him into custody and made decisions concerning his risk assessment, care plan and its implementation. It was alleged that: Due to the condition of i.e. that he was drunk and incapable, he knew or should have known that he should have been Version 0.1 Page 6 of 67

7 taken to hospital immediately and continued to be aware of that during his stay in custody, yet he failed to ensure that he was. Despite placing him on a care plan that required him to be constantly observed he failed to ensure that it was adhered to. Despite placing him on a care plan that required him to be roused every 30 minutes (and possibly every 15 minutes) he failed to carry it out and ensure it was adhered to. He inadequately tasked and/or briefed the persons tasked to carry out the constant observations and rousing, which he determined appropriate. He inaccurately recorded entries on the custody record of Mr Lloyd Butler. He failed to expeditiously ensure a medical expert attended to him. He failed to ensure that the care afforded to Mr Butler was adequate. 27. A Regulation 14A Notice was served on PS Albutt on 20 August 2010 which set out if proven, would amount to Gross Misconduct. 28. Following a review of CCTV footage from Stechford custody it was alleged that PS Albutt: Used and/or was party to language and comments, more particularly with regard to Mr Butler, which were inappropriate. 29. As a result a further Regulation 14A Notice was served on 30 September 2010 and set out if proven, would amount to Gross Misconduct. 30. PS H was the other Custody Officer on duty from s arrival in custody until approximately 3pm. It was alleged that: Due to the condition of i.e. that he was drunk and incapable, he knew or should have known that he should have been taken to hospital immediately and continued to be aware of this during his stay in custody, yet failed to ensure that he was. He failed to ensure that the care afforded to him was adequate. 31. A Regulation 14A Notice was served on 23 August 2010 which set out if Version 0.1 Page 7 of 67

8 proven, would amount to Gross Misconduct. 32. Following a review of CCTV footage from Stechford custody it was alleged that PS H: Was party to, and/or failed to challenge language and comments, more particularly with regard to Mr Butler, which were inappropriate. 33. As a result a further Regulation 14A Notice was served on 29 September 2010 and set out if proven, would amount to Gross Misconduct. 34. Detention Escort Officer (DEO) Darren Wall was on duty as assistance for the two Custody Sergeants when arrived in custody until approximately 3pm. It was alleged that: Due to the condition of i.e. that he was drunk and incapable, he knew or should have known that he should have been taken to hospital immediately and continued to be aware of this during his stay in custody, yet failed to ensure that he was. He failed to properly rouse him in accordance with the care plan devised for him. He inaccurately and/or inadequately recorded entries on the custody record of Mr Butler. He failed to expeditiously ensure a medical expert attended to him. He failed to ensure that the care afforded to him was adequate. 35. Due to periods of absence from work, a notice was served on DEO Wall on 23 September 2010 which set out if proven, would amount to Gross Misconduct. 36. Following a review of CCTV from Stechford custody it was alleged that that DEO Wall: Used and/or was party to language and comments, more particularly with regard to Mr Butler, which were inappropriate. 37. As a result a further notice was served on 21 January 2011 and set out if proven, would amount to Gross Misconduct. 38. Inspector A was the Supervising Custody Inspector for Stechford Police Version 0.1 Page 8 of 67

9 Station. He telephoned PS Albutt whilst was in custody and was aware that he had been detained for being drunk and incapable. It was alleged that he failed to ensure that was immediately taken to hospital and/or failed to obtain sufficient information to establish his health and condition to determine if he was fit to be detained and/or required immediate medical treatment. 39. A Regulation 14A Notice was served on 17 September 2010 which set out if proven, would amount to Gross Misconduct. Following a review of the evidence, on 27 July 2011 this was revised to Misconduct. 40. PS I was one of two Custody Sergeants that came on duty at approximately 3pm. During a witness interview on 18 January 2011 PS I stated he had a handover briefing from PS Albutt. It was alleged that: He was made aware of the condition of i.e. that he was drunk and incapable, and as part of his risk assessment he knew or should have known that he should have been taken to hospital immediately yet failed to ensure that he was. He failed to fully brief his custody colleagues about the condition of Mr Lloyd Butler. He failed to ensure that the available medical professional attended to him expeditiously. He failed to ensure that the care afforded to him was adequate and appropriate. 41. A Regulation 14A Notice was served on 28 January 2011 which set out if proven, would amount to Gross Misconduct. Following a review of the evidence on 27 July 2011 this was revised to Misconduct. 42. PS J was one of two Custody Sergeants that came on duty at approximately 3pm and was briefed by PS Albutt about. It was alleged that: She was made aware of the condition of i.e. that he was drunk and incapable, and as part of her risk assessment she knew or should have known that he should have been taken to hospital Version 0.1 Page 9 of 67

10 immediately yet failed to ensure that he was. She failed to fully brief her custody colleagues about the condition of him. She failed to ensure that the available medical professional attended to him expeditiously. She failed to ensure that the care afforded to him was adequate and appropriate. 43. A Regulation 14A Notice was served on 20 September 2010 which set out if proven, would amount to Gross Misconduct. Following a review of the evidence on 27 July 2011 this was revised to Misconduct. Version 0.1 Page 10 of 67

11 Chronological summary of events 44. was an occasional drug user and had a history of alcohol dependency. He had stopped drinking for an 18 month period but relapsed in January Prior to his death he had acknowledged he had an anger problem and was receiving help for this. He had been prescribed a number of different types of medication which are further described in the toxicology report detailed later. 45. On 3 August 2010 stayed at his parent s house overnight. On the morning of 4 August informed his mother; Mrs Janet Butler that the new medication he had been taking meant he could not feel his anger. He asked her if she would take him to see his friends and she described him as being in quite good spirits and very sprightly. She states they left the house at 8.25am. 46. attended Witness A s house, Witness B s house and Bains convenience store in Tile Cross Road. His friends Witness C and Witness A who had spent some time with state appeared and said he felt unwell. Whilst at Witness B s house Mr Lloyd Butler was seen to drink from a pint sized glass a mix of one and a half inches of cider, one and a half inches of Tenants Super and one inch of vodka. 47. Witness C stated that returned to Bains but his speech was slurred and he was staggering around. He stated he had never seen in that state before, and did not believe that he was drunk. 48. Once at Bains, the shop assistant, Witness D had concerns about Mr Lloyd Butler and she telephoned his parents and asked them to come and collect him. 49. His parents Mr and Mrs Butler arrived and his mother described him as being disorientated and looking straight through her. She said she was concerned and thought something was wrong. 50. It took a while to get into the car as she stated he seemed Version 0.1 Page 11 of 67

12 to have no sense of coordination. However once he had got inside he tried to punch the windows and windscreen but stopped as he got to the glass, so did not hit them with full force. When they got home would not get out of the car, and Mrs Janet Butler felt she needed the police there for everyone s safety, including s. 51. At 11.46am officers were deployed to the Butler s home address in Birmingham. Mrs Butler reported that her son was drunk and violent and was attacking her husband. 52. The officers stated that the first to arrive were PC A and PC B followed by PC Woodcock and PC C. Mrs Janet Butler told a female officer believed to be PC A that her son was acting strangely. PC A stated when she arrived was asleep in the front passenger seat and when she touched his shoulder he woke up. She felt he had been drinking and stated that did not make any sense when he spoke. 53. Shortly after the initial officers arrived PC E, PC F, A/PS D and PC G attended. A/PS D told these officers to stay back whilst he went to find out what had happened. PC G stated that upon hearing the initial report he decided to attend in a police van due to his knowledge that Mr Lloyd Butler had previously been violent to the police. 54. PC Woodcock stated Mrs Janet Butler told him that was out of control. Mrs Janet Butler also told PC B and PC C about Mr Butler s historical issues with drink and drugs and she told PC C she did not want him back in the house because of his violent past. 55. A/PS D spoke with PC Woodcock and they discussed arresting Mr Lloyd Butler. PC Woodcock says that A/PS D made the decision to arrest Mr Lloyd Butler for being drunk and incapable and PC Woodcock took hold of and said Come with us. spoke to A/PS D about his skin colour and A/PS D returned to PC F, PC E and PC G and informed them of the reasons for s arrest. S Three neighbours, Witness E, Witness F and Witness G saw Mr Lloyd Butler move from the car. They stated that the officers either side of Mr Version 0.1 Page 12 of 67

13 Lloyd Butler had to help him walk as he seemed disorientated, unsteady on his feet and he could not walk very well. 57. PC G brought the van to approximately five metres away and with assistance from officers, got himself out of the car. PC A stated that she held his hand as he moved from the car to the van whilst PC Woodcock held the other side of him to ensure that he did not fall over. As he got to the van he began singing a song and flailing his arms about, at which point he was unassisted. He also enquired about where his mum was before he got inside the van. 58. PC A and A/PS D described that got into the van and shuffled himself along the floor. PC Woodcock attempted to close the van door however s foot was caught and he shouted out. His foot was moved and the door was closed. At this point PC K and PC L arrived and were told to leave the scene as they were not required. 59. PC A stayed to have a brief conversation with Mrs Janet Butler. She stated the police were the only ones that ever did anything for Mr Lloyd Butler and Mr Butler stated it was a waste of time taking him to hospital. 60. Mr Butler and Mrs Janet Butler state that whilst the officers were outside their address an officer whom Mr Butler described as a Jamaican officer, believed to be A/PS D, queried whether should be taken to hospital however another unidentified officer responded no. None of the officers including A/PS D recall any conversation about being taken to hospital. 61. In Mrs Janet Butler s statement she states that she thought Mr Lloyd Butler was drunk, although this was unusual due to the time of day. She could not recall him smelling of alcohol but stated that if she thought his behaviour was due to his medication she would have insisted that an ambulance was called. 62. There was a consensus from the witnesses which included Mr Lloyd Butler s mother and father, that the officers did not use excessive force when they dealt with. Version 0.1 Page 13 of 67

14 63. At 12.05pm PS Albutt, on duty at Stechford Custody, took a telephone call and was told to expect a drunk and disorderly person into custody. PS Albutt passed this information to the other on duty custody staff, PS H and DEO Wall. 64. A/PS D drove the van to Stechford custody suite accompanied by PC G. A/PS D stated that he spoke to and he responded coherently. PC G also asked if he was all right on a couple of occasions during the ten minute journey and he replied that he was. PC Woodcock travelled separately to the custody suite. 65. When the van arrived at custody PC Woodcock opened the doors and Mr Lloyd Butler was asleep. PC Woodcock pinched his ear to wake him up and then assisted him out of the van. 66. The CCTV shows that at 12.18pm walked into the custody suite supported by PC Woodcock and PC G, PC C followed behind. As they approached the custody desk the officers escorting were heard on the CCTV to say that he would fall asleep again if they did not take him to a cell. PS H agreed and he, PS Albutt and DEO Wall discuss which cell to put in and it is decided he can go straight into cell M9, a cell with a mattress on a low bench that can be monitored by CCTV from behind the custody desk. was not spoken to by any of the custody staff at any point. 67. As entered the cell his trousers fell down. They were pulled back up by the officers and was then searched but was supported at all times. The officers sat on the mattress and as they left lay down on his right side. It should be noted that the in cell CCTV did not record audio. 68. At the custody desk there is a conversation regarding the previous levels of observation had been on when he had previously been in custody. PS Albutt stated that had self harm warning markers and that he was a high risk. 69. PS Albutt told PC Woodcock that drunk and incapable people should not Version 0.1 Page 14 of 67

15 come into custody. PC Woodcock stated he did not believe that came into effect until 24 August and PS Albutt responded saying, we ve recently had directions they shouldn t come into a custody block but he s here now so (inaudible). PS Albutt questioned PC Woodcock whether Mr Lloyd Butler could be dealt with as drunk and disorderly. PC Woodcock informed him that had not been disorderly and queried where Mr Lloyd Butler should be, to which PS Albutt informed him the hospital Accident and Emergency department. 70. At this point PC A had arrived in custody. She informed PS Albutt that if had been taken to hospital he would have kicked off. She also informed PS Albutt that had mental health and drinking issues and was on medication for psychotic issues. 71. PC G then questioned PC Woodcock about whether he was the arresting officer. PC Woodcock responded that this did not matter as it s only drunk and incapable (inaudible) it matters not. PC Woodcock later asked PC C if he arrested before stating that he would do it. 72. PC Woodcock provided details of the arrest to PS Albutt confirming that was incapable of looking after himself, he came out of his parents car amicably although he had to be helped into the van due to his incapability. 73. PS Albutt authorised s detention and recorded on the custody record that he was very heavily intoxicated and clearly incapable of understanding what was asked of him. It is also recorded that he could not stand without assistance, was not alert or coherent, he was a high risk detainee, and a healthcare professional was required due to his level of intoxication. He decided that should be constantly observed via CCTV with 30 minute rousing visits. 74. The conversation then focussed on getting some help for his alcoholism. There was also a conversation about obtaining the list of medication that he was on and PC Woodcock and PS Albutt made a number of derogatory comments about being drunk. Version 0.1 Page 15 of 67

16 75. PC Woodcock remained in the custody area however once Mr Lloyd Butler was placed in his cell nobody did constantly monitor him. PC Woodcock positioned himself in a place where he would be able to observe the CCTV monitor but during this period frequently left the custody desk area and did not request any other officer to perform constant observations. PC Woodcock, PS Albutt and DEO Wall glanced at the CCTV monitor at times for a matter of seconds. 76. At 12.40pm DEO Wall telephoned Primecare, the health care professionals to request the attendance of a healthcare professional. He told them was very intoxicated, had previously self harmed, had mental health issues, was high risk and was an acute alcoholic. It is recorded on the custody record they would attend within 90 minutes. 77. At 12.43pm DEO Wall commented that he would be unable to rouse Mr Lloyd Butler (due to DEO Wall s own physical restrictions which prevent him from carrying out rousing). PS Albutt stated that he would get PC Woodcock to go down and give a nudge. PS Lloyd questioned PS Albutt about whether he knew what drugs had taken and PS Albutt commented that if he had drugs in his system it could be an overdose and therefore they would need to keep a close eye on him. 78. PS Albutt then told PC Woodcock they would keep visiting him every 15 minutes until the nurse arrived. This was not recorded on the custody record. 79. Since had been placed in the cell he had moved very little and remained in the same position. 80. At 12.44pm PS Albutt and PC Woodcock visited. They opened the cell door and was seen to make a slight movement. The officers stood at the cell door for seven seconds but did not go inside. On return to the custody desk PS Albutt stated that Mr Lloyd Butler was snoring like a pig and he recorded on the custody record Visit, Version 0.1 Page 16 of 67

17 roused, PIC is still drunk but otherwise in order PC Woodcock. 81. PC Woodcock became preoccupied with a private telephone call he made to his son on the custody telephone and there was a subsequent discussion which involved PC Woodcock examining his mobile telephone. During this period PC Woodcock also made a telephone call to obtain the list of s medication which was subsequently brought to custody by PC G. Throughout this period PC Woodcock engaged with other officers and did not constantly monitor. 82. At 12.54pm DEO Wall recorded on the custody record Visit in order. This appeared to be following a visit from DEO Wall looking at through the cell door spy hole. 83. At 1.00pm attempted to sit up on a number of occasions. In the last attempt leant off the bench head first and slowly slid onto the floor where he settled into a position laying on the floor on his right side. PC Woodcock watched and at 1.03pm stood up and said I can t fucking leave him like that can I? however after a few minutes sat down again and interacted with his mobile telephone for a further five to six minutes. DEO Wall intermittently watched on the monitor as he lay motionless. 84. At 1.15pm DEO Wall and PS Albutt visited. They went inside his cell for 27 seconds and DEO Wall touched his shoulder and attempted to obtain a response from him. lay away from the camera view therefore it cannot be seen if he opened his eyes or mouth or offered any form of communication. The officers left Mr Lloyd Butler laying on the floor and on their return to the custody desk PC Woodcock commented that made a snoring noise when they went in the cell and they should let him sleep. 85. PS Albutt recorded on the custody record Visit, roused, PIC is still drunk, but otherwise in order Opened eyes. Movement observed Heavily intoxicated. Situated in recovery position. 86. For the next 11 minutes PC Woodcock watched the CCTV monitor Version 0.1 Page 17 of 67

18 intermittently. He interacted with his mobile telephone, viewed an internet website accessed by PS Albutt, made another telephone call on the custody telephone and used the desk computer. 87. At 1.27pm Inspector A telephoned PS Albutt to enquire about Mr Lloyd Butler s condition and care plan and why a drunk and incapable person had been brought into custody. PS Albutt reassured him that he had seen in that condition before and a healthcare professional was coming out. PS Albutt informed Inspector A he knew should not be there but he had spoken to the arresting officer and they were aware it was generally a hospital matter. He stated I had this conversation anyway so, so they are aware, I m sure they won t do it again, its only Rodney Woodcock. 88. When the call ended PS Albutt reiterated to PC Woodcock that Inspector A had said that should not be in custody. 89. For the next 11 minutes moved slowly on the floor and tried to stand up. He put his hand out against the wall to balance himself, went back to the floor and then got on his feet. He swayed about, slowly moved to the cell door and pressed the cell call button. PC Woodcock watched the monitor as moved around and at 1.37pm commented to PS Albutt, If he falls over and bangs his head At 1.42pm PC Woodcock went to and spoke to him through the cell door hatch. He returned to the custody desk and explained that had requested the toilet and PC Woodcock pointed it out to him in the cell. responded by commenting that he could see more than one toilet in front of him. 91. Whilst monitoring the CCTV PC Woodcock saw standing unsteady at the cell door. At 1.43pm he left the custody desk to visit Mr Lloyd Butler and as he did so stumbled backwards and appeared to hit his head on the cell wall. This was not witnessed by PC Woodcock or any member of the custody staff. 92. When PC Woodcock opened the cell door was sat on the Version 0.1 Page 18 of 67

19 bench. The CCTV showed PC Woodcock stood outside the door and that he talked to him for almost three minutes. During interview PC Woodcock stated that informed him that he had hit his head and PC Woodcock asked him if he wanted a doctor. PC Woodcock says Mr Lloyd Butler just apologised for his behaviour. PC Woodcock returned to the custody desk and informed the custody staff that he had to point the toilet out to. 93. DEO Wall updated the custody record stating Visit by PC Woodcock as PIC is pressing buzzer. Requesting toilet advised that it is in his cell. 94. At 1.50pm attempted to stand up. PC Woodcock and PS Albutt watched as fell onto the bench, and came to rest on his stomach with his bottom exposed as his trousers had fallen down. There was a conversation about whether hit his head and whether this was a controlled stumble. 95. PC Woodcock continued to interact with his mobile telephone and did not constantly monitor. Shortly before 2pm DEO Wall noticed s state of undress and there was an inappropriate conversation regarding this. PC Woodcock commented to DEO Wall, He s been like that for ages, that s how he collapsed. 96. At approximately 2pm DEO Wall opened s cell hatch door for a few seconds. remained still during this visit. DEO Wall recorded on the custody record Visit in order. 97. Following this for approximately five minutes PC Woodcock, PS Albutt and DEO Wall talked about a Facebook website involving people not wearing much clothing. PS Albutt stated this could be accessed by the West Midlands Police Facebook website and PC Woodcock attempted to access it. PS H was not present during this conversation. 98. During this period there was a lack of monitoring of and for the following ten minutes PC Woodcock intermittently used his mobile telephone. rarely moved during this time. 99. At 2.15pm PS Albutt asked when was last roused and PC Version 0.1 Page 19 of 67

20 Woodcock informed him it was five minutes ago. PS Albutt then received a telephone call and was told the healthcare professional would arrive in approximately 30 minutes At 2.17pm PC Woodcock visited. He opened the door for less than ten seconds and did not enter. cannot be seen to move or respond to PC Woodcock and he was left in a state of undress lying on his stomach on the bench. PS Albutt informed DEO Wall to record on the custody record that had been roused, his eyes were open and movement had been observed, and this is what was recorded. The officers joked about s state of undress, smacking on the bottom and about Complaints and Discipline watching the CCTV For the next ten minutes made small movements but remained lying down on the bench. PC Woodcock intermittently interacted with his mobile telephone and was not constantly monitoring Mr Lloyd Butler At 2.36pm PC Woodcock visited. He opened the cell door for eight seconds but did not enter. attempted to sit up whilst PC Woodcock was present but was unable to do so and was not assisted by PC Woodcock. As PC Woodcock shut the door Mr Lloyd Butler lay down on his right hand side, still in a state of undress with his trousers around his thighs DEO Wall recorded on the custody record Visit in order by PC Woodcock. PIC roused and awake, movement observed. PC Woodcock returned to the custody desk and intermittently interacted with his mobile telephone At 2.41pm PS I entered the custody desk area. He spoke with DEO Wall and PS Albutt about a previous detainee and discussed upcoming training. He also viewed PS Albutt s computer From 2.44pm attempted to sit up and managed to do so but then fell to the side. PS Albutt and PC Woodcock observed Mr Lloyd Butler s efforts to sit up and PC Woodcock commented on this. He also Version 0.1 Page 20 of 67

21 stated that had made similar movements in his sleep when he visited him earlier At 2.46pm DEO A passed through the custody desk area but did not become involved in any conversations At 2.47pm PS I left the custody desk area and Nurse Ian O Hare arrived, and the custody record was updated with his arrival. DEO Wall briefed the nurse about and another detainee who was on Level 2 observations and had drug issues. DEO Wall stated that had hardly spoken since he had arrived in custody and PS Albutt commented that he had called for a nurse because of s intoxication and he did not know if it was appropriate he should be in custody At 2.49pm PS I returned to the custody desk area and spoke with PS Albutt for one minute and then left. Nurse Ian O Hare remained at the custody desk area and completed paperwork whilst discussing with PS Albutt unrelated matters During this period sat up but within one minute slumped against the wall, leaning on his left hand side with his legs off the bench. Around this time PC Woodcock left the custody desk area for one minute to make a drink, leaving the CCTV unmonitored At 2.54pm Nurse Ian O Hare decided to see the other detainee first. In his statement he says that the custody staff requested that he dealt with the other detainee before however this was not evidenced by the CCTV At 2.56pm moved from a sitting position onto the floor. He moved around before he settled laying on his right hand side At 2.57pm PS J came on duty in the custody desk area. PS Albutt pointed to his computer screen and stated He s totally utterly fucking shit faced, off his face, keeps rolling round his cell. I ve put him on, he s high risk from previous dealings, he s Level 3 and 30 minutes the nurse is here but hasn t seen him, its only because he s so fucking pissed, because D Version 0.1 Page 21 of 67

22 and I s are supposed to go to hospital, because it was Rodney I let him come here PS Albutt explained to PS J that the nurse was in custody with another detainee and was going to decide if should stay in custody. He also informed her that was an acute alcoholic. PS J looked at the CCTV monitor of whom at this point was laying on the floor At 2.59pm PS I returned to the custody desk area and asked DEO Wall if the nurse was there however DEO Wall s full response could not be heard on CCTV. He commented that the detainee would need to be seen in a cell because of the state they were in, and this reference appears to be regarding. PS I briefly used the computer DEO Wall had been using but settled at the computer PS Albutt had been using At 3.02pm DEO Wall handed over to DEO A and explained that Mr Lloyd Butler was drunk and incapable when he came in but he had been roused every half an hour, had been waking up and there were no issues with him. PC Woodcock made a comment about being unconscious in the van and having to squeeze his ear At 3.05pm PS Albutt left the custody area saying No more D and I s. Immediately after this Nurse Ian O Hare returned to the custody desk area and updated DEO A on the detainee he had just assessed At 3.07pm Maxine Parry, a Substance Misuse Arrest Referral Worker arrived at the custody desk area, following a request from DEO A for her attendance. At this point Nurse Ian O Hare disappeared from this area From approximately 2.57pm to 3.08pm attempted to sit up on a couple of occasions. He then lay on his right hand side for a period but ultimately came to rest on his back at approximately 3.08pm At 3.09pm A/PS D arrived in custody and began talking to PC Woodcock At 3.11pm Nurse Ian O Hare returned to the custody desk and confirmed with PC Woodcock that he was there to assess s fitness for detention. PC Woodcock then continued to talk with A/PS D and the Version 0.1 Page 22 of 67

23 nurse spoke with Ms Parry. He stated that may not be ready to be dealt with until midnight At 3.13pm A/PS D left the custody area and during this time the CCTV appears to show s chest stop moving. PC Woodcock does not view the monitor at this time At 3.14pm, PS I updated s custody record confirming that he, PS J and DEO A were on duty and they had accepted control of the custody record and the grounds for detention still applied At 3.14pm Nurse Ian O Hare and PC Woodcock left the custody desk area and visited who was laying on his back on the cell floor. In Nurse O Hare s statements he says they entered the cell and Mr Lloyd Butler had obvious difficulty breathing. He attempted to gain a response from him and placed him in the recovery position to maintain a clear airway. He says coughed and was observed to be breathing, he confirmed that a pulse was present but he was not able to gain any physical response and so advised PC Woodcock that an ambulance was required At 3.16pm PC Woodcock left the cell and returned to the custody desk area. He told PS J to telephone an ambulance and informed her that Mr Lloyd Butler was not fit to remain in custody. PC Woodcock then returned to the cell PS J continued to discuss an unrelated matter with PS I then walked to the cell and asked if the ambulance was wanted on blue lights to which she was informed it was. 90 seconds after the initial request, PS J telephoned the ambulance and whilst she was on the telephone PC Woodcock shouted that had crashed The nurse started CPR however there was a delay in administering the breaths due to difficulties in obtaining a mouth mask At 3.22pm the first member of ambulance staff, Mr Mark Pretty, arrived. The ambulance staff administered first aid treatment in the cell and took to Heartlands Hospital. He was pronounced deceased at Version 0.1 Page 23 of 67

24 4.10pm On 6 August a post mortem was carried out by Dr Kolar. He concluded that the cause of death was alcoholic liver disease and cardiomyopathy. The toxicology results showed alcohol levels were slightly over the drink drive limit and also showed evidence of mirtazapine (an anti-depressant drug), propanolol (usually prescribed for hypertension and angina), diazepam (usually prescribed for anxiety and insomnia), promethazine (a sedating antihistamine also used as an anti-emetic drug) and olanzapine (an anti-psychotic drug). None of these drugs were recorded as above therapeutic levels On 18 August a second post mortem was carried out by Dr Shorrock. He concurred with Dr Kolar s conclusion and also noted there was evidence of severe liver and heart disease. Policies and Procedures Licensing Act Section 12 of the Licensing Act 1872 states that if a person is drunk in a highway or other public place and appears to be incapable of taking care of themselves they may be arrested. Police and Criminal Evidence Act (PACE) Section 28 of PACE requires the fact of arrest and grounds of arrest be communicated to the arrested person at the time of arrest or as soon as is Version 0.1 Page 24 of 67

25 practicable after arrest. PACE Codes of Practice Code C 132. Part 9 of Code C states that someone suspected of being intoxicated through drink or drugs or whose consciousness causes concern must be visited and roused at least every half hour, have their condition assessed in accordance with Annex H and have clinical treatment arranged if appropriate. If any person appears to suffer from a physical illness or appears to need clinical attention a custody officer must make sure a detainee receives clinical attention as soon as reasonably practicable. Annex H provides a detained persons observation list and states that if any detainee fails to meet any of the criteria, a healthcare professional or an ambulance must be called. This includes consideration of whether the detainee can be woken, respond to questions such as questioning what their name is and where they are, and respond to commands such as requesting them to open their eyes and lifting an arm. Annex H highlights that a drowsy person who smells of alcohol may also be suffering from other ailments. West Midlands Police Safer Detention and Handling of Persons in Custody Composite Policy 133. This policy (referred to hereafter as The Policy ) is based on the Association of Chief Police Officers (ACPO) document Safer Detention and Handling of Persons in Police Custody It is made up of several parts and not all of those parts were in force on 4 August 2010, however the relevant parts (2, 3 and 7) were in force at the time The Policy states that drunk and incapable persons should be treated as needing medical assistance and an ambulance called Part 2 of The Policy covers risk assessment and management of detainees Paragraph refers to a detainee prompt card which is an aide memoir for use by all operational officers to assist in identifying potentially high risk detainees and where relevant directing the detainees to hospital at an Version 0.1 Page 25 of 67

26 early stage. The Policy states the card will be carried and used by operational officers prior to making an arrest, immediately following an arrest and before arrival in the custody suite Paragraph refers to the guidance detailed in Part 7 about the levels of observation once a detainee is in custody. Level 1 observation is for general observation, Level 2 intermittent observation, Level 3 constant observation and Level 4 close proximity Paragraph states that the custody officer is responsible for managing risk in the custody suite and states that if a detainee is identified as having medical needs the custody officer must ensure those needs are acted on as soon as practicable Paragraph states the custody officer must ensure all those responsible for a detainee s custody are briefed about the risks (in particular a relieving custody officer) but it is for all staff responsible for persons in their care to self brief Paragraphs 2.6 and clearly state that a detainee requiring urgent medical attention should not be taken to a police station and...that persons who are found to be drunk and incapable are treated as being in need of medical assistance and an ambulance called. It further states that, if the detainee declines or refuses treatment, as a last resort, they can be taken into a police station. The Policy directs that if staff are in doubt about a detainees medical condition an ambulance should be called to the scene and an ambulance will always be called for any detainee appearing unconscious It also says that detainees should be able to walk to the cell and say a few words and if not, they should not be placed in a cell but transferred to hospital The Policy states that detainees who are intoxicated, are problematic users, or who are withdrawing from alcohol are at an elevated risk of suicide The Policy provides a list of circumstances in which a healthcare Version 0.1 Page 26 of 67

27 professional is required to attend custody. Relevant to this investigation this includes a detainee being on Level 3 or Level 4 observations, and in circumstances where a detainee is drunk and either fails to respond to custody staff, their condition deteriorates, or if there is a decline in the level of consciousness, for example if speech becomes incoherent Paragraph states It is emphasised that the requirement to call a healthcare professional to the police station does not remove the necessity for custody officers to direct that a detainee be removed to a hospital when the condition of the detainee indicates that it is appropriate to do so Paragraph states that Where a detainee is quiet or snoring, which can be a significant indicator of risk; he/she should be roused and checked at least every thirty minutes until he/she is talking coherently Part 3 of The Policy covers initial contact and arrest and gives guidance on ways of minimising risks and managing the risks involved in detaining a person. It also advises on the use of alternatives to arrest Paragraph states that a person must be informed of the arrest and the reason for arrest as soon as is practicable. Officers should consider the physical and mental condition of the detainee at the time of arrest, report any concerns to the Communications Centre and be aware that responsibility for the welfare of the detainee is vested in them from the moment of arrest. It advises that in cases of concern or doubt consideration will be given to seeking immediate medical assistance and to the expediency and appropriateness of taking someone to hospital Paragraph 3.4 states that a detainee is to be taken directly to hospital, preferably by ambulance, where he/she is drunk and incapable and treatment centres are not available, or is suffering from any other medical condition requiring urgent medical attention Part 7 covers detainee care and sets out the responsibilities of all staff involved in the care and detention of those held in police custody, and states it should be read in conjunction with PACE Code C. Version 0.1 Page 27 of 67

28 150. Paragraph states day to day custodial decisions relating to a detainee are the responsibility of the custody officer and paragraph states that in circumstances when there are multiple custody officers they are all responsible however it is important for custody officers to agree and identify within the respective custody records those detainees for whom supervision and care has been accepted. Custody officers must also check detainees in their cells during or following the handover by the outgoing custody officer Paragraph 7.2 details that the custody officer must make sure that a detainee receives appropriate clinical attention as soon as is reasonably practicable when required Paragraph explains it is the responsibility of the custody officer to decide whether a person is fit to be detained at a police station. They may decide that clinical attention is needed before a decision can be made. It also states that any doubt about a person s fitness to be detained must be resolved by arranging for the person to be examined by a healthcare professional Paragraph 7.6 states that in medical emergencies an ambulance should be called and the detainee taken to hospital as soon as possible Paragraph further explains the levels of observation and engagement and states that the custody officer is responsible for recording on the custody record the level of observation required, the reasons for this decision, clear directions that specify the name and title of the persons carrying out the observations and where applicable the name of the person responsible for carrying out the review of the observations level Paragraph states that it is good practice whenever practicable for the same person to conduct visits to the cell to allow for evaluation of any changes in the detainee s condition. In circumstances when it is necessary to rouse a detainee, responses to actions and questions should be recorded on the custody record. Staff undertaking visits or observation must be appropriately briefed about the detainee s situation, risk Version 0.1 Page 28 of 67

29 assessment and particular needs. They should take an active role in communicating with the detainee and building a rapport Paragraph states that all staff involved in checking and rousing detainees must follow the rousing procedure guidelines, and directs staff to PACE Code C, Annex H Detained Person: Observation List Paragraph 7.16 states that effective briefing and debriefing of custody officers and staff is essential when handing over responsibility for detainees. Information must include the risks, vulnerabilities emerging issues control strategies and the welfare needs of each detainee and this should be recorded on the custody record. West Midlands Levels of Observation 158. This explains Level 1, general observation is the minimum acceptable level for all detainees and requires them to be checked at least every hour Level 2, intermittent observation is, subject to clinical direction, the minimum level acceptable level for those suspected of being intoxicated through drink or drugs, or whose level of consciousness causes concern. It requires them to be visited and roused at least every 30 minutes and CCTV or other technologies can be used in addition Level 3, constant observation states if the detainee s risk assessment indicates a likelihood of self-harm they should be observed at this level. This requires that the detainee is under constant observation and accessible at all times, physical checks and visits are carried out and the detainee can be constantly monitored by CCTV and other technologies. It also states that issues of privacy, dignity and gender are taken into consideration, any possible ligatures are removed, the detainee is positively engaged at frequent and irregular intervals, visits and observations including the detainees behaviour/condition are recorded on the custody record and any changes in behaviour/condition must be reported to the custody officer immediately. The detainee will be reviewed by a healthcare professional. Version 0.1 Page 29 of 67

30 161. Level 4, close proximity states detainees at the highest risk of self-harm should be observed at this level. It requires the detainee is physically supervised in close proximity and CCTV and other technologies do not meet the criteria of this, but may complement it. The requirements beyond this are much the same as for Level 3. The Prompt Card Aide Memoir 162. The prompt card states that a Person In Custody (PIC) should be taken directly to hospital if any of the list of factors are identified. This includes if the detainee has been unconscious, is drunk and incapable (i.e. unable to walk and talk), is suffering from a medical condition requiring urgent medical attention, or is suffering from any condition that an arresting officer believes requires treatment prior to detention It also lists a number of factors which may identify high risk detainees and states that this information should be brought to the attention of the Custody Sergeant at the earliest opportunity. The list includes whether the detainee has a marker for self harm, suicide or mental health and whether there is any information that suggests the detainee may be alcohol or drug dependent The prompt card was produced by Inspector Nicholas Binney, responsible for Safer Detention and Central Custody Support. It was notified to officers via the force intranet in April 2010 and should have been distributed to all operational officers. Training Operational Officer Training 165. Operational officers are not specifically taught about The Policy but a module on drunkenness in a public place forms part of their probationary training, however the content is dependent on when the officers joined. Since September 1998 officers have been taught that if a person is so drunk they cannot be roused they should be taken to hospital rather than a police station. Since that date they have also been trained that drunk detainees in custody should be visited at least every half an hour and Version 0.1 Page 30 of 67