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

31 should be roused and spoken to on each visit Since December 2003 the guidance and questions contained within PACE Code C, Annex H that should be asked of a person in determining levels of rousability have been included as part of the probationary training. Custody Officer Training 167. The contents of The Policy forms the basis of custody officer training for Custody Sergeants and DEO s. PACE Code C Annex H is also covered as part of the training course The training indicates that if a detainee is drunk and fails to respond to Annex H checks, or appears to deteriorate, if they have been given a four hour period to recover and there has been no recovery, a healthcare professional should be called The training documents direct custody staff away from referring to a detainee as high or medium risk and state risks should be considered as exceptional, significant, raised, or low Stephen Forrester, a West Midlands Police trainer confirmed that all officers on the courses were provided with a custody officer checklist and PACE handouts although they were not provided with a copy of the policy itself PS Albutt and PS H received refresher training in May 2010 and during this it is reiterated that persons that cannot walk or talk should not be in the custody suite and should be taken to hospital. DEO Training 172. DEO s are required to undertake a custody course and the course attended by DEO Wall in October 2007 highlighted the dangers of alcohol, alcohol withdrawal and treating alcoholics as suffering from an illness. The training stated that where a person shows no signs of sensibility or awareness they must be sent to hospital or call the nearest available medical practitioner Annex H is also referred to during the training including the need to check Version 0.1 Page 31 of 67

32 if detainees can be woken, respond to basic questions and respond to basic commands DEO Wall also received the refresher training given to PS Albutt and PS H in May Expert Opinions 175. Two custody experts were approached for an opinion with regard to Mr Lloyd Butler s condition and the care provided for him when he arrived in custody PS Geraint James, whose main role is to deliver both initial and refresher training with regard to safer detention and custody in South Wales Police, felt that national guidance and policy had not been followed and the custody officers should have attempted to interact with on a one to one basis in order to ascertain his condition and carry out a proper risk assessment. This would also show whether he was able to answer questions and would have assisted in devising a more personal care plan not based solely on information gathered from other parties and visual observations Detective Superintendent David Imroth, of the Metropolitan Police Service (MPS) was the lead for a service improvement project in relation to police detention. Prior to this he was the MPS lead for custody from July 2006 until October 2010 and remains the MPS lead subject matter expert in relation to the detention of arrested persons. He states that after viewing the custody CCTV footage of s arrival in custody his view was that should not have been brought to custody but should have been conveyed to hospital. He states he based this on procedures stating that drunken persons should not be brought to custody, but should be treated as a medical emergency He further states that if the detainee was conveyed to a custody suite a formal risk assessment should have been conducted, a healthcare professional should have been called immediately and should have been placed in the recovery position on a mattress on the Version 0.1 Page 32 of 67

33 floor with him being constantly monitored pending the health care assessment. Responses to allegations 179. All officers were subject to a criminal interview and these interviews were also accepted and used for misconduct purposes At the time of the incident PC A stated she had been a police officer for approximately 15 years. On 4 August she heard the call regarding Mr Lloyd Butler and volunteered to attend as she had previously dealt with him and they had got on well. She arrived with PC B, at the same time as PC Woodcock. She took the lead and spoke to who was in the front passenger seat of the car She described him as drunk with slurred speech and felt that he made little sense. She recalled that he said to her I thought you were my friend and generally felt he made little sense. She persuaded him to get out of the car and said he did so as she could not have lifted him. She said she had hold of his hand and offered very little support as he was assisted to the police van. She described him singing and flailing his arms in conjunction with a song he was singing. She considered to be drunk and no more but had no involvement in any discussions concerning his arrest Once was placed in the police van she spoke to Mrs Janet Butler who told her that she had a folder containing 25 years of mental health records. PC A stated she already knew had mental health issues and was an alcoholic due to her previous involvement with him. She was also aware that could be violent, that he kept weapons in his bedroom and that on two separate incidents CS spray and a Taser had been used on him PC A had previously dealt with at a hospital in June, when he was initially calm but then became aggressive. She was concerned Mr Lloyd Butler may become violent once in custody and so went to the Version 0.1 Page 33 of 67

34 custody suite to offer assistance. However remained calm and was already in a cell PC A was asked about her understanding of drunk and incapable. She explained this to be someone who could not talk, could not walk or could not physically look after themselves. She felt that could talk and walk and although she believed he was drunk she felt he was steady enough to turn around himself once he got to the van. She says she did not see signs that he was unwell and did not believe it was necessary for him to be taken to hospital PC A stated she had not seen the prompt card and could not recall any relevant training PC B stated that at the time of the incident she had been an officer for 13 years. She stated when she heard the call to attend the incident her thought process was that the police should respond quickly as Mr Lloyd Butler was likely to be a danger to his parents or to the police officers. She went with PC A and spoke to his mother whilst PC A dealt with Mr Lloyd Butler. Mrs Janet Butler told her that had been trying to smash the car windows and they were concerned he would harm himself or someone else Mrs Janet Butler explained s medical history and that his behaviour may be a result of mixing drink and drugs. She said Mrs Janet Butler said they did not know what to do anymore and she felt the health service had let them down. PC B talked to Mrs Janet Butler about how she could get assistance from mental health services PC B says answered PC A questions, he got out of his parent s car himself and walked with support to the van. She was not involved in s arrest and did not see him get into the van. She believed he was drunk because his movements were slow but had no concerns for his immediate welfare PC B was asked about comments contained within Mrs Janet Butler s statement. She disputed that she was told that was acting Version 0.1 Page 34 of 67

35 strangely and said Mrs Janet Butler indicated that s behaviour on this occasion was following the same pattern of behaviour as previous occasions. PC B did not hear anyone mention taking Mr Lloyd Butler to hospital When asked about training, she stated that following her drink driver training she was aware of the dangers of alcohol but she had no concerns for s immediate well being believing that if he was arrested he would have been taken straight to the custody block and seen by a doctor When asked about the prompt card she stated she had not seen them until after the incident when they appeared in custody and the parade desk areas. She understood someone to be drunk and incapable if they were unable to get up off the floor At the time of the incident PC C had been an officer for over two years finishing his probationary period in January 2010, and was single crewed when he responded to the call. He went to the car was in and spoke to his mother. He said was slurring his words, was grunting and talking a bit, but was unable to engage in conversation. He also said he was incoherent but calm. He said Mrs Janet Butler stated was drunk and she did not want him back due to his violent past There was a conversation about arresting for being drunk and incapable, to which PC C agreed. He stated PC Woodcock made the decision to arrest however he was not formally arrested and PC C felt he would not have understood even if he had been PC C felt he was drunk and incapable of looking after himself. He stated could stand up and walk but needed a guiding hand because he would have staggered and potentially fallen over. He did not believe needed to go to hospital and stated he had seen many people in a worse state that had been taken to custody. He stated he had no concerns for his health and wellbeing, beyond that for any drunk person. He felt there would be little a hospital could do for someone Version 0.1 Page 35 of 67

36 who is drunk PC C returned to Stechford custody and assisted as he got out of the van. He stated he did not feel s condition had changed during the journey. PC C stated after had been placed in the cell he got down onto the mattress himself When asked about drunk and incapable training PC C stated that there was none that he was aware of. He also stated that he had not seen the prompt card until after the incident A/PS D confirmed he had eight years service and stated on 4 August he was the Acting Sergeant for the response shift that day. He heard the incident on the radio and attended with PC E and PC F. When he arrived he saw PC A talking to. He described as mumbling and on occasions spoke coherently He discussed with PC Woodcock what they would do with and discussed the offence of breach of the peace. A/PS D felt Mr Lloyd Butler was drunk and incapable because of the way he was acting and PC A was not getting through to him. He defined this as someone unable to look after themselves, unable to carry out certain actions and unable to walk properly. A/PS D stated he did not hear anyone arrest Mr Lloyd Butler A/PS D stated walked slowly to the van with the assistance of officers. He stated he was talking throughout and made a non derogatory joke about the colour of A/PS D s skin A/PS D stated he contacted control to inform them they were taking Mr Lloyd Butler to custody for being drunk and incapable A/PS D stated that when he spoke to during the journey he responded to questions coherently. On arrival at custody Mr Lloyd Butler was in the same position as when he got into the van and he seemed to be sleeping. Other officers took into custody A/PS D stated he did not know, did not speak to his parents at the scene and had no recollection of hospital being mentioned. Version 0.1 Page 36 of 67

37 He stated in the past he had dealt with drunken people worse than Mr Lloyd Butler and had not taken them to hospital and did not consider Mr Lloyd Butler to be a medical emergency A/PS D stated he was not aware of the prompt card prior to the incident nor was he aware of any policy relating to drunk and incapable people. He also stated he had received no training on dealing with drunk and incapable people and had received no training on when to take someone directly to hospital PC E confirmed he had been an officer for nearly three years and stated he was at the station with PC F when the incident came in. He recalled that PC A mentioned a Taser and CS spray had previously been used to detain He attended with A/PS D and PC Smith and as they arrived A/PS D told them and PC G to hold back. PC E saw PC A try to coax out of the car but he got out of his own accord, with assistance from the officers PC E believed was drunk because he was lethargic in his movements. He explained his understanding of drunk and incapable to be someone whom he would have concerns about their ability to walk themselves or to look after themselves PC E stated it would have been difficult for him to reach an opinion about whether was drunk and incapable as he had not had a dialogue with him and there were other officers present that were able to reach any conclusions PC E got called to another incident and had no further involvement with. He believed would be taken to custody and the Custody Sergeant would make an assessment as to whether he needed a doctor PC E was asked about the prompt card and stated he had not seen it before the incident. He also stated that he had never dealt with someone arrested for being drunk and incapable. Version 0.1 Page 37 of 67

38 210. PC F attended the incident with PC E and on arrival they were told by A/PS D to hang back because of public perception, and so as to not upset any further. She was aware that PC B and PC A were talking to him and A/PS D and PC Woodcock were present They moved a little closer and she heard a female officer tell Mr Lloyd Butler to bring his legs out of the car and he then stood up. PC F described as shuffling along and being unsteady on his feet. PC F stated she had met on previous occasions when he had been animated, which was different to his behaviour on 4 August. She also stated that during the incident was talking but she could not hear what he said A/PS D told them was drunk and incapable and PC F explained in interview she understood this to be someone that could not look after themselves. She stated during the incident she did not make an assessment about whether this was appropriate as she did not speak with She stated she had not seen the prompt cards before the incident, but stated after the incident they appeared in cell blocks. PC F also confirmed she did not hear any conversation about taking to hospital and stated there was nothing of concern to her throughout the incident PC G stated he attended the incident in a caged police van with the knowledge that had a history of violence. He was one of the last officers to arrive and was told to stay back He was aware that PC Woodcock, PC B and PC A were with Mr Lloyd Butler but he could not hear what was being said. A/PS D signalled for PC G to bring the van closer so could be brought into custody. He opened the doors and watched walk with guidance from the officers. The officers were holding onto his arms and providing support. He stated was unsteady on his feet and his speech was affected but he could understand him. then got into the van and was singing a song to PC A. Version 0.1 Page 38 of 67

39 216. PC G stated he assumed had been arrested but he did not know what the offence was When they arrived at custody was asleep however PC G stated he was sceptical about this as had replied to their questions during the journey PC G stated during the search in the cell he was holding onto Mr Lloyd Butler at all times but felt that he could have stood unaided. He said Mr Lloyd Butler got onto the cell bench himself PC G then left custody and returned later with a list of s medication which had been left in the van PC G explained his understanding of drunk and incapable to be someone who is not in full control of their faculties and is so drunk that they put themselves in danger. He felt was drunk and incapable He did not think needed to go to hospital at the time as he had no injuries and he was responding to officers. PC G also stated he had dealt with people that were more intoxicated than When asked about training PC G explained his understanding of the powers of arrest available for people that were drunk and had been trained with regard to the rousing regime in custody. However at the time of the incident he was not aware of the detainee prompt card, or the requirement to take drunk and incapable persons to hospital. The card had been handed out after the incident and he was now aware of the force policy on Safer Detention PC Woodcock stated he was single crewed when the incident involving Mr Lloyd Butler came in. He arrived and officers were engaging with Mr Lloyd Butler s parents. He recalled that Mrs Janet Butler stated that he was out of control and due to PC Woodcock s involvement in a previous incident with felt he understood what she meant by this Mrs Janet Butler told him that had behaved in the same way in the past and they had previously left him to sleep it off in the car. He said no-one discussed s state of health at the time. PC Version 0.1 Page 39 of 67

40 Woodcock could smell alcohol in the car and felt was drunk due to his demeanour. He stated was not violent and following a conversation with A/PS D the decision was made to arrest him. PC Woodcock said no formal arrest took place as PC Woodcock felt he would not understand and so PC Woodcock told him Come with us He described as compliant. He stated walked to the van held by both himself and PC A because he was under arrest, and also to prevent him from falling. No handcuffs or restraint were used He said the journey back to the custody suite took ten minutes and he arrived a couple of minutes before the van. When the van was opened he described as having his head down, eyes closed and looking asleep PC Woodcock stated that he believed he asked the custody staff if Mr Lloyd Butler could be taken straight to a cell as he would fall asleep again if they sat him down. When questioned further about why he would bring someone in this condition into custody PC Woodcock stated that it was the best thing to do. When asked why he did not take straight to hospital PC Woodcock stated that he did not see any reason for that and he had no concerns that meant hospital treatment was required PC Woodcock described the search of in the cell and stated that was unsteady but was able to stand, he smelt of alcohol and did not speak. The officers guided him to the mattress before they left When PC Woodcock was asked about PNC checks and risk assessments he said PNC checks were conducted which showed warning signs for mental health, suicide, violence and self harm and PS Albutt informed him that had previously been on Level 4 observations. In terms of risk factors, PC Woodcock stated was drunk PC Woodcock stated he had carried out Level 3 and Level 4 observations on more than ten occasions previously and it was clear to him what he Version 0.1 Page 40 of 67

41 had to do; however during the interview PC Woodcock also stated that he was unaware of what the different levels of observation meant, or what rousing was until after the incident PC Woodcock was asked to comment on events whilst was in custody. He said regarding the 12.44pm visit PS Albutt would have taken the lead and did open his eyes. PC Woodcock was unaware of any risks associated with drunken persons snoring When asked about his comment at 1.03pm about not leaving Mr Lloyd Butler laying on the floor he said he did not visit the cell because Mr Lloyd Butler had readjusted himself into a recovery position. He also said around this time he was having a text argument with his son but he did not have any concerns about and felt he could sleep off the effects of alcohol so he could be seen by an Alcohol Referral Worker later in the day Regarding the visits at 1.42pm and 1.43pm PC Woodcock said Mr Lloyd Butler told him during the 1.43pm visit he had bumped his head. PC Woodcock asked him if he wanted a doctor and responded by apologising for his behaviour. He said seemed OK and he did not see any marks on him. He said did not express any concerns about how he was feeling and nothing raised or heightened his concern about his welfare. When asked whether PC Woodcock had informed the Custody Officer that had hit his head he stated that he thought he had but could not specifically remember saying it When questioned about the comment He s been lying like that for ages, that s how he collapsed PC Woodcock stated he did not see Mr Lloyd Butler fall directly to the floor, and if he had this would have raised his concerns During the visit at 2.17pm PC Woodcock said he spoke to who opened his eyes but did not speak. PC Woodcock did not give Mr Lloyd Butler any commands and did not touch him. He had no concerns and described him as a person sleeping off the effects of alcohol who he Version 0.1 Page 41 of 67

42 left in a half cocked recovery position, on his side with his head towards the door, his legs slightly bent and his arms above his waist. He described his comment about Complaints and Discipline watching as embarrassing but said it was not intended to be disrespectful During the 2.36pm visit PC Woodcock said he called s name and he responded by opening his eyes and he moved his head slightly. PC Woodcock did not give any other commands When questioned about why he did not ask anyone to take over the role of constant observations at 2.54pm when he left to make a drink he stated that he needed a break and no-one else volunteered PC Woodcock was asked about his comment at 3.02pm that Mr Lloyd Butler had been unconscious in the van, he said this was just a term and if had been unconscious he would have gone to hospital PC Woodcock stated that when he and the nurse went into Mr Lloyd Butler s cell the nurse said that they would call an ambulance and get the hospital to look after him. Once PC Woodcock had requested an ambulance he said within a minute or two changed colour and this was when PC Woodcock shouted that he had crashed and PC Woodcock went to find a mask. CPR was administered but he says they could not get back. The paramedics arrived and took over PC Woodcock stated that whilst he had been doing observations from the custody desk had moved his legs, turned over, sat up and this was clear on the CCTV When asked about what PC Woodcock would expect in a response and what would make him visit the cell he stated he would go into the cell if the detainee had something they should not have, if they were trying to self harm or if he could not see what the detainee was doing. He stated if they were unresponsive when they were called this would be noted and dealt with. With regard to the visits, PC Woodcock stated he always obtained some sort of response from PC Woodcock stated he did not carry out 15 minute visits because based Version 0.1 Page 42 of 67

43 on his viewing of the CCTV was moving around and turning over and there was no indication he was self harming. He said he did not physically rouse but considered speaking to him and him opening his eyes was rousing. He stated he had never been taught or told how to do rousing of detainees when carrying out constant observations. He also stated that he believed the main risk factor was Mr Lloyd Butler self harming PC Woodcock explained that he thought would be the nurse s priority but around the time the nurse arrived he was distracted by talking to A/PS D He confirmed that he had in the past taken people requiring hospital treatment straight to the Accident and Emergency department With regard to constant observations he said he did take breaks, used the custody telephone and also used his own mobile telephone. He accepted that he did not constantly monitor. He also stated he only needed to glance at the CCTV occasionally to see what was going on and nothing raised his concern When challenged about the derogatory comments made by PC Woodcock and that he left in a state of undress he apologised. When questioned about whether it was appropriate for him to be viewing a website via Facebook when he should have been performing constant observations he stated it was not PC Woodcock confirmed that at no stage did he see anything that raised a real concern regarding s condition and if he had he would have informed someone At the time Mr Butler s chest appeared on CCTV to stop moving, PC Woodcock was not watching the monitor. He stated he was using his mobile telephone but at times he could not see from the CCTV the rise and fall of s chest PC Woodcock was informed that whilst he was in custody there was an A3 sized poster behind him explaining what constant observations were. Version 0.1 Page 43 of 67

44 PC Woodcock stated he had not seen it Overall he said his role was to watch and make sure he came to no harm and particularly did not self harm. At no point did he have a concern that he should not be brought into custody When asked about training PC Woodcock stated he had received no training regarding alcoholics since his initial police training, and only the basics had been covered in police safety training when dealing with conflict. He stated he had not had any training regarding alcohol and detainees PC Woodcock was asked if he had received training on rousing procedures to which he replied he had not. He referred to the prompt card which he stated he had not seen prior to the incident and had never received any training on its contents. He was asked how he had previously dealt with people arrested for being drunk and incapable and he stated that he had always taken them to a police station PS Albutt stated he was on duty and there were approximately two other detainees in custody. He received a telephone call from control stating someone was coming in for being drunk and disorderly and he accepted the detainee on those grounds When arrived two officers were holding an arm each. He walked slowly with small steps and PS Albutt was of the view that if the officers had moved away he would have been able to stand and walk on his own. He stated s eyes were half open, half closed He conducted a quick visual risk assessment and decided that Mr Lloyd Butler was too intoxicated to be given his rights and entitlements or for a full risk assessment to be completed. He directed that be taken straight to a drunk cell. He confirmed he did not talk to Mr Lloyd Butler He stated there was nothing that gave him any extra cause for concern and he had seen numerous drunk and disorderly people in custody Version 0.1 Page 44 of 67

45 before. He stated he had never dealt with a drunk and incapable person before When asked about the conversation with PC Woodcock and reasons for arrest he said he was not asking PC Woodcock to change it in order to make it fit with the guidance that drunk and incapable people should not be in custody, he was just asking if there had been any disorderly conduct as this was what he was informed by control, and this was what the original call came in as. He was unaware at the time that the guidance said drunk and incapable people must not come into custody and must go to hospital Regarding the custody record entry that was not alert or coherent, PS Albutt accepted that he did not speak to, and regarding the entry that he could not stand without assistance PS Albutt accepted that this contradicted what he had said earlier in the interview but stated could have stood without assistance He was aware had a self harm marker and as a result detainees should be placed on Level 3 observations as a minimum. PS Albutt stated if did not have the self harm marker he would have put him on Level 2 observations, and had never in the past placed someone on Level 3 observations purely through their level of intoxication. PS Albutt also stated that he was categorised as a high risk because of the marker and because he was intoxicated. He stated anyone with self harm markers is categorised as high risk PS Albutt stated he advised DEO Wall to call a healthcare professional because Level 3 observations dictate that he had to, but stated in addition was intoxicated and therefore he wanted him to be assessed. He would not usually call a healthcare professional to assess someone who was drunk and was aware he was an alcoholic PS Albutt confirmed he decided PC Woodcock would carry out the constant observations PS Albutt told PC Woodcock that was on Level 3 Version 0.1 Page 45 of 67

46 observations and felt this was a sufficient briefing for PC Woodcock as he was an experienced officer and had dealt with in the past. He expected PC Woodcock to do 30 minute visits to the cell and to get a response from the detainee. He was aware that PC Woodcock had completed constant observations in the past PS Albutt stated he did not inform PC Woodcock his rationale for putting on Level 3 observations but informed him that he was high risk When challenged about his language and derogatory comments PS Albutt made no apologies and stated this was just language that was used. However when challenged about comments made by PC Woodcock and whether PS Albutt should have challenged them he stated that in hindsight he should have done When asked about his comment about putting on 15 minute rousing he explained the visits could be 30 minutes or less but he wanted to keep an eye on him. He believed the people responsible for Mr Lloyd Butler s care were aware of this and said in hindsight he should also have recorded the requirement for 15 minute visits on the custody record. He states he made this decision as a result of s level of intoxication When asked about the visit at 12.45pm PS Albutt queried whether this was the visit referred to on the custody record as he believed that from the way it was written PC Woodcock had given him the information. However he accepted there were no other visits and the CCTV of the cell and the custody desk correlated PS Albutt stated he could not recall making the visit but stated he did not physically rouse but may have made a verbal response. PS Albutt was challenged about this as on return to the custody desk a comment was made that was snoring. PS Albutt stated may have responded either before or after the snoring was heard. Version 0.1 Page 46 of 67

47 268. Regarding the visit at 1.15pm PS Albutt stated s eyes were open and he was looking at them, he responding to his name and there was head movement. He also stated that was in an improvised recovery position so he was happy to leave him like that When Inspector A telephoned he asked why a drunk and incapable person was in custody. He was satisfied with PS Albutt s response and that PC Woodcock was aware for future reference. PS Albutt stated following his conversation with Inspector A, he believed that once someone had been arrested for being drunk and incapable they must go to hospital, however he did not believe that once they were in custody they would have to go to hospital. However he stated if it happened again, and PS Albutt felt someone was drunk and incapable he would send them straight to hospital PS Albutt was asked whether he was concerned at s request to use the toilet at 1.42pm and 1.43pm despite there being one in his cell. He stated it did not as was up and about, he pressed the buzzer and had a conversation which suggested that his level of consciousness had increased At 1.50pm PS Albutt watched s attempt to stand up and fall down and was asked if he had any concern at that point. PS Albutt stated he had not because he did not see him bang his head, he did not fall down suddenly, it appeared to be a controlled stumble and was probably because his trousers had fallen down. He stated if Mr Lloyd Butler had come in and was not drunk and then began falling over he would be concerned. He agreed that s trousers should have been pulled up or he should have been covered with a blanket Regarding the accessing of the Facebook website PS Albutt stated it was not very professional but did not believe he encouraged PC Woodcock to view it Regarding the visit at 2.17pm and PS Albutt telling DEO Wall what to record on the custody record he could not explain his comments. He stated he did not see that had been roused, he did not see Version 0.1 Page 47 of 67

48 that s eyes were open and he did not observe any movement from at this time Regarding the visit at 2.36pm PS Albutt stated it was acceptable that a different person who performed the visit updated the custody record but the person who conducted the visit should explain what had happened Around 2.44pm PS Albutt watched attempt to sit up. PS Albutt said if he thought had hit his head he would have gone to the cell and done a physical check. PS Albutt believed the CCTV showed that landed on his shoulder Regarding the briefing of the nurse PS Albutt stated it was fair to say that had not spoken much whilst he had been in custody and this did not concern him Regarding Nurse Ian O Hare asking to see the other detainee before Mr Lloyd Butler he believed the other detainee had self harm or drug issues and he did not ask the nurse to see first because he had been satisfied with s response and observation levels and there was nothing that had given him extra cause for concern Regarding his handover to PS J it was pointed out that PS Albutt did not mention s self harm marker and the comments were about his level of intoxication. PS Albutt stated he did not have concerns about s level of intoxication at this point and it was just a general observation. He did not believe was incapable at this point as he had been sat up, stood up, responded to comments and he had pressed the cell buzzer When asked during his handover to PS J why he stated was on 30 minute observations instead of 15 minute observations he stated he just read off the whiteboard and this was something he failed to mention. He cannot explain why he failed to tell PS J that PC Woodcock was doing the constant observations When asked whether he did a handover to PS I PS Albutt stated that after viewing the CCTV it did not appear that he had. Version 0.1 Page 48 of 67

49 281. PS Albutt explained the general role of the Custody Sergeant is to look after the health and welfare of detainees and ensure they are treated properly. He stated it is a responsible position and he was aware that PACE, the Safer Detention Composite Policy and Health Safety impact on his role PS Albutt accepted he had responsibility for the welfare of but felt he put him on an appropriate care plan, he assessed him and felt at the time he had dealt with him appropriately. He stated that he had the initial responsibility for booking into custody and completing the risk assessment but following that he believed both Custody Sergeants to be responsible Regarding the prompt card PS Albutt stated he had seen them before the incident but did not remember having one himself and was not aware that it stated drunk and incapable people must be taken to a hospital PS Albutt stated that his understanding that drunk and incapable people should not come to custody was gained by a training day that he had attended before the incident. He did not consider sending to hospital as he felt he they could care for him appropriately by conducting the observations and calling a healthcare professional PS Albutt confirmed that training does state that people who appear drunk may be unwell or have an underlying cause but stated no further guidance is given about what to look for and this is a reason for calling a healthcare professional PS Albutt stated he felt he had sufficient training to undertake the Custody Sergeant role however he accepted there was a lack of understanding, training or knowledge which may have resulted in a different decision being made about When asked to explain his understanding of Level 3 observations he explained that a detainee must be observed at all times and you could use CCTV to do this, the detainee must be roused and a healthcare professional must be called. Version 0.1 Page 49 of 67

50 288. When asked whether he was satisfied that PC Woodcock was maintaining a constant level of observation PS Albutt stated that it was PC Woodcock s responsibility to ensure this was completed. He stated that as was put on constant observation due to the concern he may self harm, as he was sleeping a lot of the time he would not be at risk of harming himself PS Albutt stated he was not aware that PC Woodcock was on his mobile telephone a lot of the time, he was only aware of one telephone call PC Woodcock made to his son Having viewed the CCTV PS Albutt accepted that the observations could have been conducted to a higher standard When asked to explain his understanding of rousing PS Albutt stated that Code C Annex H stated that you have to walk into the cell, the detainee should be aware of where they are, what their name is and essentially be able to have a conversation. He also stated that it said where the detainee is drunk and fails to respond, or there is a deterioration you must refer them to a healthcare professional In terms of a physical response PS Albutt stated a detainee could hold their arm up, open their eyes and move their head. PS Albutt stated that with regards to the questions detailed in Annex H a high percentage of drunk people tend not to be able to answer questions about where they are, which is why he believed it gave the option of consulting a healthcare professional rather than sending them to hospital PS Albutt stated he believed Code C to be guidance around rousing a detainee, he did not believe it was a clear direction. He stated as long as he was satisfied there is a level of consciousness and response this would be sufficient PS Albutt was asked whether was roused sufficiently. He stated that he did not believe Annex H was followed word for word but he was satisfied that responded sufficiently. He then stated he could not speak for the visits he did not conduct. Version 0.1 Page 50 of 67

51 295. PS H had been a Custody Sergeant since April 2010 and recalled on 4 August PS Albutt received a telephone call stating a drunk and disorderly person was coming into custody. PS Lloyd recalled mention of a machete at some point When arrived in custody he was upright and steadied by officers. He had his eyes open but did not talk. PS H felt that is was not practical to obtain details from and he believed him to be drunk PS Albutt took the lead and started a custody record, he also decided to put on Level 3 observations. PS H understood this mandated an immediate contact with a healthcare professional and a minimum of 30 minute rousing. He was not aware of any warning markers but believed drugs may have been involved. PS H explained that both Custody Sergeants were responsible for all detainees and are able to access information on the system. He also stated that he felt PS Albutt and DEO Wall were competent officers PS Albutt decided that PC Woodcock would perform constant observations and rousing and PS H was aware that he had performed the role on many occasions previously. He recalled PC Woodcock making visits although he did not observe any of these being carried out When asked about constant observations PS H stated he felt they were impractical to do as so much was generally going on but it was left to the designated person to carry them out He stated he was unaware that PC Woodcock was interacting with his mobile telephone and was not concerned that PC Woodcock was not conducting constant observations at all times as he and other colleagues would intermittently look at the CCTV His involvement with was limited other than to observe the CCTV occasionally. He saw moving and had no concerns whilst he was in custody. He felt the care plan in place was more than adequate and was also aware that DEO Wall had called for a healthcare Version 0.1 Page 51 of 67

52 professional to attend At no stage whilst was in custody did PS H become concerned for his welfare. He denied hearing many of the inappropriate conversations involving PS Albutt, PC Woodcock and DEO Wall and stated if he had he would have challenged them PS H did not feel there was any need to prioritise to be seen by the nurse first and believed that PS Albutt had given PS I a briefing at the end of the shift From his intermittent viewing of the CCTV he did not know if there was a change in s demeanour but said he saw breathing, moving, standing and communicating PS H was aware that policy stated drunk and incapable persons are taken straight to hospital but believed due to the initial information that had been received was drunk and disorderly. However during the interview he accepted that he heard a conversation which discussed whether was drunk and incapable and was also aware that the custody record stated was arrested for being drunk and incapable. He felt the care plan in place was appropriate and PS Albutt was privy to more information than he was PS H was familiar with the rousing procedures which involved calling a persons name and seeing if there was eye movement, speech and movement of limbs. He confirmed he had received custody training but was not sure if he was aware of the detainee prompt card before the incident DEO Wall provided a written statement and answered no comment to almost all questions On 4 August he was aware of a telephone call from the control room advising that a male had been detained on the grounds of being drunk and disorderly and was due into custody At the time arrived in custody he was assisting PS H with another detainee but described as walking, slightly Version 0.1 Page 52 of 67

53 unsteady on his feet, and he had glazed eyes. DEO Wall believed Mr Lloyd Butler to be intoxicated PC Woodcock suggested was likely to be violent and he was taken straight to a cell. PC Woodcock informed the custody staff that had been arrested for being drunk and incapable His understanding was that was placed on Level 3 observations because of his intoxication and a nurse was contacted. He advised PS Albutt that he could not rouse due to DEO Wall s own physical restrictions He did not know how many times was roused by PC Woodcock but recalled making additional visits beyond those recorded and checked him through the hatch on the cell door. At these times DEO Wall said he saw movement and breathing/snoring He said on the one visit he made with PS Albutt, opened his eyes, lifted his head, was breathing and movement was observed. He did not feel at that stage there was any deterioration in s health He remembered seeing moving about in his cell unaided and that PC Woodcock advised him about the toilet in his cell He said the nurse was briefed about when he arrived, and the nurse asked to see another detainee first. Y He said the late shift were briefed about and he specifically briefed DEO A. This included the information that Mr Lloyd Butler was about to be seen by the nurse DEO Wall apologised about inappropriate comments he had made and said they were not meant maliciously or to cause offence Inspector A was responsible for Sutton Coldfield, Kings Heath and Stechford Custody He was responsible for the maintenance of detention facilities, selection, training, recruitment and complaints against Custody Sergeants and Version 0.1 Page 53 of 67

54 health and safety matters. He said the health and safety of the detainees was not his responsibility and lay with the Custody Sergeant and Local Policing Unit (LPU) Duty Inspector. Therefore he would not normally get involved in the day to day running of the custody suite On 4 August he looked at the whiteboard for Stechford and noticed there was a drunk and incapable detainee. He contacted the custody desk as he wanted to remind staff that in the circumstances should be dealt with as a medical emergency PS Albutt told Inspector A he had seen in that condition before and he had contacted a healthcare professional to assist him with his decision. Inspector A felt that PS Albutt would have conducted a risk assessment and put a care plan in place. He asked PS Albutt to advise the officers about the policy in relation to drunk and incapable people Whilst Inspector A said he could have directed PS Albutt in a different direction if he felt he had made a mistake, he did not feel there was anything untoward on this occasion. Inspector A did not have access to the CCTV of Stechford custody suite Inspector A understood the definition of drunk and incapable to be someone who could not walk or could not talk Inspector A was aware of the prompt card and its contents however was unaware it stated drunk and incapable people would go straight to hospital. He did not tell PS Albutt to send to hospital, only that he should be treated as a medical emergency. He also stated that the prompt cards had been distributed to custody staff and there had been spares to distribute to officers. He gave a box of them to PS Wilson to distribute prior to 4 August He also stated that he felt the prompt card was only guidance and it contradicted the policy because someone could not be forced to go to hospital to receive treatment Inspector A also stated that the policy applied to conducting a risk assessment on the street. When was brought into custody Version 0.1 Page 54 of 67

55 PS Albutt s decisions followed the policy as he had called a healthcare professional. Y Having reviewed the CCTV footage after the incident, Inspector A stated he would not have arrested Mr Butler for being drunk and incapable and would have used an alternative offence. He felt based on the incident log and s history of violence the hospital was not the best place for him and the police had a responsibility for him. PS Albutt addressed s medical needs and Inspector A felt this was correct PS I had been a Custody Sergeant for three years. When he came into custody on 4 August 2010 he was told that was in custody for being drunk and incapable. PS I responded that this meant he was a medical emergency and should not be there PS Albutt informed PS I that had entered custody under his own steam and was able to converse with PS Albutt. PS Albutt mentioned he had received a telephone call from Inspector A and PS I was aware a healthcare professional was on the way. PS I stated that he would have sent to hospital but steps had already been taken to make sure that he was alright PS I also recalled that PS Albutt told him he had received two telephone calls from the control room prior to coming into custody stating that was coming in for being drunk and disorderly. He was aware was on Level 3 observations and thirty minute visits from viewing the whiteboard PS I was questioned as to when all of the information was passed to him because it was not possible to hear or see this on the CCTV footage. He said it was when he first came into custody and was moving back and forth between the room to the rear of the custody desk, and when he was stood next to PS Albutt. PS I had listened back to the CCTV footage but stated the relevant conversation was inaudible PS I was aware that drunk and incapable persons should be treated as a Version 0.1 Page 55 of 67

56 medical emergency and consideration made of taking them to hospital because it was in the Safer Detention Policy and in the prompt cards. He stated custody staff had been asked to distribute the prompt cards to operational officers prior to 4 August. He stated he had distributed the prompt cards to some officers if they brought someone in with a head injury but felt they should have been distributed elsewhere so officers knew their obligations PS I explained that the prompt card was for use by operational officers on the street, and they should call an ambulance to establish if the person needed to go to hospital. However, once a person arrested for drunk and incapable is brought into custody PS I felt the Custody Sergeant s responsibility pursuant to policy is to book a person in, carry out a risk assessment and assess whether they can walk and talk. Following this and a review of their history, the Custody Sergeant should decide if they should go to hospital or a healthcare professional should be called PS I said he had sent people away on arrival at custody due to their condition but felt that PACE limited his options to a certain extent because a custody record needed to be started. PS I explained that he would be more concerned with the effects of withdrawal a few hours after they had been in custody rather than any staggering or slurring when a person first arrived into custody PS I explained during a handover details of arrests, prisoner condition, personal knowledge of a detainee and any delays should be discussed. He said most of the handover is verbal although he understood guidance suggested it should be written if possible. He explained a Sergeant will handover to a Sergeant and a DEO will handover to a DEO. He did not feel it necessary to tell anyone about the briefing he had and assumed PS J would have received a briefing PS I said that responsibility for detainees was jointly held by both Sergeants on shift. He knew PC Woodcock having worked at the same station as him previously and assumed PC Woodcock knew what constant observations required as he had carried them out before. He expected Mr Version 0.1 Page 56 of 67

57 Lloyd Butler would have been asked questions to get him to converse, given pain stimulus and if that did not work an ambulance would have been called. PS I stated the Custody Sergeant is supposed to brief officers about the rousing policy and the levels of observation were printed in a folder in the custody area, therefore PC Woodcock should have known what to do PS I said when he looked at the CCTV he saw on the floor but as he was just off the low bench he had no concerns PS I believed Primecare were either on their way, or already present when he came on shift. He could not recall the answer given to his question of DEO Wall asking whether Primecare were there but recalled PC Woodcock giving the Primecare nurse an update later PS J had been a Custody Sergeant for ten months but had served 17 years as a police officer. Her recollection was that she was told during the handover from PS Albutt that was drunk and incapable but he was okay, had been talking to PC Woodcock and had been moving around. She was also informed that the nurse was there to see him now and was aware that PC Woodcock was conducting Level 3 observations She then became involved in locating some papers for the Magistrates Court. She felt some pressure because she believed the officers involved went off duty at 4pm and the court also shut at 4pm. Whilst she was attempting to find them PC Woodcock informed her that needed to go to hospital but she did not get the impression this was urgent PS I found the papers and PS J asked him where he had got them from and what he was going to do with them. She then went to Mr Lloyd Butler s cell to see if an ambulance was wanted on the 999 system, and to establish what was wrong with so she could inform the operator. At this time no CPR had begun She states she called for an ambulance and whilst on the telephone PC Woodcock said something which suggested in was an emergency. She Version 0.1 Page 57 of 67

58 then became involved in trying to locate a vent aid to assist with the first aid treatment With regard to briefings, PS J stated she would expect the outgoing Custody Sergeant to brief each incoming Sergeant. She assumed PS I had received a briefing and felt that if he had not, he would have requested one. She also stated that both Custody Sergeants were jointly responsible for detainees When asked if she had seen the prompt card, PS J could not be sure if she had seen it before the incident but believed it had been covered through courses she had attended. She believed that if a person could not walk and talk they should go to hospital. After she had received the information from PS Albutt she did not consider to be drunk and incapable PS J understood Level 3 observations to be constant observation, and to include half hourly checks. She also understood the requirements of rousing PS J stated if she was aware of inappropriate comments or behaviour she would have challenged them and if she had known more information she would have acted faster and would have been more concerned. Conclusions 347. Officers were initially called to a report of behaving in a violent manner. He was known to West Midlands Police and as a result a number of officers attended however many did not become involved. When they approached him he was not violent, he did not converse and was unable to walk unaided. Whilst officers may have arrested Mr Lloyd Butler for being drunk and disorderly, due to the initial report from his parents, it was reasonable in the circumstances for the officers to suspect he was drunk and incapable The Policy and the prompt cards state that drunk and incapable people should be treated as needing medical assistance and an ambulance is Version 0.1 Page 58 of 67

59 called Operational officers do not receive training on The Policy and there is no audit trail or evidence to show that the prompt cards were handed out until after the incident. PS Wilson states he handed the prompt cards out to his shift prior to 4 August, which would include PC A, however she has no recollection of this and there is no evidence to prove this was done Mr and Mrs Butler suggest that there was a conversation about taking Mr Lloyd Butler to hospital but none of the officers recollect this and there is no other supporting evidence for this There is no Misconduct case to answer for PC A, PC B, PC C, A/PS D, PC E, PC F or PC G PC Woodcock was involved in the arrest of. It is PC Woodcock who stated that due to s level of intoxication he did not formally arrest him, and therefore did not tell Mr Butler he was under arrest, or give the grounds for arrest. This does not comply with the requirements of PACE and gives an insight into s perceived level of capability When arrived at custody PC Woodcock had to pinch his ear in order to wake him and remove him from the van. This should have prompted PC Woodcock to reconsider whether custody was an appropriate place for to be Once in custody PC Woodcock was involved in a conversation about whether it was appropriate for to be there. PC Woodcock replied to PS Albutt that he did not believe the policy was enforced until 24 August which suggests PC Woodcock had some knowledge of the West Midlands Police Safer Detention and Handling of Persons in Custody Composite Policy surrounding drunk and incapable people. However the investigation cannot prove that PC Woodcock received any training on The Policy or had sight of the prompt card. It is possible that PC Woodcock saw the information on the force intranet but ultimately once Mr Lloyd Butler arrived in custody PS Albutt endorsed his decision by Version 0.1 Page 59 of 67

60 allowing to stay PC Woodcock had previously conducted constant observations in custody however the standard of this cannot be judged. On 4 August he did not receive any instructions about how to carry out constant observations, but neither did he ask for any guidance. PC Woodcock became distracted and became involved in a number of unrelated and inappropriate matters. Whilst he accepted that the constant observations were not conducted appropriately his actions fell below an acceptable standard PC Woodcock made a number of visits to and many of these did not comply with the requirements to rouse an intoxicated detainee. PS Albutt failed to brief PC Woodcock about what to do and did not set a good example on the 12.44pm visit they conducted together. It is of concern that PC Woodcock made a comment that the officers should leave to sleep which suggests he did not understand the risks associated with an intoxicated individual, nor of the requirements to rouse such a detainee PC Woodcock maintains that in every visit PC Woodcock conducted Mr Lloyd Butler gave some form of response. It is impossible to conclude whether in fact did respond meaningfully PC Woodcock was told by PS Albutt that 15 minute checks were necessary until the nurse arrived, however PC Woodcock failed to do this. He states he decided they were not necessary but he did not clarify or discuss this with PS Albutt. It is also concerning that PC Woodcock failed to inform the custody staff that had informed him he had hit his head. This is a crucial factor in determining risk assessments The comments made by PC Woodcock about s state of undress were inappropriate and he should have made attempts to preserve the dignity of Whilst was in custody he had been observed to be moving, and at a later stage had a conversation with PC Woodcock. This may have suggested to PC Woodcock that his condition was improving Version 0.1 Page 60 of 67

61 however the level of care provided by PC Woodcock and his unprofessional behaviour throughout was unacceptable There is case to answer for PC Woodcock for Misconduct PS Albutt had the greatest knowledge and involvement with Mr Lloyd Butler s care whilst he was in custody. It is recognised however this responsibility is shared with the other on duty Custody Sergeant PS Albutt made no attempt to speak with on his arrival and failed to complete a detailed risk assessment. This is a clear failing and one commented upon by the experts. On learning that the reason for arrest was drunk and incapable PS Albutt suggested PC Woodcock may wish to change it to drunk and disorderly however PS Albutt states this was a legitimate question due to the information he had initially received PS Albutt understood that drunk and incapable persons should not be in custody but stated he was unaware they must go to hospital. This is despite attending full custody training and having a refresher training day only three months earlier. He appears to use his own assessment to determine that he could provide an appropriate level of care for Mr Lloyd Butler albeit he did this in the knowledge that it was contrary to force policy and without proper regard for his condition It is accepted that Inspector A did not direct that was taken to hospital however PS Albutt had a greater knowledge of, and had received a greater level of training on the care of detainees. PS Albutt informed Inspector A that he had previously dealt with Mr Lloyd Butler in the same condition before yet he accepted in interview he had only had limited dealings with him PS Albutt stated he took the self harm markers into consideration for his care plan and suggested these were his main area of concern as he had never put anyone on Level 3 observations as a result of intoxication alone. This is not supported by CCTV when all the conversations centre around s level of intoxication. It is of significant concern that PS Albutt appeared unable to recognise the seriousness of s Version 0.1 Page 61 of 67

62 condition PS Albutt s repeated references to allowing to remain in custody because it was PC Woodcock that brought him in are of concern. This is not a legitimate reason for inadequate care. PS Albutt failed to adequately brief PC Woodcock about what constant observations require, failed to explain what was required from each visit, and failed to ensure that 15 minute visits were carried out. He did not challenge PC Woodcock when it is clear he was not conducting constant observations to the required standard During the visits PS Albutt conducted there is little evidence to show that gave any form of meaningful response. PS Albutt had a clear understanding of the rousing requirements yet failed to do so himself and failed to ensure others did this. This also resulted in inaccurate entries on the custody record. In addition, PS Albutt s instructions to DEO Wall about what to record on the custody record at 2.17pm are unacceptable as he did not conduct this visit, nor did he witness s response As a supervisor PS Albutt had a senior role to play yet failed to do so. He encouraged others to view a Facebook website, he failed to preserve Mr Lloyd Butler s dignity and many of his conversations were unprofessional and inappropriate. His attitude and behaviour evidences a lack of care and regard for s health and wellbeing, and shows a lack of recognition of the responsibility that the role of a Custody Sergeant entails It is accepted that PS Albutt could perceive there was an improvement in s condition due to his movements however he was still clearly unwell. When the healthcare professional arrived PS Albutt placed no urgency on seeing first despite failing to initially send him to hospital PS I stated PS Albutt had given him a briefing which stated that Mr Lloyd Butler could walk and talk. There is no evidence to prove this conversation took place. The briefing he provided to PS J failed to mention that 15 Version 0.1 Page 62 of 67

63 minute visits were required. This information was also not mentioned in the custody record There is a case to answer for PS Albutt Gross Misconduct PS H had the least involvement with during his time in custody however the responsibilities remain the same for both Custody Sergeants. He failed to attempt to speak to and he initially decided could be taken straight to a cell, and thereby failed to ensure a risk assessment was conducted PS H was aware that drunk and incapable persons should go to hospital and was aware of a conversation discussing this point, yet he failed to challenge the officers that brought him in, and failed to challenge PS Albutt when he allowed to remain in custody It is accepted that throughout the majority of his shift PS H does not involve himself in inappropriate conversations or behaviour and is involved in other matters PS H did hear references to stumbling and hitting his head and this should have raised his concern, however in the circumstances it was reasonable for him to rely on the fact that proper visits were being made to regularly assess s health With regard to the observations being conducted by PC Woodcock, PS H said he was not concerned PC Woodcock was not observing all the time as his colleagues would intermittently view the CCTV. As he understood that PC Woodcock was undertaking those observations and was aware there were periods of time when this was not done PS H should have challenged this PS H, who had performed the role of Custody Sergeant for approximately three months, failed to ensure the care afforded to was appropriate. However in reality he had to rely on PS Albutt and PC Woodcock to monitor s health and to adequately implement the care plan that had been put in place In relation to PS H, there is no case to answer for Misconduct or Gross Version 0.1 Page 63 of 67

64 Misconduct however the force may wish to consider Unsatisfactory Performance Procedures DEO Wall was part of the custody team that were dealing with Mr Lloyd Butler and he had received the same refresher training as PS Albutt and PS H a few months earlier where officers were told that people that could not walk and talk should not be in custody. He was aware of Mr Lloyd Butler s condition and the comments by PS Albutt that he should not be there but did not comment on or challenge the decision to allow Mr Lloyd Butler to stay On the visit DEO Wall conducted with PS Albutt it appears that he failed to obtain a verbal response from and therefore this visit was not PACE compliant. However it is accepted that this visit, and the efforts of DEO Wall were the greatest effort made by anyone to obtain a response whilst was in custody On instruction of PS Albutt, DEO Wall recorded a custody record entry following the visit at 2.17pm. He failed to ask PC Woodcock what occurred during the visit and the CCTV does not support the view that Mr Lloyd Butler was adequately roused. Therefore the entry was misleading and inaccurate When DEO Wall briefed the incoming DEO, he said had been roused every 30 minutes and there were no issues with him. He knew or should have known this was not true In addition DEO Wall is party to and makes comments that show a lack of respect for and evidences a lack of care for his well being There is a case to answer for DEO Wall for Misconduct Inspector A knew about the prompt cards and was aware that drunk and incapable persons needed to be taken to hospital. However during interview he maintained that the prompt cards are inconsistent with force policy as a hospital may refuse to give treatment or a detainee may refuse to receive treatment He was concerned enough about there being a drunk and incapable Version 0.1 Page 64 of 67

65 person in custody to telephone PS Albutt but did not ask whether Mr Lloyd Butler refused treatment, whether a hospital refused to administer treatment or about the condition of. These would be reasonable questions given his understanding of the prompt cards, force policy and him being told that was in the same condition as he was when he was in custody previously Inspector A could not view any CCTV and therefore it is accepted to a large extent he had to rely on PS Albutt to make an accurate risk assessment and implement an appropriate care plan Inspector A has outlined his position having now watched some of the CCTV footage. Whilst Inspector A may not have seen all of the available footage, the evidence suggests should have been taken to hospital and it is important for someone in Inspector A position to appreciate this. It is also important that all officers including Inspector A are aware it is the current condition of a person that determines whether a person goes to hospital and it is not necessarily determined by the offence for which someone is arrested. Although the force policy is clear about drunk and incapable persons a person arrested for another offence may equally be drunk and incapable (unable to walk or talk) There is no Misconduct case to answer for Inspector A however the force may wish to consider Management Action to ensure Inspector A fully understands the requirements of The Policy PS I claimed to have had an extensive briefing from PS Albutt however the CCTV footage does not corroborate this. There are short periods of inaudible CCTV when PS Albutt was talking to PS I however it is unlikely that the extent of information PS I claims he was given was provided to him at that point. He was present when DEO Wall provided a briefing to DEO A but it is quite likely that PS I was made aware of the majority of the information at a later point It is accepted however that PS I was aware that was drunk and incapable when came into custody. Version 0.1 Page 65 of 67

66 393. There is no record on the custody record to say a briefing had been received and PS I assumed PS J had received a briefing. This is not something that should be assumed especially as neither Custody Sergeant appeared to take any control of s care PS I formally accepted the transfer of the custody record but was not diligent or pro active in ensuring that the nurse saw expeditiously. Like PS J he seemed content for PC Woodcock to oversee and did not ensure he understood his role PS I stated in interview he felt his options were limited once a drunk and incapable detainee arrived in custody despite him being clear that such a person should not be there, as he said that a custody record needed to be started. It is important that there is no confusion on the part of any Custody Officer that drunk and incapable persons should be taken to hospital irrespective of other procedural needs such as whether a custody record had already been, or needed to be started There is no Misconduct case to answer for PS I PS J was told by PS Albutt during a handover that was brought in because he was drunk and incapable but PS Albutt let him stay in custody because it was PC Woodcock that brought him in. She was also told that he kept rolling around in his cell and PS J failed to challenge any of this. It is accepted however that she was told the nurse was present and it should have been more expedient for to remain in custody. PS J states she was told that had been talking however there is no evidence to support this PS J assumed that PS I had received a briefing about. As they are both jointly responsible for detainees both Sergeants should be clear about the briefings received and it is not safe to assume they have received the same briefing. She also relied on PC Woodcock knowing what he was doing PS J is told by PC Woodcock to call an ambulance. It is accepted from viewing the CCTV that PS J became distracted with another matter but Version 0.1 Page 66 of 67

67 she stated if she had received more information she would have acted quicker. PS J has to take some responsibility for this. She delayed calling an ambulance and based on the briefing she had already received her lack of urgency is of concern There is no Misconduct case to answer however the force may wish to consider Management Action. Darren Wall Lead Investigator Gemma Jackson Deputy Senior Investigator December 2011 Version 0.1 Page 67 of 67