This document is classified as OFFICIAL in accordance with the IPCC s protective marking scheme

Case 4 Bulletin 23 Man with a head injury who was also intoxicated Published 26 March 2015 For archived bulletins, learning reports and related background documents please visit www.ipcc.gov.uk/learning-the-lessons Email learning@ipcc.gsi.gov.uk This document is classified as OFFICIAL in accordance with the IPCC s protective marking scheme Man with head injury who was also intoxicated Handling of a man with a head injury, raising issues about: deciding whether a person is intoxicated or drunk, under the influence of alcohol, or has a head injury providing information from the arrest onto the custody sergeant to inform the risk assessment completion of risk assessments recognising whether a detainee needs to be checked and roused carrying out cell checks and recording information on the custody record recognising the symptoms of a brain injury training on force policy and national guidance clarifying the role and responsibilities of the whiteboard sergeant Overview of incident Mr A left a public house at around 12.15am. There were some reported sightings of him postincident between 12.30am and 1.50am in the local area, acting strangely, walking up and down, and stopping and talking to people. At times he was spotted in the middle of the road trying to stop cars. A number of cars stopped including a passing police car but then continued on their way. Around 1.50am Mr A got into a taxi and went initially to one area but was then taken by the taxi driver to the town centre as the taxi driver was unclear which exact address he wanted to be dropped off at. The taxi driver later reported that Mr A was talking nonsense; at times he appeared to be talking to himself and was also speaking from time to time in a Liverpool accent. Several times during the journey the taxi driver stated that Mr A rolled his eyes back into his head briefly, before refocusing. When the taxi arrived in the town centre the taxi driver beckoned over Police Constable B and asked for help. Following a conversation between the man and officers, the man left the taxi. Police Constable B arrested Mr A for being drunk and disorderly. Police Constable B took hold of one of Mr A s arms and Special Constable F took the other. Independent Police Complaints Commission. All Rights Reserved. Page 1 of 6

Mr A was described as struggling and twisting his body as if he was trying to get away. The officers tried to get Mr A in an arm lock to try and control him, but he continued to shout and move his head around violently. Mr A kicked out at an officer. Other officers and a door supervisor became involved. Mr A was taken to the ground by a number of officers and the door supervisor, and Mr A may have hit his head on the pavement. Officers reported later that they heard a noise that may have been Mr A hitting his head, and initially thought he had hit his head. Mr A was handcuffed and he was placed in Violent Person Restraint straps (VIPER). Mr A was then carried to the police van by four officers. Police Constable B and Police Constable C remained in the van during transportation to custody. On arrival at custody five officers carried Mr A into the custody suite. Mr A was taken into a cell and was placed on the floor on a mattress with his head nearest the door. Officers conducted a cell exit routine, removing handcuffs and the restraints. During this time CAPTOR spray was discharged by the custody officer at Mr A as he was threatening to bite and spit at officers. None of the expected aftercare was given following the use of CAPTOR spray. Furthermore, a written risk assessment was not carried out on Mr A. No information was passed to the custody officer about Mr A possibly hitting his head while he was arrested. This was not followed up by any other officer on duty at the time which meant that Mr A was not properly assessed for over seven and a half hours. There was confusion and a lack of team work among the custody officers who were on duty at the same time about the local practice of allocating a whiteboard sergeant who had responsibility for the care of detainees while in custody. Initially Mr A moved around the cell and eventually appeared to fall asleep. He remained asleep until just after 5am when he started tossing and turning on the bench. Thirty minute non-rousing checks were carried out throughout Mr A s time in custody. These checks were of a very poor standard and staff failed to recognise Mr A was in a coma. Staff also made an assessment that snoring meant the man was sleeping when in fact he was in a coma. During one visit to Mr A his arm was shaking as a result of his brain injury which the custody assistant determined as Mr A being awake. On one occasion Mr A tried to lay down on the bench, but slid to the floor. He tried to get up, but was unable to do so, and remained lying on the floor with his right arm over his eyes and holding his head. His left arm remained at his side, bent towards his body. Mr A remained in this position until approximately 9.30am when he stopped moving completely. At around 11am Police Sergeant E entered the cell and checked Mr A. He then put Mr A into the recovery position before leaving the cell to get help. An ambulance was called and Mr A was transferred to hospital where he was found to have a serious head injury. Type of investigation Independent Police Complaints Commission. All Rights Reserved. Page 2 of 6

IPCC independent investigation Findings and recommendations National recommendations Finding 1 1. The interpretation of PACE Codes of Conduct Code C, paragraph 9.3 on whether someone is intoxicated was an important issue in this case. The custody sergeant who booked in the man described his behaviour as that of someone drunk or under the influence of alcohol, not intoxicated and therefore not falling into the category requiring rousing. The reviewing inspector and the other custody sergeants on duty shared this view when asked about what circumstances would trigger a mandatory rousing regime under paragraph 9.3. 2. Ambiguity exists and the practice applied in this case suggests that staff do not set rousing checks unless they consider the state of the person in front of them is such that their intoxication borders on incapability. National recommendation 1 3. Custody staff should interpret intoxicated in the ordinary sense ie. under the influence no matter what degree of either drink (alcohol) or drugs or both has been taken. In that way, the possibility of missing a more serious underlying medical condition, such as a head injury, would be minimised. The Home Office should consider re-drafting paragraph 9.3 of PACE Code C to more explicitly define intoxication. Such a measure could help prevent future cases of death or serious injury in custody. Local recommendations Finding 1 1. The custody officer did not complete a written risk assessment on the man when he was booked into custody and he and other custody officers on duty failed to follow this up leaving the risk assessment uncompleted while he was in custody. He was not properly assessed for over seven and a half hours at which point he was found unconscious in the cell. Local recommendation 1 Refresher training on risk assessment 2. It was recommended that custody staff receive refresher training on risk assessments. Finding 2 3. The standard of care demonstrated by privately contracted custody staff and custody officers over that seven and a half hours was inadequate. Their collective failure to realise something was wrong contributed to the man remaining in a coma longer than he should. Independent Police Complaints Commission. All Rights Reserved. Page 3 of 6

Local recommendation 2 - Refresher training on cell checking and custody record entries 4. It was recommended that staff receive refresher training on cell checking, custody record entries and how to recognise and act on risk factors. Finding 3 5. There was a collective absence of understanding of how to recognise the signs of alcohol intoxication and how alcohol, snoring and heightened sexual drive can either mask or be direct signs of someone suffering from a brain injury. Local recommendation 3 Refresher training 6. It was recommended that custody staff receive refresher training on these issues. Finding 4 7. There was a collective lack of appreciation of the content and importance of following force policy and the Safer Detention Guidance, in particular amongst the private contractor staff and custody officers. Local recommendation 4 Local force policy training 8. It was recommended that staff receive refresher training on local force custody policies and Safer Detention Guidance. Finding 5 9. The local procedure of one custody officer being allocated the role of whiteboard sergeant led to confusion and an avoidance of responsibility amongst the custody sergeants on duty. There was a distinct lack of team work amongst all the custody staff that systematically failed to provide the man with an adequate level of care. 10. In conclusion, the investigation found that the force failed the man in that the combined actions and inactions of custody sergeants and privately contracted staff in the custody centre contributed to a systematic failure to adequately look after the man while he was in their care. Local recommendation 5 Roles and responsibilities 11. It was recommended that the force review the whiteboard sergeant system and introduce a written policy and procedure to clearly set out the role and responsibilities. The force should consider assessing any best practice from other forces that run large custody centres. Force response National recommendations National recommendation 1 1. Para 9.3 of PACE code C was amended to state: Independent Police Complaints Commission. All Rights Reserved. Page 4 of 6

Those suspected of being under the influence of drink or drugs or both or of having swallowed drugs, or whose level of consciousness causes concern must, subject to any clinical directions given by the appropriate healthcare professional: be visited and roused at least every half hour have their condition assessed as in Annex H and clinical treatment arranged if appropriate Note 9C of PACE code C also states the following: A detainee who appears drunk or behaves abnormally may be suffering from illness, the effects of drugs or may have sustained injury, particularly a head injury which is not apparent. A detainee needing or dependent on certain drugs, including alcohol, may experience harmful effects within a short time of being deprived of their supply. In these circumstances, when there is any doubt, police should always act urgently to call an appropriate healthcare professional or an ambulance. Paragraph 9.5 does not apply to minor ailments or injuries which do not need attention. However, all such ailments or injuries must be recorded in the custody record and any doubt must be resolved in favour of calling the appropriate healthcare professional. The Authorised Professional Practice detention and custody was also amended and provides the following guidance on drunk and incapable: a drunk and incapable person is someone who has consumed alcohol to the point that: they cannot walk or stand unaided, or they are unaware of their own actions, or they are unable to fully understand what is said to them. It also states in the under the influence section that: All detainees should be risk assessed on arrival in custody and throughout their detention. Where a risk assessment shows that the person is not drunk and incapable but that they have a degree of impairment from alcohol or drugs to the extent that any of the following apply, they should be considered as being under the influence and treated accordingly: close proximity (level 4) monitoring constant observation (level 3) monitoring the requirements for PACE Code C Annex H rousing checks. Local recommendations Local recommendation 1 Refresher training on risk assessment 2. Since this incident the force has assured itself that custody officers are aware of keeping the medical care of detainees at the forefront of the mind of custody officers. The force has given refresher training to custody officers through work booklets and authorised professional practice packages, as well as new training on the initial custody officer course. The custody computer system has also been updated to ask more specific questions about detainee care to enable the correct risk assessment to take place. Independent Police Complaints Commission. All Rights Reserved. Page 5 of 6

Local recommendation 2 - Refresher training on cell checking and custody record 3. This case and others nationally highlighted the need for joint training between the police and the custody service provider carrying out detainee welfare checks. A full training programme was conducted involving all custody officers and staff from the contracted company to carry out in-cell detainee welfare training. This training was carried out with stooges in cells who acted out different welfare and medical needs and the response of custody officers and custody staff was viewed and feedback given as appropriate. The training was well received by custody officers and custody staff. This training also reminded staff of the need to record as much information as possible on the custody record and to communicate medical needs amongst the team on duty. Local recommendation 3 - Refresher training 4. This issue was also covered in the refresher training as detailed in response to recommendations 1 and 2. Further to this, first aid training given to all police officers and custody staff covers recognising and responding to head injuries. Local recommendation 4 - Local force policy training 5. Joint refresher training and joint working practice between the force and the contractor has re-emphasised the importance of following guidance. The force has introduced a principal custody policy to support custody staff in the decisions that they make particularly with regard to getting the support they need when dealing with difficult medical issues. 6. Training was achieved through the online Authorised Professional Practice packages and also through the custody officer refresher booklets. Un-announced inspections also took place where the head of custody and the custody policy officer would attend custody centres and review the knowledge of the custody staff on duty and the custody inspectors. Local recommendation 5 - Roles and responsibilities 7. Visits of other custody facilities took place across the force and best practice was observed. All the custody facilities in the force area now operate a dedicated principal custody officer role and this person takes primary responsibility for detainee care. Outcomes for officers and staff 1. Three officers received formal advice following this investigation. 2. Three custody sergeants received formal advice for failing to properly look after Mr A during his time in custody. 3. Police Constable B and Police Constable C were provided with advice from their supervisors in relation to their failure to pass on information to the custody officer about what happened to Mr A when he was detained in the street. If you need more information about this case, please email learning@ipcc.gsi.gov.uk Independent Police Complaints Commission. All Rights Reserved. Page 6 of 6