By Gabriel Princewill-
An investigation by the Independent Police watchdog has concluded that an unnamed healthcare professional had a case to answer for misconduct for failing to properly assess a man who died in police custody or identify that she required medical assistance that could not be provided to him within the custody suite.
A jury returned the damning findings following a two-week inquest at Nottingham Council House into the death of 50-year-old Darren Brown from Mansfield.
Mr Brown was arrested in a park off Sandy Lane, Mansfield on suspicion of a drugs offence shortly after 8pm on Friday 23 June 2017. He was then taken to Mansfield Police Station where he was later found unresponsive in his cell after a routine check the following morning. Paramedics attended and he was sadly pronounced dead at 5:13am that day.
Pathologist Guy Rutty, who watched CCTV footage of Mr Brown in the hours before he died, described him as behaving in a “bizarre” manner.
“He appeared to me to be restless and performing unusual arm and hand movements, placing his hand to his mouth area, and picking up a food spoon and moving it up and down his body,” Prof Rutty said.
He said Mr Brown then went to the toilet.
“He remained on the toilet and looked in discomfort,” he said.
“He was seen to slump backwards against the wall and he remained in this position between 04:12 and 04:36.”
The police watchdog found that the health professional failed to recognise the immediate need to send Mr Brown to hospital for treatment. As the individual no longer works for Nottinghamshire Police, having been a contractor at the time of the incident, no disciplinary action could be taken, the watchdog found. The information was passed to the Health and Care Professions Council.
The IOPC’s investigation that the detention officer had a case to answer for misconduct for failing to carry out checks on Mr Brown to a sufficient standard and for failing to identify that his condition had deteriorated.
The half hourly checks of Mr Brown between 12:03am and 04:03am on 24 June fell below the expected standard, with observations conducted solely through the cell door spyhole and hatch and too briefly to adequately assess Mr Brown’s deteriorating condition. Following a misconduct meeting held by the force in June 2020, misconduct was found proven in respect of not conducting thorough checks on Mr Brown, but not proven in respect of her having not recognised or acted upon his deterioration.
The meeting also found misconduct proven in the making of false entries on the custody record. The outcome was management action, an unsatisfactory outcome for utterly shameful conduct by a health professional.
The IOPC also concluded a second detention officer had no case to answer for misconduct, but found performance issues over the sufficiency of a welfare check and custody record entry.
The inquest which ended this week (24 February 2022), has recorded an outcome of ‘drug-related death’ for a man who died while in police custody in Nottinghamshire in 2017.
A jury returned the findings following a two-week inquest at Nottingham Council House into the death of 50-year-old Darren Brown from Mansfield.
An Independent Office for Police Conduct (IOPC) investigation began following a mandatory referral from Nottinghamshire Police. It found some failings in the care afforded to Mr Brown while at the police station by both custody and healthcare staff. We also found some learning for the force, recommending staff input a higher level of detail into custody records to help with the care of detainees.
The investigation examined the circumstances surrounding Mr Brown’s death, the medical care and treatment he received, and the decisions made by custody officers and staff when conducting checks and whether they were in accordance with local and national policies. We examined evidence, which included custody suite CCTV footage, Mr Brown’s custody records, accounts from police staff and officers along with medical reports.
Following a misconduct meeting held by the force in June 2020, misconduct was found proven in respect of not conducting thorough checks on Mr Brown but not proven in respect of her having not recognised or acted upon his deterioration. The meeting also found misconduct proven in the making of false entries on the custody record. The outcome was management action.
No marks and injuries were found on his body that he believed were “caused by the bizarre hand movements and the spoon”.
“There were no marks to suggest that at any point he had been the victim of an assault or been restrained against his will, and there’s no such evidence of that on the CCTV,” Prof Rutty said.
Prof Rutty said toxicology tests carried out after Mr Brown died showed he had amphetamine, heroin, synthetic cannabinoids, and a drug called gabapentin in his system.
Prof Rutty believes Mr Brown died as a result of “polydrug toxicity”, meaning his death was the result of more than one drug.
According to the expert, the drugs caused cardiac arrhythmia, meaning Mr Brown’s heartbeat became irregular and eventually stopped.
Toxicologist Stephen Morley said he agreed with Prof Rutty’s proposed cause of death.
He said three of the drugs – amphetamine, synthetic cannabinoids and gabapentin – were known to directly cause abnormal heart rhythms.
He added the drugs would also explain Mr Brown’s unusual behaviour in the hours before he died.
IOPC Regional Director Derrick Campbell said: “The inquest has found that Mr Brown sadly died from cardiac arrhythmia and polydrug toxicity. The inquest jury noted that toxicology results showed high levels of a combination of drugs including amphetamine, heroin, synthetic cannabinoids, and gabapentin which contributed to his death. The inquest jury also commented that poor communication within the multi-disciplinary team led to a missed opportunity in recognising deterioration and seeking further medical help.
“We carried out a thorough investigation into the circumstances of his death and found there were some failings by those responsible for Mr Brown’s care while in police custody. Some welfare checks weren’t carried out adequately and the opportunity to transfer him to hospital for medical treatment was missed. We found learning for the force around better inputting of information on custody records and a case to answer for misconduct for two employees.
“After the inquest conclusion, our thoughts remain with Mr Brown’s family who have waited a long time for these proceedings following the tragic loss of their loved one.”