In June 2017, a man was arrested in a park off Sandy Lane, Mansfield on suspicion of a drugs offence shortly after 8pm. He was 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.
We investigated the circumstances surrounding the man’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, custody records along with medical reports. We also interviewed police officers and staff to obtain their accounts.
The evidence obtained indicated the care which had been provided may have fallen below the required standard in the monitoring of their state during their detention.
Our investigation concluded in December 2019.
We waited for all associated proceedings to be finalised before publishing our findings.
We found that a healthcare professional had a case to answer for misconduct for failing to properly assess the man’s condition and for a failure to recognise the immediate need to send the man 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. Information was passed to the Health and Care Professions Council.
We found a detention officer had a case to answer for misconduct for failing to carry out checks on the man to a sufficient standard and for failing to identify that his condition had deteriorated. Following a misconduct meeting held by the force in June 2020, misconduct was found proven in respect of not conducting thorough checks on the man 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.
We 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.
An inquest concluded in February 2022 and recorded an outcome of ‘drug-related 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 carefully considered whether there were any learning opportunities arising from the investigation. We make learning recommendations to improve policing and public confidence in the police complaints system and prevent a recurrence of similar incidents.
We found learning for the force around better inputting of information on custody records to help with the care of detainees. We progressed these areas of organisational learning under Paragraph 28A, Schedule 3, Police Reform Act 2002.
An act of parliament that provides the core framework of police powers to combat crime and provide codes of practice for the exercise of these powers.
Leads and manages the development of the police service in England, Wales and Northern Ireland.
The body that represents the interests of all police constables, sergeants, and inspectors.
Deals with someone’s inability or failure to perform to a satisfactory level, but without breaching the Standards of Professional Behaviour.
Focuses on putting an issue right and preventing it from happening again by encouraging those involved to reflect on their actions and learn. It is not a disciplinary process or a disciplinary outcome.
Department within a police force that deals with complaints and conduct matters.
Refers to lower-level misconduct or performance-related issues, which are dealt with in a proportionate and constructive manner.
This means doing what is appropriate in the circumstances, taking into account the facts and the context in which the complaint has been raised, within the framework of legislation and guidance.
The average is calculated using the individual results of the forces in that most similar force group.
An investigation carried out by IOPC staff.
Carried out by the police under their own direction and control. The IOPC sets the terms of reference and receives the investigation report when it is complete. Complainants have a right of appeal following a supervised investigation (unless it is an investigation into a direction and control matter).
This act sets out how the police complaints system operates.
How a police force is run, for example policing standards or policing policy.
An investigation carried out by the police under the direction and control of the IOPC.
The organisation that is responsible for assessing how to deal with a complaint. For example – whether it can be handled locally or reaches the criteria for referral to the IOPC. The appropriate authority may be the chief officer of the police force or the PCC for the force. If a complaint investigation finds that someone has a case to answer for misconduct, the appropriate authority is responsible for arranging any misconduct proceedings. If you make a complaint, the appropriate authority for your case will contact you.
An intelligence-led agency with law enforcement powers, it is also responsible for reducing the harm that is caused to people and communities by serious organised crime.
Policing bodies include police and crime commissioners, the Common Council for the City of London, or the Mayor's Office for Policing and Crime.
Investigations carried out entirely by the police. Complainants have a right of appeal following a local investigation (unless it is an investigation into a direction and control matter).
IOPC guidance to the police service and police authorities on the handling of complaints.
A complaint or recordable conduct matter that doesn’t need to be referred to the IOPC, but where the seriousness or circumstances justifies referral.
Parameters within which an investigation is conducted.
A person is adversely affected if he or she suffers any form of loss or damage, distress or inconvenience, if he or she is put in danger or is otherwise unduly put at risk of being adversely affected.
This is where a manager deals with the way someone has behaved. It can include: showing the police officer or member of staff how their behaviour fell short of expectations set out in the Standards of Professional Behaviour; identifying expectations for future conduct; or addressing any underlying causes of misconduct.
This could be the Police and Crime Commissioner, the Common Council for the City of London, or the Mayor's Office for Policing and Crime.
A flexible process for dealing with complaints that can be adapted to the needs of the complainant. It may involve, for example, providing information and an explanation, an apology, or a meeting between the complainant and the officer involved.
A flexible process for dealing with complaints that can be adapted to the needs of the complainant. It may involve, for example, providing information and an explanation, an apology, or a meeting between the complainant and the officer involved.
A breach of standards of professional behaviour by police officers or staff so serious it could justify their dismissal.
A matter where no complaint has been received, but where there is an indication that a person serving with the police may have committed a criminal offence or behaved in a manner that would justify disciplinary proceedings.
Disapplication means that a police force may handle a complaint in whatever way it thinks fit, including not dealing with it under complaints legislation. This may only happen in certain circumstances where the complaint fits one or more of the grounds for disapplication set out in law.
The ending of an ongoing investigation into a complaint, conduct matter or DSI matter. An investigation may only be discontinued if it meets one or more of the grounds for discontinuance set out in law.
Quarter 1 covers 1 April - 30 June
Quarter 2 covers 1 April - 30 September
Quarter 3 covers 1 April - 31 December
Quarter 4 covers the full financial year (1 April - 31 March).
You can request a review/appeal if you’re not satisfied with how your complaint has been handled.
Used to house anyone who has been detained.
Complainants have the right to appeal to the IOPC if a police force did not record their complaint or notify the correct police force if it was made originally to the wrong force.
The purpose of an investigation is to establish the facts behind a complaint, conduct matter, or DSI matter and reach conclusions. An investigator looks into matters and produces a report that sets out and analyses the evidence. There are three types of investigations: local, directed and independent.
The ending of an ongoing investigation into a complaint, conduct matter or DSI matter. An investigation may only be discontinued if it meets one or more of the grounds for discontinuance set out in law.
The type of behaviour being complained about. A single complaint case can have one or many allegations attached.
A person who makes a complaint about the conduct of someone serving with the police.
The ending of an ongoing investigation into a complaint, conduct matter or DSI matter. An investigation may only be discontinued if it meets one or more of the grounds for discontinuance set out in law.
List of officers and staff who have been dismissed from policing, or would have been if they had not retired or resigned.
The type of behaviour being complained about. A single complaint case can have one or many allegations attached.
Disapplication means that a police force may handle a complaint in whatever way it thinks fit, including not dealing with it under complaints legislation. This may only happen in certain circumstances where the complaint fits one or more of the grounds for disapplication set out in law.
An independent judicial officer, the coroner enquires into deaths reported to him/her.
A breach of the Standards of Professional Behaviour that would justify at least a written warning.
No further action may be taken with regard to a complaint if the complainant decides to retract their allegation(s).
A record is made of a complaint, giving it formal status as a complaint under the Police Reform Act 2002.
This is a format where information is written in plain English and short sentences.
The IOPC must be notified about specific types of complaint or incidents to be able to decide how they should be dealt with.
No further action may be taken with regard to a complaint if the complainant decides to retract their allegation(s).
Casework involves assessing appeals. Casework staff also have a role in overseeing the police complaints system to help ensure police forces handle complaints in the best possible way.
Disapplication means that a police force may handle a complaint in whatever way it thinks fit, including not dealing with it under complaints legislation. This may only happen in certain circumstances where the complaint fits one or more of the grounds for disapplication set out in law.
Conduct includes acts, omissions, statements and decisions (whether actual, alleged or inferred). For example: language used and the manner or tone of communications.
You can request a review/appeal if you’re not satisfied with how your complaint has been handled.
You can request a review/appeal if you’re not satisfied with how your complaint has been handled.
