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The Independent Police Complaints Commission (IPCC) has found poor performance by staff and made a number of recommendations to Greater Manchester Police (GMP) following an independent investigation into the death of a man who suffered epileptic seizures while being held in custody.

Billy Salton suffered two epileptic seizures at Cheadle Heath custody suite, where he was held for a total of 33 hours. He had a third fit in a cell at Stockport Magistrates’ Court after being transferred there for a court hearing and died three days later in Stepping Hill Hospital on 9 July 2012.

The IPCC investigation found that although mistakes were made and poor operating practices observed, there was insufficient evidence to suggest any individual officer or member of GMP staff breached their standards of professional behaviour.

However, the investigation did find there had been a sloppy approach to Mr Salton’s care by GMP and medical staff.

Mr Salton, 19, could have been processed through custody quicker had custody sergeants adhered to the Police and Criminal Evidence Act (PACE), which is law, rather than the guidance they used.

Had the investigation progressed more speedily under the terms of PACE, his first seizure would have been identified sooner, and he would have been more likely to have left detention and appeared before court a day earlier, the IPCC investigation found.

Neither of the two fits Mr Salton suffered during his detention at Cheadle Heath were spotted by custody staff, despite the fact he had been placed in a cell covered by CCTV.

There was also confusion and delay in getting epilepsy medication to Mr Salton, working practices meant opportunities were missed to progress enquiries and either place him before the court or release him from custody.

A care plan put in place by a custody sergeant was not consistently adhered to, briefing between staff was ineffective when measured against national guidance for force policies, which led to a missed opportunity for staff caring for Mr Salton to have a full picture of his needs.

The IPCC found evidence of poor risk assessment, custody record entry, visiting regime, communication with clinicians and use of CCTV. The IPCC has recommended that GMP consider addressing these as a training issue for sergeants and custody detention officers. The force should also consider where CCTV monitors are placed to ensure that they can be easily be viewed by staff. A number of similar issues and recommendations had been previously identified following other IPCC investigations into the Cheadle Heath custody unit.

IPCC Commissioner for Greater Manchester James Dipple-Johnstone said: “The care afforded to Mr Salton during his lengthy detention at Cheadle Heath custody suite should have been of a higher standard.

“Although it cannot be said that this contributed to Mr Salton’s death there are a number of issues from this tragic case and other IPCC investigations of the same unit that need to be addressed by Greater Manchester Police to ensure that a better standard of care is given to others in a similar situation.

“Mr Salton’s family has been made aware of our findings and I offer my sincere condolences to them for their loss.”

A copy of the investigation report is available on the IPCC website.

An inquest recorded that Mr Salton died of natural causes after suffering a heart attack brought on by a third epileptic fit he suffered after transfer to Stockport Magistrates' Court.