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The Independent Police Complaints Commission (IPCC) has today published the findings of its investigation into the death of Sean Walsh in Warwickshire Police custody.

At approximately 5.30pm on Thursday 1 May 2008, 42-year-old Mr Walsh was arrested on suspicion of theft of a bottle of alcohol and taken to custody at the Warwickshire Justice Centre in Nuneaton, where he was assessed as being unfit for questioning because he was intoxicated.  He was detained in custody overnight.  

Just after 8am the following morning, while still in custody, Mr Walsh collapsed.  He was placed in the recovery position by officers and an ambulance was called.  At approximately 8.30am he was transferred to George Elliott Hospital where he was pronounced dead at 10.09am.

An inquest into Mr Walsh’s death concluded on 23 July 2010 and found he died from cardiac arrest resulting from conditions associated with chronic alcoholism.

The death was mandatorily referred to the IPCC by Warwickshire Police on 2 May 2008 and following an assessment an independent investigation was carried out.  

The investigation looked into the actions of the officers on duty during Mr Walsh’s time in custody.  In particular it looked into the actions of two custody sergeants and found that on occasion the care afforded to Mr Walsh fell below the standard expected.  It included:

• thorough and appropriate risk assessments were not carried out throughout Mr Walsh’s time in custody;
• custody records were not kept adequately updated with all the necessary information, including Mr Walsh suffering from panic attacks, alcohol withdrawal and depression;
• officers failed to seek medical advice at appropriate times including when officers found that Mr Walsh did not have his anti depressant medication, when officers became aware that he was suffering from alcohol withdrawal and when officers found him in his cell bleeding from his mouth and appearing dazed.

Following the completion of the investigation, one custody sergeant has received formal words of advice and a second has received a written warning.  

IPCC Commissioner, Len Jackson, said:

“I would again like to extend my sincere condolences to Mr Walsh’s family for their loss.  This is a sad case and it was only right that we conducted an independent investigation into the circumstances leading up to Mr Walsh’s death.  While the care afforded to Mr Walsh did not meet the usual standards set by the police, I am pleased that Warwickshire Police acted quickly following this incident and put in place a number of actions to ensure they have learnt from this sad incident. This case highlights some of the difficulties experienced in dealing with individuals with alcohol-related health matters and we would advocate that forces review their own practices in light of the learning that has come from this case."

As a result of the investigation Warwickshire Police implemented a number of changes to their custody procedures including:

• amending the custody risk assessment to identify any issues regarding alcohol dependence or alcohol related illness;
• outlining the actions to be taken, in accordance with the codes of practice, if a person is intoxicated;
• if a person is identified as dependent on alcohol, seeking advice from a doctor on how to manage the withdrawal prior to the symptoms developing;
• consideration by Forensic Medical Examiners to an appropriate care plan to manage withdrawal; and
• any person identified as dependent on alcohol should be subject to a pre release risk assessment and should have a PNC marker created.

Some of these changes, which offer officers better ways of identifying and dealing with individuals affected by alcohol-related issues, have been adopted by other UK police forces as areas of best practice.  These changes made by Warwickshire Police, and the swiftness in which they were implemented, were also praised by the Coroner at the end of the inquest.