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An inquest which ended last 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.

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.

An Independent Office for Police Conduct (IOPC) investigation began after we received 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.

We investigated 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.

We found that a healthcare professional had a case to answer for misconduct for failing to properly assess Mr Brown’s condition or identify that she required medical assistance that could not be provided to him within the custody suite. Our investigation found she 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. 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 Mr Brown to a sufficient standard and for failing to identify that his condition had deteriorated. Our investigation found her 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.

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.

IOPC Regional Director Derrick Campbell recently 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.”