Independent Office for Police Conduct (IOPC - formerly IPCC)
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IOPC response folliowing inquest into a man's death in Northumbria Polce custody

An Independent Office for Police Conduct (IOPC) investigation found evidence of ‘serious failings’ leading up to the death of man in Northumbria Police custody. 

On the afternoon of 28 March 2013 Stephen Berry, aged 43, was arrested after failing to appear in court. He was detained for two days before he collapsed in his cell and died a short time later.

We completed our investigation in December 2013. The jury at the inquest into the death of Mr Berry concluded, on 18 December 2019, that his death was due to the effects of alcohol withdrawal in circumstances where there were avoidable delays to emergency medical interventions.

Mr Berry was declared, by a force medical examiner, as fit to be detained from 5pm on 28 March and prescribed medication. He was detained for a longer period than is usual due to Friday 29 March 2013 being a Bank Holiday; the intention was to take him to court on the Saturday morning. He was assessed as requiring half-hourly checks, during which he should have been be roused.

The independent investigation analysed CCTV footage, witness accounts, police custody logs and statements from the officers and staff at the scene. Our investigation found:

  • There were six false entries, and other inaccuracies, in the custody record relating to checks made on Mr Berry.
  • Mr Berry was left unchecked and not roused for almost five hours during his detention.
  • His health deteriorated rapidly from 7pm on 29 March; he was seen sweating, shaking, and having difficulty breathing. He asked to be taken to hospital but this was refused.
  • A detention officer reported concerns for Mr Berry’s welfare, to a custody sergeant, but these were ignored or dismissed.
  • A custody sergeant contacted a doctor, but told him Mr Berry’s condition was not urgent: resulting in Mr Berry not receiving any medical attention on 29 March until after his health had deteriorated considerably. He was eventually examined by a doctor at 11.28pm and an ambulance requested at 11.34pm.

We interviewed the two custody detention officers who were responsible for checking on Mr Berry overnight from the 28 March. We found that they had a case to answer for misconduct for making inaccurate and false entries in the custody log, and failing to undertake proper welfare checks the proper checks on his welfare were not made. This finding was accepted by the force and both officers admitted misconduct; both received written warnings in June 2016.

The investigation found evidence of a case to answer for gross misconduct for two custody sergeants, who were responsible for Mr Berry’s welfare during this detention, for:

  • Instructing a custody officer not to record the symptoms of Mr Berry’s physical decline.
  • A failure to ensure Mr Berry received prompt medical attention on a number of occasions during his detention.
  • Not requesting a doctor when informed of Mr Berry’s declining physical condition by colleagues, and later causing a delay in the doctor attending.
  • Not documenting or taking action when informed, by detention officers, that Mr Berry was showing signs of deteriorating physical and mental health.

We referred the evidence to the Crown Prosecution Service (CPS) as there was an indication that a criminal offence may have been committed by both sergeants. The CPS made the decision not to bring charges. Mr Berry’s family appealed this decision and the CPS decided, in September 2015, not to prosecute.

Northumbria Police agreed with our findings in respect of both custody sergeants. One of the sergeants retired after conclusion of the investigation and it was not possible under the regulations that existed at the time to proceed with disciplinary action against him. A gross misconduct hearing was scheduled for the second sergeant but it was not possible to proceed with the hearing due to the officer’s health. The officer retired on medical grounds in 2018.

We commend the efforts made by an acting inspector and a detention officer, not subject to this investigation, in attempting to revive Mr Berry after his collapse.

IOPC Interim Regional Director David Ford yesterday said:

“Firstly, our thoughts remain with Mr Berry’s family. Our findings make for difficult reading, not least because they recount the obvious distress Mr Berry was in during his detention.

“Our evidence demonstrates there were, overall, serious failings in the care afforded to Mr Berry. Thankfully such incidents are rare; the vast majority of police officers and staff understand their responsibilities and uphold the highest professional standards.”

The IOPC has waited until the conclusion of the inquest to publish the findings from the investigation so as not to prejudice these proceedings.

The IOPC is not involved, nor does it influence, the scheduling of misconduct hearings and/or decisions made concerning officer retirement.


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