WIREDGOV

Our investigation into the death of a man shortly after being restrained at Haverfordwest police station found that a full mental health assessment, and the creation of a custody record, should have taken place as a result of his earlier detention.  

Meirion James, 53, from Crymych in Pembrokeshire, who suffered from bipolar disorder, was involved in a minor road traffic incident at Llanrhystud on the A487 in Ceredigion on 30 January 2015. Dyfed-Powys Police attended and he was detained under Section 136 of the Mental Health Act. While in police custody at Aberystwyth, Mr James disclosed he had earlier taken a lot of his medication. He was taken to Bronglais Hospital and was discharged by medical staff about five hours later.

In the early hours of the following day Mr James was arrested after he reported to Dyfed-Powys Police that he had assaulted his mother. When at the custody suite in Haverfordwest, he charged out of a cell and became unresponsive after restraint and use of PAVA spray by police officers and staff. He was pronounced dead at Withybush Hospital later the same morning.

Following the completion of our investigation into prior police contact with Mr James in June 2016, we made a number of recommendations intended to improve the force’s handling of detainees with mental health issues. In our opinion, two officers had a case to answer for misconduct, who were subsequently given management action by the force.

Dyfed-Powys Police accepted our findings and learning from the investigation in 2016, and has advised us that the force has improved mental health training for its front-line officers, and undertaken work with partners to help ensure a cohesive response to people who are in crisis.

Issuing our findings has awaited an inquest, which ended at Haverfordwest County Hall last week and returned a narrative conclusion. The jury decided death was caused by positional asphyxia due to restraint following acute behavioural disturbance, and obesity. They determined police were justified in using restraint but that Mr James spent an excessive length of time in the prone position which contributed to his death. The inquest considered the interaction Mr James had with hospital medical staff, a GP, and ambulance personnel, as well as police officers and staff, and the force medical examiner.

IOPC Director for Wales, Catrin Evans said: “I send my condolences to the family and friends of Mr James, along with everyone affected by his sad death. We will consider the jury’s findings. Based on the evidence gathered during our independent investigation into police contact, we found the actions of officers and staff in using restraint and PAVA spray when Mr James rushed out of a cell did not merit any disciplinary proceedings.

 “We did find some aspects of the police involvement with Mr James were not in accordance with procedure. In particular, a custody record should have been created for his detention at Aberystwyth police station, which would have made important information about Mr James’ condition readily available to colleagues at Haverfordwest custody suite the next day. Procedures should have been followed by the police to ensure Mr James received a full Mental Health Act assessment following his Section 136 detention. 

“Medical staff who saw Mr James at Bronglais Hospital did not note any outward symptoms of his psychiatric condition, but they asserted they had not been informed of his detention under the Mental Health Act. It cannot be known whether a full mental health assessment by doctors and an approved professional would have altered the tragic outcome.”

The IOPC recommendations made to Dyfed-Powys Police were:

• to review the Mental Health Act protocol between the force and its inter-agency partners including local authorities, the Hywel Dda University Health Board and the ambulance service, to consider the roles of healthcare professionals and information sharing;
• to review the force’s contract with healthcare professionals to ensure suitable expertise is available for the mental health needs of detainees;  
• to remind police officers of the process, and their individual responsibilities, when detaining someone under the Mental Health Act; of the requirement to open a custody record whenever someone is detained; and of the need for a clear handover of relevant information.

The investigation reviewed CCTV footage, relevant national and local policies, and involved interviews with over a dozen police officers, and a number of detention officers, paramedics, medical staff and members of the public. Opinions from the pathologist, forensic scientists, and experts on mental health and in the use of restraint by police, were taken into account by investigators. At the conclusion of our investigation, the findings were shared with the family of Mr James, HM Coroner, and Dyfed-Powys Police.