The death of any person who dies while in police custody is automatically referred by the Chief Constable to the Police Ombudsman for investigation.
The Police Ombudsman was called in to examine one such case involving the death of a man while in custody at a police station on 27 July 2001. The man was found dead in his cell just before 8am, having died at some stage during the night. We have not identified the police station in this account to avoid any further distress to friends and relatives of the deceased.
During their investigation Police Ombudsman's investigators established that the man was last checked upon by an officer at 3.48am. At that stage he was awake but did not express any concerns about feeling unwell.
The body was found at 7.59am when an officer went to administer the man's regular prescription of tablets. An ambulance was summoned and arrived at 8.05am, and the man was subsequently certified dead by a Forensic Medical Examiner.
During their investigation Police Ombudsman investigators examined the man's medical records to determine his state of health prior to being placed in custody. They also examined the custody records, which revealed that, as a matter of routine, the man had twice been examined by a doctor during his time in custody.
Forensic analysis of three small spots of blood found in the custody area was also carried out and this established that the blood was not the deceased's.
A subsequent post mortem established that the man had died of natural causes.
Outcome of investigation:
Police Ombudsman Mrs Nuala O'Loan concluded: "There is no evidence to suggest that the man's death was suspicious. To the contrary all the evidence is consistent with a man who was unwell prior to his death and the death, whilst untimely, was ultimately due to natural causes."
Mrs O'Loan also referred to a number of minor irregularities in relation to administrative procedures uncovered during the investigation. She pointed out, however, that these had played no part in his death. They included the fact that:
- Cash was found in the possession of the deceased, conflicting with an entry on his custody record that he had no money.
- And that police had failed to complete a form (PACE16) designed to alert officers to potential risks to prisoners. Although these details were filled in on the custody record, the Police Ombudsman was concerned that the entry would be easy to miss within a larger document.
Recommendations made to police as a result of the investigation:
A report was sent to the then Royal Ulster Constabulary containing the following recommendations:
- The design of the form referred to above (PACE16) should be redesigned to reflect its importance and to highlight immediately any potential risks to people in custody.
- The Police Ombudsman recommended that a review be carried as a first step towards installing CCTV cameras within police station custody suites across Northern Ireland.
- Procedures for the release of prisoners should be reviewed so that the welfare of each prisoner is checked before any are released. In this case another prisoner who may have been able to provide vital independent evidence was released a few minutes prior to the discovery of the body. Due to his itinerant lifestyle, Ombudsman investigators were subsequently unable to locate him.