The Police Ombudsman has recommended disciplinary action against a number of police officers after an investigation identified failings which provided a prisoner with the opportunity to take his own life while in police custody.
However, Mr Al Hutchinson found no evidence that police had subjected the prisoner to any form of harassment or inappropriate behaviour during his time in custody.
John Brady (40) was found, by his solicitor, hanged in a consultation room at Strand Road Police Station in (London)Derry shortly before 5pm on 3 October 2009. He had used his shoelaces, which had been tied to a window opening mechanism.
Mr Brady had been arrested in Strabane the previous evening following a report that he had been involved in an assault and had made threats to kill. At the time of his arrest he was on weekend home leave as part of a pre-release process from Maghaberry Prison.
Speaking after briefing the family on the findings of his investigation, Mr Hutchinson said: "The death of anyone is a tragic event. It is even more so when someone takes their own life while in the custody and care of the police. The grief of the family needs to be respected. In situations such as these it is essential that the circumstances of the death should be closely examined."
Mr Hutchinson said that a 12 month investigation by his Office had found that "several failings in the management and design of the custody suite at Strand Road were contributing factors in providing Mr Brady with the opportunity to self harm."
While acknowledging that officers within the station's custody suite would have had no indication that Mr Brady was at risk of self-harm, and that they had conducted the associated necessary checks, he said that they had repeatedly breached guidelines designed to minimise risk to prisoners, police and others in the custody suite.
"Mr Brady was left alone and unsupervised in the consultation room on a total of nine occasions, for periods of up to 33 minutes at a time.
"It is totally unacceptable that any prisoner should have been left unsupervised for such significant periods of time, particularly while in possession of shoelaces in a room with a viable ligature point," said Mr Hutchinson.
As part of their investigation, Police Ombudsman Investigators obtained all relevant police documentation and analysed all CCTV footage and audio recordings made in the Strand Road custody suite during Mr Brady's period of detention.
Although there were no cameras in the consultation room in which Mr Brady died, a CCTV camera provided uninterrupted coverage of the only door into the room. Footage from this camera shows that no one entered or exited the consultation room during the 33 minute period that he was alone in the room prior to being found by his solicitor.
Investigators established that there was no other way into or out of the room, even via the ceiling. The void above the room's suspended ceiling was found to be completely enclosed.
They found no evidence that any police officer, other than uniformed custody office staff and officers involved in his arrest, transportation and interview, had contact with Mr Brady during his time in custody.
Anyone who had had contact with Mr Brady following his arrest was interviewed by Police Ombudsman investigators, and the relevant aspects of their accounts verified through comparison with CCTV footage.
Mr Hutchinson also revealed that the first aid treatment administered to Mr Brady was not in accordance with police training. An officer used cardio-pulmonary resuscitation techniques in an attempt to revive him, but did not additionally make use of a defibrillator and oxygen supply, as recommended in training. A medical expert concluded, however, that the additional use of the defibrillator and oxygen supply would not have revived Mr Brady.
Mr Hutchinson also pointed out that the officers should have been aware from police guidance that prisoners may be particularly vulnerable when they know that they are to face criminal charges. Mr Brady had been told during the final consultation with his solicitor that he was going to be charged.
The Police Ombudsman added that an officer's indication to Mr Brady, shortly after he was admitted to custody, that he would be taken to court, "had the potential to affect his emotional state, given that he was looking forward to release from a long prison sentence".
However, on the basis of the information police had available to them at that time there were sufficient grounds for his arrest and detention.
The Police Ombudsman also criticised "a generally lax attitude" towards the management of the custody suite. Failings included inaccurate record keeping relating to night time checks on detainees and inadequate communication between officers during shift handovers.
Mr Hutchinson said: "These failings were highlighted to the PSNI at an early stage, along with recommendations for steps to be taken to help prevent a reoccurrence."
The Police Ombudsman added that he had decided "in the public interest" to report on his findings regarding police interaction with Mr Brady, in advance of an inquest into his death.
ENDS