The inquest into the death of Jake Anderson – which concluded on Friday – found he died an alcohol related death whilst held in Peterlee police custody.
The Independent Office for Police Conduct investigated the circumstances surrounding police contact with Mr Anderson, prior to his death on June 25, 2019.
The 24-year-old was arrested at around 10.30am on June 24 and taken to Peterlee Police station, where his mental health began to deteriorate.
He was seen by medical professionals who concluded he should be transferred to a mental health unit and he remained in custody until a bed could be found in a suitable facility.
Mr Anderson was found unresponsive in his cell shortly after midnight.
Staff called an ambulance and performed CPR but he was pronounced dead in his cell at around 12.30am.
The IOPC investigation concluded on June 19, 2020 and findings were shared with Durham Constabulary and the coroner in advance of the inquest, which took place at Durham Miner’s Hall.
During their investigation, they advised a police sergeant and two members of police staff their conduct, following Mr Anderson’s arrival at the police station, was under investigation.
The IOPC also found the sergeant, who was responsible for Mr Anderson’s care and detention during the night shift, failed to adequately assess, review and record the appropriate levels of observation for Mr Anderson and failed to consider raising his observation level following his mental health assessment in line with the police guidance.
The force agreed he had a case to answer for misconduct in relation to breaches of the standards of professional behaviour regarding duties and responsibilities.
The sergeant was given a written warning following a misconduct meeting in November 2020.
Investigators found two detention officers failed to conduct appropriate checks on Mr Anderson while in custody and failed to accurately record the result of the checks.
The force agreed both had a case to answer for misconduct in relation to breaches of the standards regarding duties and responsibilities.
Following misconduct meetings in July 2020, one was given a written warning while the other received formal management advice.
The IOPC also identified issues with the way information entered on to the electronic custody records was displayed to users and identified learning for the force to ensure this information is visible on the main log screen.
IOPC regional director Miranda Biddle said: “This was a tragic case in which a young man lost his life and our thoughts remain with his loved ones.
“Any death in custody must be thoroughly investigated in order to establish all the facts. Our investigation was independent of the police and considered evidence from witnesses as well as CCTV and body-worn video camera footage.
“As well as ensuring lessons are learned from Mr Anderson’s death, our investigation has also helped to inform the inquest proceedings.”
The charity INQUEST, which provides expertise on state related deaths and their investigation is now calling for change.
Jodie Anderson, senior caseworker at INQUEST said: “Police custody is no place for a person suffering physical or mental ill health. It was evident early on that Jake was suffering and it should have been clear to custody staff at Peterlee station that the safest place for him was in a hospital, not in a police cell. Custody staff missed obvious signs that Jake was in distress and agitated, signs that a medical response was urgently required. Jake deserved a basic duty of care and yet even when he was unconscious, the officers assumed that he was feigning it. Unless there is a cultural change within the police force and proper overhaul in the way people in mental health crisis are treated both by Durham Constabulary and also TEWV NHS Trust mental health service, these deaths will sadly continue.”