A man who died in police custody hid a bag of cocaine in his mouth when he was arrested at his 21st birthday party.
Officers only discovered the plastic bag containing two hours after he arrived at Motherwell police station and after James MacGregor appeared to have consumed cocktail of drink and drugs at the do in his Hamilton home.
A Fatal Accident Inquiry heard the Lanarkshire man had been searched by cops and his hands cuffed behind his back when he was taken into custody.
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Two PCs were supposed to monitor the father-of-one as he waited in a holding area they busy station, but they didn't notice him retrieving the bag from elsewhere on his body and placing it in his mouth.
CCTV later showed that despite being handcuffed, MacGregor managed to reach both hands to his trouser pocket area and near his sock, while one PC could be seen scrolling through his phone and the other's attention elsewhere.
One of the officers said the prisoner appeared drunk and drowsy, but did not think he needed urgent medical attention and seemed to be no different from the many people under the influence he had arrested.
He told the inquiry at Hamilton Sheriff Court that custody sergeants often sent persons to hospital when in his view it was overly cautious. It was a general belief that people were often taken to hospital when they did not need to be. He said doctors would tell officers that they shouldn’t be there.
However, when the shift changed and MacGregor was finally taken to the charge bar by two different officers the item was spotted in his mouth. He refused to give it up and had to be held down and it was forcibly removed.
A short time later MacGregor took ill and was taken to Wishaw General Hospital, where he became aggressive and agitated, before suffering what appeared to be a fit and then became unresponsive. He was resuscitated and eventually put into a coma, and died 10 days on August 26, 2019 later from multiple organ failure.
Presiding over the inquiry, Sheriff Linda Nicolson heard evidence that the bag was sealed when it was removed from MacGregor's mouth, whether or not he consumed additional cocaine after his detention, the outcome is not likely to have been different.
However, she criticised the what appeared to be "a lack of basic knowledge of the guidance contained within the police's own Standard Operating Procedure" in dealing with prisoners and the length of time MacGregor waited in the holding area, explaining that this "resulted in a loss of concentration by the officers tasked with monitoring the deceased at that time".
Sheriff Nicolson made several recommendations around the monitoring of prisoners in a similar situation, pointing out: "The Standard Operating Procedures should be reviewed to consider whether they should include guidance on being alert to any situation arising which impacts on their ability to maintain concentration on their task, such as a delay in the processing of persons in custody.
"Consideration should also be given as to whether guidance or training, or both, should include steps that might betaken to reduce the impact loss of concentration, such as officers taking turns in maintaining observations during any extended delay in the process.
"Where an officer is monitoring a detained person, the officer should not make use of a mobile telephone or other device unless it is strictly necessary for operational reasons at that time.
"Where an officer requires to use such a device in these circumstances, they should bring this to the attention of any accompanying colleague in order that the colleague can maintain attention to the detained person; and the officer should end their use of the device as soon practicably possible."
In the wake of the incident Police Scotland issued a note to all staff reminding them of the procedure for observing and transporting prisoners and improved handover procedures between shifts in custody suites to try and reduce delays, they also increased infrastructure to assist procedures.
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