Missed opportunities and 'inadequate checks' were recorded into an inquest into the death of a man who died in custody at Mansfield Police Station.
Darren Brown, 50, who was of Charlesworth Court in Mansfield Woodhouse, died just after 5am on June 24 2017 after being arrested the previous evening.
An inquest into his death concluded on Thursday (February 24), where Assistant Coroner Laurinda Bower concluded 'it is highly likely that he took drugs while in police custody'.
Toxicology results found high levels of amphetamine, heroin, synthetic cannabinoid and gabapentin in his system.
Miss Bower concluded this was a drug-related death, but in her final written record, said there were a number of missed opportunities and 'inadequate cell checks or meaningful engagement'.
At the opening of the inquest on February 14 this year, members were told Mr Brown was found laying on a grass bank by two patrolling police officers in the evening of June 23 2017.
They discovered there was a warrant for his arrest and subsequently arrested him, where he was found to be in possession of amphetamine.
Miss Bower concluded: "He was dishevelled in appearance, was shuffling and was slow in his movements.
"Darren seemed to be under the influence of something, but he was polite, fully compliant and respectful in his manner.
"On arrival, a pat down search was performed by the detention officer; an intimate search was deemed unnecessary."
A care plan was arranged and was set to be reviewed every 30 minutes.
Mr Brown complained of having stomach pains as well as leg pulses, and had a history of vomiting jet black fluid.
He had admitted to a history of taking illicit drugs.
In her written conclusion, Miss Bower said: "During Darren's 13 minute medical assessment by the healthcare professional, it was determined he should be detained and it was not necessary to admit him to hospital.
"Darren's level of cell checks were not altered by the healthcare professional, and there was here a missed opportunity to escalate to a forensic medical examiner to send Darren to hospital for further medical interventions.
"Inadequate cell checks or meaningful engagement in line with policies and procedures failed to spot behavioural changes and health deterioration, this being another missed opportunity to escalate and seek medical help.
"However it is impossible to determine whether earlier transfer would probably have prevented Darren's death."
At 9.07pm, Mr Brown was interviewed by police, the inquest heard.
Just after 4.30am the next day, a medical emergency was called by the custody sergeant and a first responder arrived within minutes.
Miss Bower wrote: "Poor communication within the multi-disciplinary team led to a missed opportunity in recognising deterioration seeking further medical help.
"It is highly likely that Darren took drugs while in police custody."
Independent Office For Police Conduct Regional Director Derrick Campbell said: “The inquest has found that Mr Brown sadly died from cardiac arrhythmia and polydrug toxicity. The inquest jury noted that toxicology results showed high levels of a combination of drugs including amphetamine, heroin, synthetic cannabinoids, and gabapentin which contributed to his death. The inquest jury also commented that poor communication within the multi-disciplinary team led to a missed opportunity in recognising deterioration and seeking further medical help.
“We carried out a thorough investigation into the circumstances of his death and found there were some failings by those responsible for Mr Brown’s care while in police custody. Some welfare checks weren’t carried out adequately and the opportunity to transfer him to hospital for medical treatment was missed. We found learning for the force around better inputting of information on custody records and a case to answer for misconduct for two employees.
“After the inquest conclusion, our thoughts remain with Mr Brown’s family who have waited a long time for these proceedings following the tragic loss of their loved one.”
Assistant Chief Constable Rob Griffin, of Nottinghamshire Police, said: “Officers from our Professional Standards Department have been present throughout the inquest which was completed on Thursday (24 February 2022) and I am now fully sighted on the conclusion.
“Firstly I want to say my deepest sympathies remain with Mr Brown’s family and friends. This is a truly tragic case.
“Whenever a person dies in police custody or following contact with us it is a tragedy and we always ensure that the circumstances are fully investigated and scrutinised and that any lessons are learned.
“This is why we immediately referred the death of Mr Brown to the Independent Office for Police Conduct (IOPC) which is in effect the police watchdog and an entirely independent organisation. The recommendations that came out of that investigation have been fully implemented.
“Since 2017 we have also invested significantly in our custody facilities across Nottinghamshire and in the staff who work within them. We now have health care professionals based within our custody facilities who work there 24 hours a day, seven days a week. We have also delivered further training to staff and implemented a much improved CCTV facility.
“To compliment these improvements, we have introduced new technology in the form of tablets at our cell doors, which enables our detention officers to update their observations contemporaneously.
“As the coroner indicated I have regular meetings with her and the outcome of this case will be discussed in depth at our next meeting. “Following on from that I will personally ensure that any lessons learned from the findings of the inquest are fully implemented across Nottinghamshire.”
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