Inquest Jury finds failings by...

On Friday 9th July 2021 an Inquest Jury today reported on the death of young man, Jake Anderson who on the 25th June 2019 was sadly found dead in the custody of Durham Constabulary at Peterlee Police Station. The jury saw CCTV showing the 24-year-old was left naked in a urine soaked cell for hours, while talking to himself, hallucinating and in distress.

They heard how Jake had previously suffered with his mental health for many years, had been under the care of Tees, Esk and Wear Valleys Foundation NHS Trust (TEWV),He had also been using alcohol to self-medicate. In the month prior to his death. Jake had been referred to the Crisis Resolution Home Treatment Team (CRHTT) on two occasions; 12th April 2019 and again on 23rd June, just days before his death, and had informed police of this on his arrival at the station, as well as his dependency on alcohol.

The custody staff that day took the decision that Jake did not need first aid or medical treatment as he appeared to be “under the influence”. Instead he was placed on level 2 observations involving checks every 30 minutes.

Detention staff stated to the Jury that the reason they didn’t provide food to Jake was due to a lack of additional support to enter the cell. However, CCTV showed that the Detention Officer asked the Custody Sergeant “How do you feel about giving Looney Tunes food and drink?” and he replied “I wouldn’t bother”. The Detention Officer then pointed out that the Doctor had asked if Jake had been fed and watered and the Custody officer replied “I can’t see the point actually”.

They concluded he had died from the effects of alcohol withdrawal; alcohol ketoacidosis, not a natural death. The jury were critical of observations not conducted in accordance with procedure, the inadequacy in documentation and the unsatisfactory provision of food , fluids and toilet facilities, to Jake throughout his 12 hour detention. Although shockingly to the family and legal team, they did not find these to have contributed to his death.

Following an investigation by the Independent Office for Police Conduct (IOPC), two Detention Officers and a Custody Sgt were referred to Durham Constabulary for misconduct proceedings. They found Harron should face disciplinary action for ‘failing to adequately assess, review and record the appropriate levels of observation’ for Jake and for ‘failing to consider raising his observation level’ once his mental health problems became known. Kenny and a third officer Patrick Varley were also criticised for failures in monitoring and recording. But following misconduct proceedings by Durham police, their only sanctions were a 12-month written warning for Harron, the man in charge and mere words of advice for the two custody officers.

The inquest jury found that:
• Jake had a history of mental health problems with an alcohol and drug misuse
• The level 2 observations were appropriate for the initial presentation
• These observations, on occasions, were not carried in accordance with procedure and documentation was unsatisfactory
• The frequency of refreshment offered to Jake was unsatisfactory
• The increase of observations as suggested by the FME cannot be established on findings of fact and on the balance of probability the decision to increase to level 3 observations was not communicated adequately, although it may have been more appropriate at that time
• It was agreed that once Jake was found unresponsive, assistance was provided in a prompt manner
• There is no evidence to suggest that if the management had been different that this would have had an effect on the overall outcome.

A Serious Incident Review carried out by Tees, Esk and Wear Valleys Foundation NHS Trust (TEWV) highlighted there were missed opportunities between the multi-agencies, to communicate effectively in sharing information about Jake’s physical health and for a care plan to be put in place to monitor Jake in custody while a bed was located.

Jake Andersons final 12 hours:

Jake was arrested at 10.30am on 25th June 2019, and arrived at Peterlee Police Station at 11.53am. On arrival at Peterlee Jake had advised officers he suffered from mental ill health including depression and a personality disorder, also that he was dependant on alcohol.

It was reported that over the course of the next few hours, Jake’s behaviour become more alarming. He expressed a belief tat he was in Lanchester Road Hospital; a local mental health facility, rather than in police custody. By 2:00pm he had become incoherent, confused and was experiencing hallucinations. CCTV footage reviewed showed Jake talking to himself and visibly hallucinating inside his cell.

At 8:00pm Jake was assessed by a Force Medical Examiner (FME) who concluded that he required an assessment under the Mental Health Act. Evidence was heard from the FME that upon examining Jake, he advised the Custody Sgt that Jake’s level of observations should be increased to level 3 which involved constant observations, due to concerns about Jake’s high level of risk.

Sadly Jake’s observations were never increased and the Custody Sgt maintained in evidence at the inquest that this conversation did not take place. Regardless, a Mental Health Act Assessment was carried out at 10:30pm, which concluded that Jake was suffering from drug induced psychosis. Jake’s detention was further authorised under section 2 of the Mental Health Act. He was detained in the cell whilst a bed was located in a mental health hospital, for him.

By 23:30, a Detention Officer is said to have checked on Jake and noted that he was lying face down on the floor, on a mat. Jake remained in this position until 00:01 when the same officer raised concerns about Jake’s welfare. The officer can be seen on CCTV to request back-up support from the Custody Sgt, to enter the cell and check Jake. Both officers reported they believed Jake to be feigning unconsciousness at this point. Staff entered the cell and shook Jake by the shoulder, but he was unresponsive. The Custody Sgt gave evidence that he thought Jake was resisting being shaken as arms were stiff. Both officers returned to the custody desk stating that they didn’t believe he was unconscious.

On re-entered the cell at 00:05 that officers attempted to find a pulse. CPR was commenced but sadly Jake was pronounced dead at 00:30 on 25 June 2019. At the time of his death Jake was in a state of alcoholic ketoacidosis.

Following the Inquest Jury conclusions Jodie Anderson, Senior Caseworker at INQUEST charity who had been working with the family commented: “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.”

Jake’s mother, Alison Anderson, added: “Jake was our first child. He was loved and adored by all the family. The last time I saw him, he was leaving with two police who reassured me that he was being taken to the police station to calm down for a couple of hours. Jake should never have been arrested as all charged were dropped once the neighbour knew who Jake was. His mental health should have been managed and treated rather than the assumptions which were made about him being under the influence. It’s been every parent’s worst nightmare to watch the CCTV footage. Police officers are supposed to be trained to deal with people with mental health issues but we strongly believe Jake was left to die in those last hours of his life with no one caring for him at all. If staff had treated Jake with even basic medical care, then he would still be here.”

In summing up Alistair Smith Solicitor at Watson Woodhouse Law Firm, representing the family said: “Jake died in police custody. He should have been safe. He wasn’t. The family looked after Jake for years during all his troubles, but when in the hands of the state for less than 12 hours, he was tragically and fatally let down. The inquest has heard of the failure to provide basic rights, food and drink and consistent monitoring. Jake should have been in hospital or anywhere his most basic human rights were considered. They were not in the custody suite at Peterlee Police station. This was clearly an avoidable death involving multiple missed opportunities by multiple agencies of the state. Alison and Robert have lost a son, a sister her brother and her children an uncle. Jake should be here today and isn’t. I commend their dignity. It’s tragic the same standards were not shown by Durham Police.”

Alistair Smith is on holiday but Sarah Magson Head of Civil Litigation, and Mr and Mrs Anderson, Jakes parents, are available for Interview on Tuesday 10th and Wednesday 11th August by request.

For the full Independent Office for Police Conduct report: