The inquest in to the death of Adrian Coldwell in police custody has identified several failures.
Coldwell, who had mental health problems and a history of self-harm and suicide attempts, hanged himself with the cord from his tracksuit bottoms in a cell at Pontefract Police Station in West Yorkshire in December 2004.
On two previous occasions, Coldwell had been arrested and kept under policy custody, as a place of safety, under the Mental Health Act.
In a critical narrative verdict, the jury said the police failed to have a doctor examine Coldwell and proceeded to give him medication without a doctor’s direct supervision.
It also found the police had given unsatisfactory levels of supervision and checks, before and after he was given medication, and had failed to act upon warnings over Coldwell’s tracksuit bottom cord.
The jury identified a further failure whereby the policy had not brought up Coldwell’s previous custody records because they had mistyped his surname.
However, Ruth Bundey, the INQUEST solicitor representing Coldwell’s sister, Jane Sharp, said: “Ironically, the very custody sergeant on whose watch Adrian died had admitted him to the police station three months before his death, after he had attempted suicide with a pipe attached to his car exhaust.”
Sharp added: “My brother should never have died. He should never have had a Class A drug, morphine sulphate, given to him by a PC while in custody, without a medical examination. I think the dosage he received scrambled his mind.”