An inquest jury returned a narrative conclusion and said observations of 46-year-old Adam Rice in a cell at the police station in Leeds were not carried out in accordance with Police and Criminal Evidence Act (PACE) guidelines.
However, the jury concluded Mr Rice’s death in May 2014 was “coincidental and not as a consequence of his detention” at the police station.
West Yorkshire Coroner David Hinchliff said he would file a report to West Yorkshire Police’s chief constable in a bid prevent the risk of further deaths in custody.
Mr Hinchliff said his report will state that the force should ensure all custody staff have full knowledge of the relevant codes of practice and guidelines, including the Police and Criminal Evidence Act.
He said his report will also state that West Yorkshire Police should only recruit custody staff of the “highest “calibre” and that where possible there should be a bank of trained staff who could be drafted in to the custody area during busy periods.
Alcoholic Mr Rice suffered heart failure and died in a police cell at the Elland Road station between checks by officers on May 12 2014.
The inquest jury was told staff had monitored Mr Rice via CCTV during his detention.
Independent Police Complaints Commission investigator Lindsay Harrison told the inquest jury that staff were distracted and “engaged in casual conversation” while Mr Rice was lying in his cell.
She told the jury: “There was “no handover process and staff appeared confused about what they were doing.”
The inquest jury had heard homeless Mr Rice been taken to Leeds General Infirmary with a suspected head injury on May 11 2014 after being found asleep under a ramp at Hyde Park skate park
But he refused to have a scan and discharged himself that evening, at which point he was arrested for failing to answer bail over an allegation of theft and taken to Elland Road police station.
Mr Rice, who also suffered from schizophrenia, diabetes and angina, was put in a cell subject to half hourly checks by officers at the station, the inquest heard.
In the narrative verdict, the jury foreman said: “Adam was placed in cell 19, where observations were not in accordance with PACE. Adam’s care plan escalated due to symptoms of alcohol withdrawal, which caused confusion regarding levels of observations. He was checked in his cell at 6.33am and seemed OK. At 6.37am he had his first seizure and then found at 7.04am in his cell unresponsive. At 7.09am, after an initial casual response, CPR was commenced. Parmedics arrived shortly afterwards and took over. Adam was pronounced dead at 07.43am on May 12 2014 at Elland Road custody suite.”
The inquest heard Mr Rice’s heart failed as a result of a dissection of the aorta vessel, probably as a result of high blood pressure.
Mr Hinchliff said he would also file a report to the medical director of Leeds Teaching Hospitals NHS Trust.
Mr Hinchliff said that report would state that hospital staff should inform police when a patient, who is likely to be arrested, leaves hospital against medical advice.
Detective Superintendent Oz Khan, of West Yorkshire Police’s professional standards department, said after the inquest: “The circumstances surrounding Adam Rice’s death while in custody at Leeds District Headquarters on May 12, 2014 were the subject of an independent investigation by the Independent Police Complaints Commission.
“As a result, a police officer was served with a misconduct notice and attended a misconduct meeting where the matter was found not proved. Two police staff detention officers were served with misconduct notices. One was found to have no case to answer and the other was found to have a case to answer which resulted in them being given of a three-month action plan.
“A copy of the IPCC report was provided to our central custody services department to identify any lessons to learn or training issues and to circulate those to the relevant staff as necessary.
“West Yorkshire Police takes its duty of care to individuals it comes into contact with extremely seriously and will continue to do everything we can to ensure the circumstances of any incident involving death or injury following police contact are fully explored and any lessons learned.”