Police and medical staff have been criticised for their “sloppy approach” to the care of a teenager who died after suffering three epileptic fits whilst being held in custody in connection with an alleged burglary.
The Independent Police Complaints Commission (IPCC) said custody staff at Greater Manchester Police failed to spot two seizures suffered by Billy Salton, 19, when he was being held at Cheadle Heath, despite the fact that his cell was fitted with CCTV.
The custody team had been told to check him every 30 minutes after learning he suffered repeated epileptic fits but failed to carry out the nurse’s instructions on 18 different occasions, the report said. One officer was seen eating cereal before failing to notice one of Mr Salton’s four-minute fits displayed on a split screen in the control room.
The watchdog said there was “confusion and delay” in getting the medication for his condition after he attended the police station in July 2012. Failures to adhere to the Police and Criminal Evidence Act meant he was held for 33 hours – suffering a third fit in a cell at Stockport Magistrates’ Court where he was attending a hearing.
Mr Salton, a father of one, died three days later in hospital following a heart attack resulting from the series of fits, an inquest found.
Investigators said delays – caused by poor operating practices – meant his first seizure was not spotted sooner and resulted in him being kept in custody for a day longer than necessary.
The IPCC said it had warned previously over issues at Cheadle Heath but said that the failures had not caused his death.
However, it found that a care plan put in place by a custody sergeant was not adhered to whilst staff were not told of Mr Salton’s medical needs. There was evidence of poor risk assessment and record keeping as well as issues over communication with clinicians, the investigation found.
However, the watchdog said there was insufficient evidence to blame any individual officer or civilian member of staff for the tragedy. Following the inquest into his death, deputy coroner Joanne Kearsley wrote to police, prisoner transport service GEO Amey, and police medical contractors Medacs, raising concerns over Mr Salton’s death. A doctor and a nurse from Medacs, whose work is criticised in the report, carried out two separate examinations at the station which lasted a total of seven minutes.
The IPCC commissioner for Greater Manchester, James Dipple-Johnstone, said: "The care afforded to Mr Salton during his lengthy detention at Cheadle Heath custody suite should have been of a higher standard.
"Although it cannot be said that this contributed to Mr Salton’s death there are a number of issues from this tragic case and other IPCC investigations of the same unit that need to be addressed by Greater Manchester Police to ensure that a better standard of care is given to others in a similar situation.”
GMP Assistant Chief Constable Garry Shewan said: “We have already studied the report and put in place a number of measures to improve care and safety in the custody environment.”