A coroner is writing to police with suggestions for change following the inquest into a Cobridge man’s death in police custody.
North Staffordshire Coroner Ian Smith called for improvements in communication between police and medics after 34-year-old Nicholas Rowley, of Waterloo Road, died at Staffordshire Police Northern Area Custody Facility on October 2 2011.
A jury at his inquest ruled that Mr Rowley had died as a result of methadone intoxication and alcohol withdrawal.
The hearing was told Mr Rowley had been arrested the day before his death, October 1, for breach of bail after being found asleep in the stairwell of John Street car park, Hanley.
The Hanley Town Hall inquest was told Mr Rowley had been taking the heroin substitute methadone for an extended period before his death and that he had only taken his normal dose.
He was found unresponsive in his cell just before 9pm on October 2 and pronounced dead an hour later.
Over the course of the 10-day inquest, the jury was told of several apparent breakdowns in communication between staff at the custody suite and medical professionals who examined Mr Rowley.
Coroner Ian Smith said it seemed to him there had been very poor communication between the doctors and custody sergeants at the time of Mr Rowley’s death, although this was not a factor in his death.
Mr Smith said he would be writing to Staffordshire Police, the Association of Chief Police Officers, and the Department of Health as well as private companies that provide doctors and custody suite staff to make suggestions.
These suggestions include more joint training, better training in various observation levels in custody suites, that staff should be aware of the risks of drug and alcohol abuse and withdrawal and that doctors should tell custody sergeants of their findings, as well as noting them down in the record.
However Mr Smith said that the officers on duty on the night of Mr Rowley’s death should not feel responsible for what happened.
He said: “Whatever they did or did not do it did not contribute to Nick’s death.
After the inquest, Mr Rowley’s mother, Karen Barber, said she believed her son should have been sent to hospital when a doctor at the custody suite diagnosed him with “significant” alcohol withdrawal.
She said: “I am very concerned and upset to hear of the numerous failings in the way that Nick was cared for while in police custody.
“While the medical evidence heard at the inquest suggested that these did not directly lead to Nick’s death I will never know for sure whether this was the case.
“I firmly believe he should have been sent to hospital when he showed signs of serious alcohol withdrawal and asked to see a doctor.
“ I hope the report the coroner is to write will be properly considered and changes made.
“I hope that any lessons that can be learnt from this are shared across the country as these may prevent the loss of a loved one’s life in the future.”