Inquest jury finds catalogue of failings by Staffordshire Police, G4S and Primecare nurses leading up to death of Darren Lyons

The jury identified a catalogue of failures by police, civilian custody staff and medical professionals in the care of Darren Lyons, who had a history of mental ill health and alcohol dependency.

Police were called to Darren’s home, where he lived with and helped care for his grandmother, on 12 January 2014 following verbal threats and concerns over his deteriorating health. Darren was found on the floor of his bedroom, unable to stand. He had a pressure sore and was unkempt and covered in his own faeces.

Darren’s family told police that he had stopped taking his medication and needed urgent medical help. But police officers stood down an ambulance called to the scene and instead handcuffed Darren and took him into custody.

During his seven-hour detention, Darren was left half naked on the cell floor, covered in his own faeces. At no point was he able to stand. His cell door was kept shut and only two attempts were made to briefly enter his cell, despite CCTV showing him making almost no movement. CCTV footage showing Darren having a seizure at 22.50 that night went unobserved.

Medical experts told the inquest that Darren was clearly unwell and should have been transferred to hospital, not the police station. Other failings by Staffordshire Police, G4S detention custody officers and nurses employed by Nestor Primecare identified by the jury were:

• observations to establish Darren’s welfare in his cell were insufficient and inconsistent – and hampered by the closure of his cell door
• no doctor was called and no full medical examination was completed – despite the fact that the custody sergeant was aware from Darren’s medical records of his mental ill health and history of “strange behaviour” when withdrawing from alcohol, triggering seizures, which had led to his admission to hospital in three previous occasion
• communications and handover of information from all service providers operating within the Northern Custody Suite was insufficient and not accurately recorded

Darren’s mother Diane Aqeel said: "I was brought up to have such faith in the police but that faith has been completely shattered. I truly believed Darren was safe and would receive the medical help he needed.  It is vile to think about how he was left to die, naked and covered in his own faeces on a cell floor. No dignity, no care, nothing. They treated him worse than a dog. His death and the actions of Staffordshire Police have knocked everything out of me.  I had to find out about the condition of my son who was critically ill, fighting for his life in a local newspaper. I rang the police to enquire which hospital my son was admitted to and no one to this day has ever contacted me or apologised." 

Deborah Coles, Director of INQUEST said: “Over seven hours, barely moving on his cell floor, Darren Lyon’s urgent need for help was ignored at every stage. This is the second death at the same police station exposing wholescale failure by Staffordshire Police, G4S and Primecare to apply the longstanding national framework for the care and welfare of vulnerable individuals held in police custody.  Action must be taken to hold the force to account for such gross failures of basic policing standards towards a man so clearly physically and mentally unwell."

Diane Aqeel’s solicitor, Gemma Vine, said: “This case illustrates the lack of understanding in custodial settings of those who have complex medical needs. Of greater concern is that there was a failure to meet Darren’s welfare and care needs not only by Staffordshire Police but also by two experienced Primecare nurses who failed to assess Darren appropriately. The seriousness of Darren’s presentation was clearly evident and it only took a common sense approach to realise this gentleman was undoubtedly in need of help. Custody was not the right place for him and he should have been transferred to hospital at the very outset of his arrest.”

INQUEST has been working with the family of Darren Lyons since his death. The family is represented by INQUEST Lawyers Group members Gemma Vine and Komal Hussain of Minton Morrill Solicitors and Anna Morris of Garden Court Chambers.