Matthew Terrill: Concerns over police training after man under observation died in police custody in Sheffield

A prevention into future deaths report has been issued following the death of a man in police custody in Sheffield.

Matthew Terrill died of cardiorespiratory arrest on April 20, 2020, aged 46, after being arrested and taken to into custody.

An ambulance was called by officers in the community but cancelled 16 minutes later, and he was taken to Shepcote Custody Suite.

The jury at the inquest saw CCTV footage which showed Matthew “exhibiting behaviour of drug intoxication, possibly combined with acute mental health symptoms, and ultimately required restraint by officers,” which lasted for around 11 minutes.

He was put on constant observation, with two officers assigned to him between 12.16pm and 1.28pm, in which time, he stopped breathing.

In the report, Alexandra Poutney, HM Assistant Coroner, states her concern about whether officers are briefed effectively by the custody sergeant when tasked with constant observations.

She said: “I am concerned that there is no evidence of consistency in this task being completed to an appropriate standard or at all. 

“There is a risk that in a busy custody suite, this briefing will be overlooked or omitted, and in fact that was the evidence in this case.

“There is no evidence to reassure me that this [omission] was a one-off incident, rather the evidence before me suggested that it was not.

“This gives rise to a risk of future death for detained persons on level 4 constant observation.”

The coroner’s concerns also include lack of police training in recognising signs of mental health issues, drug intoxication, and the increased risk of asphyxia in intoxicated people.

The report states: “Accepting that police officers are not medical professionals, I am concerned that there is no guidance on recognition of symptoms of mental health conditions.

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“[So], detained persons suffering from a mental health episode, or with pre- existing mental health conditions, may be at risk of future death.”

The report notes police officers are trained in communicating with people having mental health episodes, but not how to recognise the symptoms.

Mr Terrill’s cause of death was cardiorespiratory arrest, with an underlying cause of hypoxic ischemic brain injury.

Further underlying causes were notes as cocaine, heroin, pregabalin, gabapentin and dihydrocodeine toxicity (with associated acute agitation), and ischemic heart disease.