“Serious and significant” police misconduct contributed to the death of Kelly Hartigan-Burns, a jury has found.
An inquest, which has been going on for five weeks, learned how the 35-year-old suffered from an episode of mental health on December 3, 2016.
The jury spent two days conferring before reaching the conclusion that ‘significant and serious’ misconduct by the police contributed to Kelly’s death.
The jury spoke of how the issues of lack of training, absence of cabin crew members, lack of communication between the senior case officer and the transport team and the management of the duty room contributed to the Kelly’s death.
The jury’s conclusion said: ‘If the Lancashire Police officers involved in this incident had shown more compassion, acted diligently, practiced common sense, followed advice and followed procedure from the time they found Kelly in the church yard and throughout her detention there might have been a different outcome.
DCC Sacha Hatchett, of Lancashire Police, said: “Today our thoughts are first and foremost with the family of Kelly Hartigan-Burns and all those close to her.
“The Lancashire Constabulary have a duty of care to everyone in our care and they should be able to rely on us to keep them safe.
“We weren’t able to do that with Kelly and we’re really sorry about that.
“Since that night, we have taken a number of steps to minimize the risk that such a tragedy could happen again. This includes a number of system changes to strengthen our processes when taking custody and increasing staff training on how to recognize when people are vulnerable and how to care for them while in our care.
“After Kelly’s death, the matter was referred to the Independent Police Conduct Office which reviewed the conduct of five officers and two detention officers.
“An officer was taken to a gross misconduct hearing but retired before that hearing was held. The hearing determined he would have been fired had he not retired. A another officer was the subject of unsatisfactory performance procedures and management action.
“We are grateful to HM Coroner for considering this matter in detail during the inquest and to the jury for their careful consideration. As the Lancashire Constabulary is a learning organisation, we will of course consider their findings in detail and take into account all the other lessons we can.
“Once again, our thoughts and sympathy go out to all of Kelly Hartigan-Burns’ loved ones at this time.”
Kelly died at the Royal Blackburn Hospital on December 5, 2016, after being found unconscious in a cell at Greenbank Police Station in Blackburn in the early hours of the morning on December 4.
Officers were on high alert after a woman reported seeing Kelly threatening her life.
After her arrival, PC Simon Haigh and PC Rebecca Price, who were completing her training, reunited with Kelly who was by then “calm but upset”.
They called to check the PNC check and were told Kelly had a suicide marker on her file.
She was taken to her home on Barley Bank Street in Darwen where his wife Collette said she had been punched by Kelly earlier that night which led to an arrest for assault.
Kelly was taken by two different officers into custody in Blackburn, with Special Sergeant Megan Dawson, a volunteer officer, noting her book about the domestic violence incident but no record of the suicide marker, something Special Dawson has said was not communicated to him by Training Officer PC Haight.
After arriving in police custody in the early hours of December 4, Guard Sergeant Jason Marsden “failed to engage” with Kelly, only asking her name just before she was taken to a cell.
An incident in which Kelly moved her arm while an officer attempted to remove her rings was deemed an attempt to hit the officer, so Kelly was subdued.
The four-minute check-in process has been described by Christopher Hampshire, an acting inspector who took part in a nationwide inquest into deaths in police custody, as “completely unacceptable”.
A handover by Sgt Marsden included details about Kelly, including that she had a suicide tag on her file from earlier in the year and was on mental health medication.
She was checked shortly after by another watch sergeant, CEO Miller, who checked on Kelly and woke her up.
At another check around 1:30 a.m., Kelly was found after attempting to kill herself.
She was taken to Royal Blackburn Hospital where she died on December 5.