Home AffairsWritten evidence submitted by the family of Sharon McLaughlin [IPCC 21]


Christian Khan Solicitors write on behalf of the family of Sharon McLaughlin to provide submissions to the Inquiry into the Independent Police Complaints Commission (“IPCC”).

Background Facts

Sharon McLaughlin was 32 years old when she died in Worthing Custody Centre in West Sussex on 16 May 2010 as a result of cardiac arrhythmic failure. At the time of her death Worthing Custody Centre was manned by both officers under the direction and control of the Chief Constable of Sussex Police, and custody staff employed by Reliance Secure Task Management (“Reliance”).

By way of background, police forces may enter into contracts with third parties for the provision of police services. In those circumstances, police forces at present have a choice as to whether or not to “designate” employees of the contractors.

Section 39 of the Police Reform Act 2002 (“PRA 2002”) sets out that, where a police authority has entered into a contract with a person (including a legal person such as a limited company) for the provision of services relating to the detention or escort of persons who have been arrested or are otherwise in custody, it may designate an employee of that contractor to be a detention officer or an escort officer.

Significantly, Section 39(4) PRA 2002 states that:

“A chief officer of police shall not designate a person under this section unless he is satisfied that that person:

(a) is a suitable person to carry out the functions for the purposes of which he is designated;

(b) is capable of effectively carrying out those functions; and

(c) has received adequate training in the carrying out of those functions and in the exercise and performance of the powers and duties to be conferred on him by virtue of the designation.” [our emphasis]

Further, Section 39(5) PRA 2002 states that:

“A chief officer of police shall not designate a person under this section unless he is satisfied that the contractor is a fit and proper person to supervise the carrying out of the functions for the purposes of which that person is designated.” [our emphasis]

For reasons that have never been explained to the family, the Chief Constable of Sussex did not designate Reliance staff. As set out below, this has had very serious repercussions in terms of investigating the cause and circumstances of Ms McLaughlin’s tragic death.

Ms McLaughlin was arrested and taken to Worthing Custody Centre on 15 May 2010 on suspicion of shoplifting. On arrival, she informed the custody sergeant that she was dependent on heroin. When searched, she was found to be in the possession of over 50 needles as well as drug paraphernalia and some Class A drugs. During the search, Ms McLaughlin had asked the officer if the needles could be returned to her on her release so that she can re-inject any residual drugs. It was therefore clear that Ms McLaughlin suffered from an established heroin addiction. In addition, she informed the custody sergeant that she had previously self-harmed.

The care of vulnerable detainees was, at the time of Ms McLaughlin’s death, subject to guidance both in Code C of the Police and Criminal Evidence Act 1984 (“PACE Code C”) and the 2006 Home Office/Association of Chief Police Officers (ACPO) “Guidance on the Safer Detention and Handling of Persons in Police Custody” (“the Guidance”).

Paragraph 9 of PACE Code C sets out the care and treatment of detained persons. Paragraph 9.5 of Code C sets out the circumstances in which a custody officer must make sure a detainee receives appropriate clinical attention as soon as reasonably practicable. Paragraph 9.5B sets out that:

“The custody officer must also consider the need of clinical attention as set out in note for guidance in 9C relation to those suffering the effects of alcohol or drugs.”

Practice Note 9C sets out in turn that:

“A detainee who appears drunk or behaves abnormally may be suffering from illness, the effects of drugs or may have sustained injury, particularly a head injury which is not apparent. A detainee needing or dependent on certain drugs, including alcohol, may experience harmful effects within a short time of being deprived of their supply. In these circumstances, when there is any doubt, police should always act urgently to call an appropriate healthcare professional or an ambulance...”

Ms McLaughlin received no medical attention despite the fact that the custody officer was, or should have been, aware of the fact that she suffered from a drug addiction.

Whilst in the police cell, Ms McLaughlin displayed signs of being unwell. She was cold and asked for a blanket and vomited on at least two occasions. Ms McLaughlin refused food over a lengthy period.

The custody support officers employed by Reliance were heard on the custody suite CCTV sitting in front of their computers discussing the fact that Ms McLaughlin had vomited. Neither was willing to clean it up and one was jokingly asking whether she was “still alive”. Ms McLaughlin was left in her own vomit for a number of hours.

However, of even greater concern is the fact that, upon becoming aware of the fact that Ms McLaughlin had vomited, no police officer or custody assistant visited Ms McLaughlin in her cell to speak to her and/or assess her. Incredibly, Ms McLaughlin was never seen or examined by a nurse, despite the fact that she was highly dependent on intravenous heroin, had not eaten for a considerable period and had vomited.

Twenty-two and a half hours after Ms McLaughlin’s arrest, she was visited in her cell by a police officer to release her. She was found unconscious and pronounced dead at approximately 2pm on 16 May 2012.

The IPCC Investigation

Prior to the Inquest, the IPCC carried out an investigation into Ms McLaughlin’s death. They found a number of serious breaches of the Standard Operating Procedures on behalf of police officers in the employment of Sussex Police. A copy of the full report is attached for your information.1

However, because Reliance staff were not designated, the IPCC lacked jurisdiction to question, interview and investigate the actions of custody staff in the employment of Reliance. Reliance were therefore left to speak to their staff and carry out an internal investigation, which (in evidence at the Inquest) Reliance’s Operations Manager Claire Boffee accepted lacked any independent input.

Reliance staff were not interviewed (on tape or otherwise) and the report failed to touch on key factual and legal issues.

The Inquest

As is frequently the case, the Inquest into Ms McLaughlin’s death did not occur until some considerable time after her death, in this particular case some 18 months. HM Coroner Mr Burgess commenced the two week inquest on 14 November 2011.

At the inquest, evidence was heard from three pathologists and a doctor as to the cause of Ms McLaughlin’s death, as well as a large number of witnesses of fact.

In light of the medical evidence, the following possible causes of death were explored:

SADs abnormal heart—there may have been a heart abnormality that was not obvious/detected during the autopsy.

SADs with a normal heart.

SADs with Chronic Drugs Use.

Chronic Drug Use and Arrhythmic Failure.


However, because no independent body had investigated or recorded the accounts of staff in the employment of Reliance crucial factual evidence was lost. Reliance staff were repeatedly able to rely on a lack of recollection due to the passage of time in the course of their evidence. The only record of their account was the internal report carried out by Reliance, which lacked both detail and independence.

In addition, one of the key staff members of Reliance who had been responsible for Ms McLaughlin during her time in custody (and who was subject of some of the most severe criticism) had been released from the employment of Reliance at the time that the Inquest took place. He failed to attend the Inquest (despite having been summoned) having previously endeavoured to instruct independent legal representatives following concerns that his evidence could potentially lead to criminal charges being brought against him. It subsequently transpired that he was not able to obtain public funding for his representation and as such he was not able to afford legal representation at the Inquest. At short notice, a doctor’s note was produced stating that he was unable to attend.

As a result of these issues, flowing ultimately from the lacuna in the IPCC’s jurisdiction, were therefore significant gaps in the factual evidence before the Jury, Coroner and medical experts and crucial information was lost.

The family argued that, without knowing the precise circumstances surrounding or cause of death, it could not conclusively be said that a nurse or medically qualified person would not have identified symptoms related to a cardiac failure (whether by a vital signs observation, eliciting responses by questioning or otherwise). Consequently, the possibility of further medical treatment having been capable of preventing her death could not be excluded.

The jury ultimately returned a verdict of natural causes, but the evidence at the inquest, which revealed failings by those responsible for her in the care and treatment she received, caused the Coroner to write to the Home Secretary and Chief Constable with a report under Rule 43 of the Coroners Rules 1984 (as amended).

In summary, he wrote as follows:

1.This case has found that all custody officers and Reliance custody staff involved in Ms McLaughlin’s detention had a lack of awareness of the Home Office Guidance on the Safer Detention and Handling of Persons in Police Custody.

2.There were similar failings identified in the IPCC investigation into the death of Garry Reynolds in March 2008. There was also a lack of appreciation of the importance of Sussex Police Policy and Home Office Guidance, amongst custody officers and Reliance staff.

3.The Coroner recommended that Sussex Police reviews its custody officer training to ensure that it is fit for purpose and complies, with the Home Office, guidance. Furthermore, that Sussex Police reviews whether any of the officers involved in this incident need to re-attend custody officer training to ensure they fully understand the requirements of to continue in the role.

4.Although no link has been established between Ms McLaughlin’s death and the time she spent in custody, it is clear from the evidence that having vomited, no-one treated her with the consideration, professionalism and dignity which she should have been able to expect as a detainee in custody.

5.Whilst it is probable that no medical treatment could have prevented the death in this instance, not only was it suggested (and accepted by Sussex Police) that her previous medical history should have resulted in an examination by a “health care professional” but her sickness in the morning (between 5:00 and 6:00 hrs) went unremarked and unrecorded.

6.It is also clear from the evidence that none of the custody sergeants were fully conversant with the Home Office Guidance on the Safer Detention of Persons in Custody, nor did their conduct comply fully with the guidance.

7.There were also problems with the way in which the detention records were kept and the various periodic observations recorded.

8.The Coroner recommended that Sussex Police, and the specific custody staff and officers involved in this incident, need to reflect on this incident in order to learn from it and develop improved custody practices which comply with the guidance laid down by the Home Office.

Furthermore, the inquest revealed a number of “structural problems”:

1.The differences in wording between the 2006 Home Office/ACPO “Guidance on the Safer Detention and Handling of Persons in Police Custody” and the 2008 “Police and Criminal Evidence Act 1984 (PACE)—Code C (Code of Practice for the detention, treatment and questioning of persons by police officers)” resulting in differences of approach and potential conflicts in interpretation and practice.

2.There were also difficulties for the IPCC in that as the Custody Assistants and Detention Supervisors employed by Reliance were not “designated” by the Sussex Police, the IPCC could not interview and investigate their actions/failures to the same extent as they could individual police officers.

We enclose copies of the HM Coroner’s letter under Rule 43 of the Coroners Rules, as well as the responses from the Secretary of State for Home Department (undated) and the Chief Constable of Sussex Police Martin Richards dated 4 January 2012.2

Broader Legal Framework and Submissions

You will no doubt be aware of the State’s obligations under Article 2 of the European Convention of Human Rights, actionable under the Human Rights Act 1998, which enshrines the right to life.

It is a well established principle that Article 2 includes a positive obligation on the State to prevent the loss of life, which in turn gives rise to an investigative duty where an individual dies in police or prison custody. This duty is often discharged through the IPCC investigation and inquest.

Ms McLaughlin’s case is a tragic example of the State’s failure to secure a full and effective investigation into her death, in part as a result of the IPCC’s impotency in investigating the role of staff employed by non-State actors in the context of a death in custody. It is wholly unacceptable in this context that State agents such as the Chief Constable of Sussex Police are allowed to abdicate responsibility for detainees’ wellbeing by contracting out responsibility to private companies and are able to avoid accountability by deciding not to designate staff.

In addition, the family are concerned that Ms McLaughlin’s case demonstrates a lack of transparency in the course of the IPCC investigation in terms of their communications with the police. Although a number of recommendations were made, Sussex Police were given an opportunity to comment on the investigation report without such comments being disclosed to the family. Further, the family’s experience was that there was insufficient communication and transparency in terms of the police force’s subsequent decisions as to whether or not to act on such recommendations. Therefore, additional measures to ensure better transparency should be put in place and a framework should be developed which requires public responses to concerns raised by the IPCC.

The problems faced in holding private companies to account in the context of Ms McLaughlin’s death was not an isolated incident. We enclose a print-out of an article in the Independent Newspaper regarding Ms McLaughlin’s death highlighting the broad-scale concerns that this case exemplifies.

Ms McLaughlin’s Family

Ms McLaughlin left behind a young daughter, and her four siblings, Graeme Lloyd, Emma Lloyd, Carol McLaughlin and Amanda Taylor, as well has her father Philip McLaughlin.

The family are devastated by her loss, which they believe could have been prevented by better care by both Sussex Police and Reliance staff. The medical circumstances around Ms McLaughlin’s death were complex and the Inquest was unable to conclude that if medical assistance had been provided earlier her death would have been avoidable.

However CCTV footage undoubtedly demonstrates that Ms McLaughlin was treated with a lack of respect and that her final hours were spent in an undignified and inhumane state. This is echoed by HM Coroner in his letter to the Secretary of State and Chief constable.

Ms McLaughlin’s family have, throughout the course of the investigation and subsequent Inquest, conducted themselves with the utmost dignity, as recognised by HM Coroner at the conclusion of the Inquest. Their sole desire is to see improvements in accountability and transparency of investigations into deaths in State custody, including where public functions are contracted out to private companies.

It is hoped that the Home Affairs Select Committee inquiry will review these submissions favourably and improve the IPCC’s ability to ensure that lessons are learnt from such tragic deaths so that they can be prevented in the future.

Christian Khan Solicitors on behalf of the family of Sharon McLaughlin

June 2012

1 Not printed.

2 Not printed.

Prepared 1st February 2013