14 June 2019

Before HM Senior Coroner for South Manchester, Alison Mutch OBE
The Coroner’s Court, Stockport
Monday 3 June 2019 – 13 June 2019

The inquest into the death of Adam Harris, who died in the custody of Greater Manchester Police (GMP) on 20 April 2018, has concluded. The jury found that the cause of death was cocaine and alcohol toxicity. The Coroner has indicated that she will be sending a preventing future deaths report to GMP.

Adam was 34 years old and was the father to three children. He was from Dukinfield, Tameside, and his family describe him as a brilliant and doting dad who would do anything for anybody.

The inquest heard that in the early hours of 20 April, GMP were called to attend an incident outside Adam’s home in Dukinfield. He was taken to Ashton-under-Lyne police station where he was held in a van dock area outside the custody suite for 54 minutes before being taken into the custody suite. This practice followed the removal of a GMP policy known as “custody silver”, which was axed in order to save half a million pounds by replacing the previous system of allocating people to custody suites according to available space.

Evidence was heard that between Adam’s arrest and his arrival at the custody suite he was not searched. Whilst held in the van dock Adam began to demonstrate increasingly bizarre and concerning behaviour, but the custody sergeant was not alerted. There was no system in place for prioritising access to the custody suite or “triaging” detainees held in the van dock so as to prioritise them according to need.

When Adam was eventually taken to the custody suite he was not subject to a risk assessment. He was forcibly strip-searched before being left on his back in a cell, which the Senior Coroner observed carries a risk of aspiration, i.e. the airways becoming blocked, where the person is intoxicated. He was in the custody suite for an hour before the custody sergeant and a nurse recognised a need to enter his cell. By that stage his condition had begun to deteriorate further. A short time later Adam produced a small plastic ‘snap bag’ from his mouth and told the custody sergeant and a nurse that he had taken cocaine.

This was finally recognised by the custody sergeant and the nurse as being a medical emergency, because of the dangers of swallowing packaged drugs, but there was a delay of some six minutes before an ambulance was called. By this stage Adam’s condition was rapidly deteriorating. He began having seizures and went into cardiac arrest. He was later pronounced dead at Tameside General Hospital.

HM Senior Coroner for South Manchester has indicated that she will be making a report to prevent future deaths report in relation to:

  • the role of transport officers, the communication to them, and the expectations of their role in terms of the handover to the custody sergeant;
  • the quality of triage in the van dock area and assessment of risk; and
  • the use of handwritten notes during the custody booking-in process.

Adam’s family have issued the following joint statement: We remain very concerned and upset about the evidence we have heard and seen in this case and what we see as a lack of concern for Adam’s wellbeing by those who were supposed to be looking after him. We are pleased that the Coroner has recognised that there were issues arising from Adam’s death which need to be addressed to stop this happening to others in the future. We want to thank our legal representatives for their efforts in this case in helping to expose what happened.”

Leanne Devine, Head of Inquests & Inquiries at Broudie Jackson Canter said: “We are pleased that the coroner has seen fit to make a preventing future deaths report and would expect Greater Manchester Police practices to reflect upon the issues raised in order to learn lessons and avoid this situation being repeated in the future

It is of concern to Adam’s family that this case was not adequately investigated by the IOPC. We will be making a request to the IOPC to reopen their investigation into Adam’s death now that the full facts have been aired.”

Deborah Coles, Director of INQUEST said: “In the last few weeks multiple inquests have taken place on deaths in police custody of individuals who swallowed or secreted packaged drugs. Clearly there are widespread issues with the police response to this as well as recognition of medical emergencies.

The coroner has taken an important step to highlight continued dangerous Greater Manchester Police practices. These reports to prevent future deaths must be considered at a national level and a broader review of police practices regarding drug swallowing is urgently required.”


For more information contact Lucy McKay on email or 020 7263 1111

INQUEST has been working with the family of Adam Harris since November 2018. The family is represented by INQUEST Lawyer’s Group members Leanne Devine of Broudie Jackson Canter Solicitors and Matthew Stanbury of Garden Court North Chambers, and previously represented by Ruth Bundey of Harrison Bundey Solicitors.

Other interested persons represented at the inquest were Greater Manchester Police and Care in Custody “MITIE”, (private company supplying nurses), and the IOPC

Other recent inquests of relevance:

- Inquest identifies missed opportunity by Kent Police to seek medical treatment for Carl Maynard after suspected drug swallowing, Media Release, 11 June 2019. The inquest jury found that ‘failing to take Carl directly to hospital’ represented a ‘missed opportunity to increase Carl’s chance of survival’.  Since Carl’s death Kent Police changed their policy shortly to ensure that anyone suspected of swallowing a substance should be taken directly to hospital. 

- Jury concludes death of Edir ‘Edson’ Da Costa following restraint by Metropolitan Police was misadventure, Media Release, 6 June 2019.  Edir was stopped by Metropolitan Police, during which he placed a package (later identified as containing drugs) into his mouth and was restrained. Edir became unconscious and was taken to hospital where he later died. A jury returned the conclusion that Edir died by ‘misadventure’. The jury narrative noted, “Mr Da Costa died from the consequences of cardio respiratory arrest after his upper airway was obstructed by a plastic bag containing drugs he had placed in his mouth.”

- Inquest into death of Leroy Junior Medford in Thames Valley police custody, Media Release, 7 June 2019. Junior was arrested in Reading and shortly after was admitted into Royal Berkshire hospital as police officers suspected that he had secreted drugs on his person. He was later discharged back into police custody where officers were tasked to keep Junior under constant observation. However, Junior was able to retrieve the secreted item and swallow it within minutes of being placed under constant observation. He was later found unresponsive in his police cell shortly before being pronounced dead. The inquest continues.

Also see the conclusion of the inquest into the death of Rashan Charles, Media Release, 20 June 2018, which found the officer involved did not follow prescribed police protocol for when someone is not breathing and suspected of swallowing drugs.