2nd December 2016

An inquest jury today (1 December) concluded that a 43-year-old man died following police custody as the result of a seizure followed by cardiac arrest.


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 occasions

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.






For further information, please contact Laura Smith at INQUEST on [email protected] or 020 7263 1111.


  1. Previous death at Northern Area Custody Facility: An inquest in 2015 found that 34-year-old Nicholas Rowley, also detained at Northern Area Custody Facility, Etruria, Stoke-on-Trent, died in 2011 in circumstances involving failures of care by custody and medical staff in response to a vulnerable intoxicated detainee. HMC Ian Smith issued a Prevention of Further Death report to Staffordshire Police, G4S and Nestor Primecare identifying evidence of “poor or no communication between doctors and custody sergeants and frequent misunderstanding over the required level of observation.” https://www.judiciary.gov.uk/publications/nicholas-rowley/


  1. Full timeline of events on 12 January 2014:


  • Fearing for Darren’s safety, the police forced entry into his room which they found in a serious state of neglect with evidence of unopened medication. Darren was on the floor, had defecated and was unable to stand. He was seen to have a pressure sore on his back. He was handcuffed and officers carried him outside, initially placing him in a police car. He was punched on the leg in response to allegations that he had hit out at police. He was then transferred from the car onto the pavement.


  • According to neighbours it was a cold day and Darren remained on the pavement for 15-20 minutes shouting "help me" while police awaited arrival of a police carrier. An ambulance summoned to the scene was instructed to stand down. Darren was carried into the carrier and transferred to Northern Area Custody Facility. Unable to walk, at 15.28 he was carried directly into a police cell. He was placed on a mattress on the floor and stripped of his lower garments.


  • Police accounts described Darren as violent, uncooperative and engaging in a "dirty protest". According to evidence to the inquest, Darren had lost control of his bowels and at no stage was violent in the custody suite. CCTV shows Darren remained on his cell floor throughout his seven hours of detention, for much of that time barely moving.


  • After 4.30pm, Darren was left half naked and covered in his own faeces for the remaining period of is detention.


  • Two detention custody officers (DCOs) were overheard making derogatory comments about Darren’s state including referring to Darren as a “shitty bum” and a “dirty bastard”. Another detainee also overheard a few DCOs discussing the fact that Darren had done a “Shart, they said what’s a shart, a shit fart, he shit himself”.


  • Darren entered custody at 3.30 and after 4.30 there was only one further entry by custody sergeants at approximately 21.45 to move Darren away from the cell door and back onto the mattress, no other attempt was made to enter his cell. After 21.45 CCTV shows him lying face down, with almost no discernible movement.


  • At 23.00 officers entered his cell and found Darren unresponsive. He was transferred by ambulance to University Hospital, North Staffordshire, where he was placed on life support. A&E staff were informed that Darren had “seemed ok” only the minute before being found collapsed. He was pronounced dead on 15 January 2014.


  1. Other information:


Staffordshire Police, Nestor Primecare (responsible for the health and forensic services to Staffordshire Police) and G4S (responsible for the Custody Detention Officers), three police officers and one civilian detention officer were all separately represented at the inquest.


Of the two custody nurses employed by Nestor Primecare responsible for medical care during the period of Darren's custody, one resigned immediately following Darren's death and the other was dismissed following misconduct action.


DCOs described not being given information about Darren's conditions or alerted to what to look out for during their observations. Some had not been trained on the effects of alcohol withdrawal and its life threatening risks.


For further information, please contact:


INQUEST provides specialist advice on deaths in custody or detention or involving state failures in England and Wales. This includes a death in prison, in police custody or following police contact, in immigration detention or psychiatric care. INQUEST's policy and parliamentary work is informed by its casework and we work to ensure that the collective experiences of bereaved people underpin that work. Its overall aim is to secure an investigative process that treats bereaved families with dignity and respect; ensures accountability and disseminates the lessons learned from the investigation process in order to prevent further deaths.


Please refer to INQUEST the organisation in all capital letters in order to distinguish it from the legal hearing.