11 August 2021

Before HM Assistant Coroner Oliver Longstaff
Durham Miners Hall, Redhills, Durham, DH1 4BE
2 – 6 August 2021

The inquest into the death of Jake Anderson has concluded he died of an alcohol related death whilst held in Peterlee police custody. The jury were critical of observations not conducted in accordance with procedure, the inadequacy in documentation and the unsatisfactory provision of food and fluids to Jake throughout his 12 hour detention. They did not find these to have contributed to his death.

Jake is described by his mother as a kind, caring and loving young lad who had his whole life ahead of him. Jake loved to make people laugh and was a much loved son, brother, grandson and uncle.

Jake had suffered with his mental health for many years and had been under the care of Tees, Esk and Wear Valleys Foundation NHS Trust (TEWV). Jake suffered with undiagnosed Asperger’s as well as diagnoses of schizophrenia, personality disorder and anxiety and had been using alcohol to self-medicate. In the month prior to his death, Jake was referred to the Crisis Resolution Home Treatment Team (CRHTT) on 12 April 2019 and again on 23 June, just days before his death on 25 June 2019.

On 24 June 2019, Jake was arrested and taken into police custody at 10:30am. Officers took him to Peterlee Police Station. He arrived there at 11:53am where he told officers that he had mental ill health including depression and a personality disorder, and that he was dependant on alcohol. Staff concluded that Jake did not need first aid or medical treatment as he appeared to be “under the influence”. He was placed on level 2 observations which should have involved checks every 30 minutes.

Over the course of the next few hours, Jake’s behaviour become more and more alarming. He believed that he was in Lanchester Road Hospital, a local mental health facility, rather than in police custody. By 2:00pm he had become incoherent, confused and was experiencing hallucinations. CCTV footage showed Jake talking to himself and visibly hallucinating inside the cell.

At 8:00pm Jake was assessed by a Force Medical Examiner (FME) who concluded that he required an assessment under the Mental Health Act. Evidence was heard from the FME that upon examining Jake, he advised the Custody Sgt that Jake’s level of observations should be increased to level 3 which involved constant observations. This was due to concerns about Jake’s level of risk. However, Jake’s observations were never increased and the Custody Sgt maintained in evidence at the inquest that this conversation did not take place.

A Mental Health Act Assessment was carried out at 10:30pm, which concluded that Jake was suffering from drug induced psychosis. Jake’s detention was further authorised under section 2 of the Mental Health Act, whilst a bed was located in a mental health hospital.

The inquest heard that besides water upon arrival, there was no record of food or drink being offered to Jake during the 12 hours he was in custody. Expert pathology evidence was provided that when diagnosed early enough, ketoacidosis can be treated with fluids and dextrose sugar. Detention staff stated that the reason they didn’t provide food to Jake was due to a lack of additional support to enter the cell. However, CCTV showed that the Detention Officer asked the Custody Sergeant “How do you feel about giving Looney Tunes food and drink?” and he replied “I wouldn’t bother”. The Detention Officer then pointed out that the Doctor had asked if Jake had been fed and watered and the Custody officer replied “I can’t see the point actually”.

At 23:30, a Detention Officer is said to have checked on Jake and noted that he was lying face down on the floor, on a mat. Jake remained in this position until 00:01 when the same officer raised concerns about Jake’s welfare. The officer is seen on CCTV to request back-up support from the Custody Sgt, to enter the cell and check Jake. Both officers believed Jake to be feigning unconsciousness at this point. Staff entered the cell and shook Jake by the shoulder, but he was unresponsive. The Custody Sgt gave evidence that he thought Jake was resisting being shaken as his arms were stiff. Both officers returned to the custody desk stating that they didn’t believe he was unconscious and it was only when they re-entered the cell at 00:05 that officers attempted to find a pulse. CPR was commenced but sadly Jake was pronounced dead at 00:30 on 25 June 2019. At the time of his death Jake was in a state of alcoholic ketoacidosis.

A Serious Incident Review carried out by Tees, Esk and Wear Valleys Foundation NHS Trust (TEWV) highlighted that there were missed opportunities between the multi-agencies, to communicate effectively in sharing information about Jake’s physical health and for a care plan to be put in place to monitor Jake in custody while a bed was located.

Following an investigation by the Independent Office for Police Complaints, two Detention Officers and a Custody Sgt were referred to Durham Constabulary for misconduct proceedings.

The inquest jury found that:

• Jake had a history of mental health problems with an alcohol and drug misuse
• The level 2 observations were appropriate for the initial presentation
• These observations, on occasions, were not carried in accordance with procedure and documentation was unsatisfactory
• The frequency of refreshment offered to Jake was unsatisfactory
• The increase of observations as suggested by the FME cannot be established on findings of fact and on the balance of probability the decision to increase to level 3 observations was not communicated adequately, although it may have been more appropriate at that time
• It was agreed that once Jake was found unresponsive, assistance was provided in a prompt manner
• There is no evidence to suggest that if the management had been different that this would have had an effect on the overall outcome.

Jake’s mother, Alison Anderson, said: “Jake was our first child. He was loved and adored by all the family. The last time I saw him, he was leaving with two police who reassured me that he was being taken to the police station to calm down for a couple of hours. Jake should never have been arrested as all charges were dropped once the neighbour knew who Jake was. His mental health should have been managed and treated rather than the assumptions which were made about him being under the influence. It’s been every parent’s worst nightmare to watch the CCTV footage. Police officers are supposed to be trained to deal with people with mental health issues but we strongly believe Jake was left to die in those last hours of his life with no one caring for him at all. If staff had treated Jake with even basic medical care, then he would still be here.”

Alistair Smith of Watson Woodhouse solicitors said: “Jake died in police custody. He should have been safe, he wasn’t. The family looked after Jake for years during all his troubles, but when in the hands of the state for less than 12 hours, he was tragically and fatally let down. The inquest has heard of the failure to provide basic rights, food and drink and consistent monitoring. Jake should have been in hospital or anywhere his most basic human rights were considered. They were not in the custody suite at Peterlee Police station. This was clearly an avoidable death involving multiple missed opportunities by multiple agencies of the state. Alison and Robert have lost a son, a sister her brother and her children an uncle. Jake should be here today and isn’t. I commend their dignity. It’s tragic the same standards were not shown by Durham Police.”

Jodie Anderson, Senior Caseworker at INQUEST said: “Police custody is no place for a person suffering physical or mental ill health. It was evident early on that Jake was suffering and it should have been clear to custody staff at Peterlee station that the safest place for him was in a hospital, not in a police cell. Custody staff missed obvious signs that Jake was in distress and agitated, signs that a medical response was urgently required. Jake deserved a basic duty of care and yet even when he was unconscious, the officers assumed that he was feigning it. Unless there is a cultural change within the police force and proper overhaul in the way people in mental health crisis are treated both by Durham Constabulary and also TEWV NHS Trust mental health service, these deaths will sadly continue.”


For further information, interview requests and to note your interest, please contact INQUEST on 020 7263 1111 or [email protected]

Jake’s family are represented by INQUEST Lawyers Group members Alistair Smith and Sarah Magson of Watson Woodhouse Solicitors and Clare Ashcroft of Garden Court North Chambers. The family are supported by INQUEST senior caseworker, Jodie Anderson.

Other Interested persons represented are Durham Constabulary and Tees, Esk and Wear Valleys Foundation NHS Trust (TEWV).

INQUEST is the only charity providing expertise on state related deaths and their investigation to bereaved people, lawyers, advice and support agencies, the media and parliamentarians. Our specialist casework includes death in police and prison custody, immigration detention, mental health settings and deaths involving multi-agency failings or where wider issues of state and corporate accountability are in question, such as the deaths and wider issues around Hillsborough and Grenfell Tower. Our policy, parliamentary, campaigning and media work is grounded in the day to day experience of working with bereaved people.

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