24th June 2014

The jury at the inquest into the death of Lloyd Butler in police custody in Birmingham has found that his death may have been preventable. In a highly critical conclusion, they found that he should not have been detained in custody but instead taken to A&E.

An inadequate risk assessment led to discretion being applied to keep Mr Butler in custody. Rousing checks were not adequately carried out and visits were not maintained on schedule. There was also a delay in the arrival of the healthcare professional to the custody block.

The jury concluded that had Mr Butler been monitored in hospital at the time of his heart attack, the probability is he was more likely to have survived.

The medical cause of death was cardiac arrest, alcoholic liver disease and alcoholic cardiomyopathy.

Background to Lloyd Butler’s death is here.

Janet Butler, Lloyd Butler’s mother said:

“All we have ever wanted was to know the truth about Lloyd’s death and for those responsible to be held to account.  Lloyd died nearly four years ago and it has been a long and painful battle to reach this point.  Nothing will bring back our dearly loved son but the inquest has at last finally given us a clear picture of what took place over those hours and exposed the degree of police failure and neglect that led to Lloyd’s death. 

“We call now on West Midlands Police to act in response to the evidence that has come out during Lloyd’s inquest and for proper action to be taken against those responsible.”

The seriousness of the case was reflected in the unusual steps taken by the IPCC in recommending disciplinary action for gross misconduct against several officers involved with Lloyd’s care.

Disciplinary hearings that took place before the inquest found that scheduled cell checks did not take place and that officers failed to comply with police procedures requiring intoxicated detainees to be woken during monitoring checks.  Officers were seen making personal phone calls and browsing the internet instead of monitoring CCTV.   Despite being found guilty of gross misconduct in his public duty, Sgt Mark Albutt received a final written warning and did not face dismissal.  PC Dean Woodcock was found guilty of misconduct in his public duty and was said by West Midlands Police to have received ‘management advice’.

A freedom of information request made by INQUEST last year revealed that between 2009 and 2012, the IPCC found that 15 officers investigated in relation to a death in or following police custody had a case to answer for gross misconduct.

Three of the officers resigned or retired prior to the gross misconduct hearing taking place.  Of the rest, 8 were found guilty, but only one was dismissed.  The rest were allowed to keep their jobs.

Helen Shaw, co-director of INQUEST said:

“Evidence during the inquest has revealed shocking and inhuman treatment of this vulnerable man.  Basic police procedures that exist to keep detainees safe were not followed. Lloyd failed to receive the emergency medical care he required and was left in a police cell uncared for and unmonitored.  Learning from his tragic and preventable death must applied nationally across all forces.

“It is not acceptable that sanctions for the officers found guilty of misconduct have not been more serious.  For the public to have any faith in the police they must be seen to be held to account, with sanctions proportionate to the seriousness of the charge.”

INQUEST has been working with the family of Lloyd Butler since his death in August 2010. The family is represented by INQUEST Lawyers Group members Ifti Manzoor from Irwin Mitchell solicitors and Stephen Cragg QC of Doughty Street chambers.


  1. The IPCC report into Lloyd’s death was published today. Further information is available here