13 February 2020

Before HM Assistant Coroner for Surrey, Alison Hewitt
Woking Coroner’s Court
3 February 2020 – 12 February 2020
 
The inquest into the death of Miranda Stevenson, 42, has concluded, with the jury finding she died a ‘sudden death during alcohol and drug withdrawal’ at Guildford Police station on 31 May 2015. The jury agreed unanimously with the pathologist’s review of the CCTV footage that Miranda died suddenly following abnormal breathing at 7.29pm on 31 May. Despite multiple ‘welfare checks’ she remained in her cell for a further 12 hours until an officer entered the following morning at 7.15am.
 
Miranda is described by her mother as a loving and kind daughter, sister and mother. She was living in Guildford at the time of her death and was excited about the upcoming arrival of a new grandchild.
 
Miranda had been in police custody since the early hours of 30 May 2015. She was visited by a healthcare professional at 8.14am after vomiting in the cell and was treated for symptoms of alcohol and drug withdrawal. Later that morning, CCTV footage showed Miranda was still in pain, moaning and moving around on the bed in the cell. She was unable to keep any liquids or medication down due to vomiting profusely. She was revisited by the healthcare professional who referred her to hospital.
 
At 1.31pm Miranda was escorted to Royal Surrey Hospital with two police officers Miranda was again treated for alcohol withdrawal and was examined by an A&E doctor. He assessed Miranda as being clinically stable and discharged Miranda with no further prescription, but noting that she should be returned to hospital if there were any changes to her presentation. Miranda returned to police custody around 6pm on 30 May. Upon her return, Miranda was assessed by a healthcare Professional who assessed her as fit for detention and updated her care plan to 30 minute welfare checks and medical reviews.
 
On the 31 May, Miranda was seen by a healthcare professional again at around 8am and at 5pm where it was confirmed she was still complaining of feeling pain and shakes, and she was prescribed further medication. Welfare checks continued to take place every 30 minutes, with no rousing required. At around 5.30pm on 31 May, Miranda made a phone call to family. Further 30 minutes checks between 6.15pm and 7.15pm recorded that Miranda was asleep/resting and breathing normally. At 7.25pm a custody sergeant completed custody review and reported movement on the bench and that Miranda appeared to be asleep
 
Audio on the CCTV footage from Miranda’s cell showed that she began to hyperventilate at 7.24pm for around two minutes on 31 May before becoming still and silent. The pathologist told the inquest that it is probable that this was when Miranda died. Despite the lack of movement and noise from Miranda’s cell after 7.29pm, six detention officers and a custody sergeant purported they checked Miranda throughout the night and early morning on 1 June. It was not until 7.15am that a detention officer and healthcare professional entered her cell and found her dead.
 
The inquest heard that each check throughout the night shift was carried out by looking through the spyhole rather than by opening the cell door hatch. Opening the cell door hatch enables a more accurate assessment of the condition of the person in the cell as the officer can be provided with other information such as sounds and smell.
 
Evidence was heard that after Miranda had died officers incorrectly observed breathing movement during the spyhole checks. The logs completed on the computer system throughout the night were often selected through the drop-down menu options and included entries such as ‘visited detainee in cell asleep/resting – breathing regular, correct’ and ‘DP was asleep and breathing was noted.’
 
The inquest heard evidence from Chief Inspector David Mitchell that in retrospect, it is apparent that a ‘culture’ developed where detention officers and staff were regularly using the spyholes to conduct welfare checks. This was despite the Authorised Professional Practice (APP) guidance stating that spyhole checks were insufficient and ‘do not constitute an acceptable welfare check under any circumstances’.
 
Wendy Inman, Miranda's mother, speaking on behalf of the family said: “Miranda was a much loved daughter and mother. A happy go lucky person who would help anyone out even when she had nothing but now we have been deprived of her love. We are disgusted at the way Miranda has been depicted throughout this process which has obscured the focus away from the lack of care provided to her. Miranda was unwell and we cannot understand why she was not taken back to hospital. Instead of treating her as a medical emergency they locked her up in a cold hard cell and left her to die.”
 
Anita Sharma, Head of Casework at INQUEST said: “Police custody is no place for a person suffering physical or mental ill health. The signs that Miranda was in pain and required a medical response were clear. It is shocking that despite being on 30 minute observations no one realised that Miranda was dead for 12 hours. The family have waited for five years for the systemic failures to come to light. It is imperative that regular reviews are conducted to ensure dangerous ‘cultures’ do not develop to prevent future loss of life.”

Mike Pemberton, Partner at Stephensons Solicitors LLP, who acted for the family said: “This case is one of my longest running matters and the delays have added to the family’s distress whilst awaiting the findings of this inquiry into the death of Miranda. The case has raised obvious concerns about cell checking and should serve as a reminder that the vulnerabilities of those held in custody require care rather than a click mentality.”

ENDS

NOTES TO EDITORS:

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

Miranda’s mother is represented by INQUEST Lawyers Group members Mike Pemberton of Stephenson’s Solicitors and Stephen Cragg QC of Doughty Street Chambers. The family are supported by INQUEST Head of Casework, Anita Sharma.
 
Other Interested persons represented are the Chief Constable of Surrey Police, Tascor and Royal Surrey County Hospital NHS Foundation Trust.
 
In the period 2008/9–2017/18 there were a total of 17 deaths of women in or following police custody. Further information available in the Independent Office for Police Conduct statistics here.
 
Deaths of women in police custody:
 
Toni Speck, 31, was found slumped in a police cell and later died in hospital in 2011. She was detained by North Yorkshire Police under the mental health act. The jury concluded that the nurse called to the cell should have realised she required urgent treatment.
 
Sharmila Ullah, 30, died in 2014 after she was held at Bloxwich police station. Whilst in police custody she became unwell and was taken to hospital. She was taken back to the police station the next day after receiving treatment. The inquest concluded her death was likely due to the effects of withdrawal. A police officer was sacked for gross misconduct for failing to conduct cell visits which had been documented.
 
Claire Harper, 41, was found unconscious and unresponsive in a police cell in West Yorkshire and later died in hospital in 2018. The inquest is awaited.