Northumbria Police made a series of failings leading up to the death of a man in custody, a police watchdog has said.
Stephen Berry, 43, had been detained for longer than normal as it was the Easter weekend, when he collapsed in his cell and died a short time later.
An inquest has found his death was due to the effects of alcohol withdrawal in circumstances where there were avoidable delays to emergency medical interventions, the Independent Office for Police Conduct (IOPC) said.
Two detention officers accepted misconduct and received warnings, while two Northumbria Police sergeants were found to have a case to answer to gross misconduct but both retired, the IOPC said.
Separate from the inquest proceedings which concluded on Wednesday, the watchdog carried out its own investigation into what happened at Washington police station, Tyne and Wear, on March 28 2013.
Mr Berry had been arrested for failing to appear in court and was declared fit to be detained by a medical examiner and prescribed medication.
He was detained for longer than usual as March 29 was Good Friday - a Bank Holiday - and the plan was to produce him in court on the Saturday.
The IOPC said he was assessed as requiring half-hourly checks, during which he should have been be roused.
Inquiries from CCTV footage, witness accounts, police custody logs and statements from the officers and staff at the scene found:
- There were six false entries, and other inaccuracies, in the custody record relating to checks made on Mr Berry
- Mr Berry was left unchecked and not roused for almost five hours during his detention
- His health deteriorated rapidly from 7pm on March 29 and he was seen sweating, shaking and having difficulty breathing
- He asked to be taken to hospital but this was refused
- A detention officer reported concerns for Mr Berry's welfare to a custody sergeant but these were ignored or dismissed
- A custody sergeant contacted a doctor but told him Mr Berry's condition was not urgent. He did not receive any medical attention on March 29 until after his health had deteriorated considerably.
Two detention officers later admitted misconduct and were given written warnings in June 2016.
Two custody sergeants were investigated for gross misconduct for telling a colleague not to record symptoms of the detainee's physical decline and failing to ensure he got prompt medical attention.
The Crown Prosecution Service considered bringing charges but chose not to and both sergeants retired - one on medical grounds.
IOPC interim regional director David Ford said: "Our findings make for difficult reading, not least because they recount the obvious distress Mr Berry was in during his detention.
"Our evidence demonstrates there were, overall, serious failings in the care afforded to Mr Berry.
"Thankfully, such incidents are rare - the vast majority of police officers and staff understand their responsibilities and uphold the highest professional standards."
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Assistant Chief Constable of Northumbria Police Rachel Bacon said: “Our thoughts continue to be with the family and friends of Stephen Berry following his tragic death in 2013.
“As a Force, we take the welfare of people in our custody extremely seriously with officers and staff thoroughly trained in caring for detainees.
“The importance of risk assessments, observations and treatment of people who are alcohol dependent or suffering alcohol withdrawal are important factors of this training.
“I take note of the findings made at the inquest into Mr Berry’s death which concluded on Wednesday.
“In the years since 2013, procedures have been reviewed and many changes have been made, which was accepted at the inquest.
“This is very much an ongoing process to ensure we continue to meet the needs of those who come into custody.
“As with any death in police custody, an immediate referral was made to the Independent Office for Police Conduct who carried out an investigation.”