Ivan Ignatov
8 Jun 2023 · Coroner Rachael Griffin · Dorset
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. lack of mental health assessment
“During his time in police custody, it was identified by the custody sergeants that [the deceased] required a face to face assessment by the mental health practitioner. This did not happen. Further at approximately 09.00 hours on the 19th July he was seen to place an item around his neck which was interpreted by the custody sergeant as being an act of self-harm. At this time his risk of harm was assessed as low as his clothing had been replaced by rip stop clothing.”
2. missing first-time custody record
“When detained at the Police station it was not recorded anywhere on the custody record or associated Niche paperwork that this was [the deceased]'s first time in police custody. There is no set question for this on the risk assessments within the custody log system held on Niche.”
3. lack of risk level guidance
“In the APP Guidance on detention and custody risk assessment there is no specific guidance on what may fall into the category of low, medium or high risk when a person is being assessed by a custody sergeant.”
4. no guidance for addressless release
“There is no formal guidance given to custody sergeants or police officers as to what to do when a detainee has no place to reside upon release from police custody.”
5. untranslated mental health leaflets
“Upon his release from police custody, [the deceased] was given leaflets, such as the mental health safety netting advice leaflet detailing the mental health services he could access. These were given in English and placed with his property which was given to him upon his release from custody . They were not translated or explained to him”
6. fragmented emergency service communication
“The police radio was accessible by Dorset Police and NPAS as a channel of communication and HMCG and RNLI are able to communicate via VHF radio but there is no direct communication between all services, for example for NPAS and HMCG to directly communicate, they go via the police command centre. This can lead to a misunderstanding of what is going on, on the ground.”
Linked reports
Closely relatedConfidence 0.92 · high
Earlier report
“Despite this, no psychiatrist visited or attempted to visit Mr. [name redacted] in custody which it was stated in evidence was the usual practice of the team.”
This report
“During his time in police custody, it was identified by the custody sergeants that [the deceased] required a face to face assessment by the mental health practitioner. This did not happen.”