A Glasgow woman died in police custody after being arrested wearing just vomit-stained pyjamas.
Caroline McLeod was rushed to hospital where it was discovered she was suffering from sepsis and had pneumonia in both lungs just hours after she appeared in Glasgow Sheriff Court.
The 42-year-old was transferred to three different police custody suites where the severity of her condition went unnoticed.
It wasn't until she was remanded in custody by a judge and was being returned to the female cell area that a member of security staff raised concerns about her health.
A Fatal Accident inquiry found that her death could not have been prevented but that protocols for Police Scotland regarding people in custody who need medical help might not be "clear enough" for staff.
The report into the circumstances of Caroline's death detailed that she had been found standing outside a common close in Glasgow wearing just her pyjamas and a coat back in September 2019.
Residents couldn't make sense of what she was saying so let her inside the close and made her a cup of tea while waiting for the police to arrive.
Officers sent to the scene discovered that she had two outstanding warrants for apprehension by Glasgow Sheriff Court so was arrested and placed into a police car.
Despite being described as "confused, unkempt, and possibly under the influence", responding officers didn't believe she needed medical treatment.
She was first taken to Baird Street police office where she denied having taken any drugs or alcohol and was able to walk, talk and answer questions.
A police Seargent deemed Caroline to be 'high-risk' and should be seen by a medical professional, however, this was missed by the second Seargent at Govan police office where she was later transferred.
Before her case was called at Glasgow Sheriff Court, a worker noticed that her breathing had changed. She then disclosed that she had COPD and had not taken her medicine for a 'few days'.
A judge remanded Caroline in custody and she was later checked over by a nurse after she became paler.
Medical staff found her to be "significantly unwell" and meeting the criteria for sepsis.
It was discovered that she had pneumonia in both lungs and "significant underlying lung disease". After being taken to intensive care, it was also found that her small bowel had died due to a lack of blood supply.
Caroline passed away on October 8 after her condition deteriorated rapidly.
A mandatory Fatal Accident Inquiry was called into her death as it occurred while she was detained in legal custody.
It concluded that it would "not be reasonable for non-medically trained personnel in the absence of Ms McLeod complaining of ill-health to detect or diagnose Ms McLeod's underlying health condition based on her clinical presentation during her time in custody."
Findings by a Dr O'Keefe concluded that if she had been seen by a Health Care Professional (HCP) whilst in custody and sent to hospital at an earlier stage this would not have prevented her death.
It was found that there is confusion amongst Police Scotland staff as to who is responsible for contacting an HCP in a situation where a person in custody is assessed as requiring to see one but is then transferred from a custody suite in one police office to a custody suite in another police office.
It also found that the marker placed on a person's custody record and displayed on the Police Scotland custody "whiteboard" screen, indicating that the custody requires to be seen by a HCP, may not be sufficiently clear and obvious.
