A heartbroken mum from Bolton has spoken out for the first time since a jury ruled that “serious and significant” police failures contributed to her daughter's death in custody. Kelly Hartigan-Burns, 35, was found unresponsive at Blackburn's Greenbank Police Station in the early hours of December 4, 2016.
After an agonising wait of more than five years, Kelly's inquest was finally heard at Preston Coroner's Court last month. It was found that “if officers had shown more compassion, acted diligently, practiced common sense, followed guidance and procedure from the moment they found Kelly and throughout her detention there may have been a different outcome”.
An open conclusion was reached but a narrative detailed a litany of failures, including the failure to record previous incidents on the system, to obtain and relay the relevant information, and in the management of Kelly in the custody suite. Following the tragedy, seven officers were investigated; one was found guilty of gross misconduct and barred from working in the force and a second offer was disciplined.
READ MORE: Police 'truly sorry' over death of Bolton woman found unresponsive in police cell
Kelly's mum June, a 66-year-old retired NHS worker, has opened up about her loss. She said: “I miss my beautiful daughter every single day. The inquest has shown what I already knew; Kelly was failed by police, and she could and should be alive today."
Kelly was the elder of June’s two children and had 'no problems at all' until her dad, Martin, died when she was 19.
"Kelly was really bright," June added. "She was training as an accountant and had been a keen chess player since she was a small child. She’d just moved into her own place at 19, and her dad was planning to help her to build some wardrobes.”
But Martin tripped on fencing on his way home from an evening out and fell into a deep trough which had been dug to replace water pipes. His body was not found for two days.
June said: “It was a horrific ordeal and affected Kelly very badly. She blamed herself, because she had texted him that night and he hadn’t replied. She felt she might have saved him if she had chased him up. She blamed herself for everything, irrationally.
“We got his possessions back from the police; his phone and his wallet, and she slept with them every night. She completely clammed up. She didn’t talk at all for a month. I was desperately worried about her.”
Kelly began to suffer with severe depression, June said.
“Kelly never recovered from losing her dad," she added. "She was drinking heavily, because of her depression, and I got her on detox programmes, but there was always a long waiting list.
"I even did my own detox for her at home. But nothing worked for long. She was so beautiful, so intelligent, she had her life ahead of her, and yet it was all slipping away. Sometimes, I’d wake at 2am and she’d be outside the front door, just wanting a cuddle.
"She didn’t ask for money, she never got into any trouble. She just wanted to get better, but she didn’t know how.”
Kelly eventually met her partner, Colette, and married in a civil ceremony. She did a degree and qualified as a substance misuse
practitioner, and June hoped that this might be a new start.
But she then had a car accident and lost her job, and her mental health declined once again. She began self-harming and towards the end of 2016, moved back home to live with her mother to help her recovery.
June said: “Kelly became very paranoid, and thought we were all against her. She was becoming very ill.”
"Kelly seemed to improve throughout November. We had a petty fall out over Christmas plans and I will always regret that. That was the last real conversation we had.”
Kelly moved back in with Colette but she was arrested a few days later after police found her on a main road, stepping in front of traffic and saying 'I want to die'. Collette also told police that Kelly had hit her earlier that day.
Recalling the horrifying moment that she found out what happened to Kelly in custody: “I got a call in the middle of the night to say Kelly was in hospital on a life support machine.
"Kelly had never been in trouble with the police. I was shell-shocked and horrified because she was in no fit state to be left in a police cell. She was extremely vulnerable.”
Kelly was pronounced dead on December 5 2016, aged 35. Colette died four years later.
In October 2021, a finding of gross misconduct at a professional standards hearing was made against Jason Marsden, the custody sergeant involved in Kelly’s death, barring him from returning to work for the police. He had previously retired. His appeal against the findings of the hearing will be heard later this month.
At the conclusion of last month's inquest into Kelly's death, the jury found that issues with lack of training, the absence of PNC (Police National Computer) markers, lack of communication between the senior attending officer and the transportation team, and management in the custody suite contributed to Kelly’s death.
The jury's conclusion said: “If officers of Lancashire Constabulary involved in this incident had shown more compassion, acted diligently, practised common sense, followed guidance and procedure from the moment they found Kelly in the church yard and throughout her detention there may have been a different outcome.”
DCC Sacha Hatchett, of Lancashire Constabulary, said: "Our thoughts first and foremost today are with the family of Kelly Hartigan-Burns and with all of her loved ones. Lancashire Constabulary owes a duty of care to all of those in our custody and they should be able to rely on us to keep them safe. We failed to do that with Kelly and for that we are truly sorry.
"Since that night we have taken a number of steps to minimise the risk of such a tragedy being able to ever happen again. This includes a number of system changes to strengthen our processes when booking people into custody and increasing training for staff on how to recognise when people are vulnerable and how they should be looked after when in our care.
"Following Kelly’s death, the matter was referred to the Independent Office of Police Conduct who looked into the conduct of five officers and two custody detention officers. One officer was taken to a gross misconduct hearing but retired before that hearing took place. The hearing determined that he would have been dismissed had he not retired. Another officer was subject to unsatisfactory performance procedures and management action.
"We are grateful to HM Coroner for examining this matter in such detail during the course of the inquest and to the jury for their careful consideration. As Lancashire Constabulary is a learning organisation, we will of course study their findings in detail and take on board any further lessons that we can. Once again, our thoughts and sympathies are with all of Kelly Hartigan-Burns’ loved ones at this time."
The inquest reached an open conclusion with a narrative detailing a litany of failures which contributed to Kelly’s death, including the failure to record previous incidents on the system, to obtain and relay the relevant information, and in the management of Kelly in the custody suite.
