An inquest jury has concluded that serious and significant police failings contributed to the death of a Bolton woman found unresponsive in a cell.
The jury heard that Kelly Hartigan-Burns, 35, died at Royal Blackburn Hospital in 2016 after being found unresponsive at Greenbank Police Station in the early hours of Saturday December 4. A five-week hearing into her death finished earlier this week, after members of the jury were sent out to consider their verdict on Tuesday, April 5.
After two days of deliberation, the jury returned to County Hall, Preston, to deliver a conclusion on Thursday afternoon, April 7, after being asked by Senior Coroner Dr James Adeley to consider a potential conclusion of unlawful killing as well as options including suicide, accidental death and an open conclusion.
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The jury cited contributing factors including the absence of PNC warning markers on Kelly's record, lack of training in the PNC marker system, the failure of the senior attending officer to inform the transporting officer or the custody staff of the suicide or self harm risk, and the management of Kelly in the custody suite, Lancs Live reports.
The failure to explain the custody process and the speed and manner in which Kelly was processed also increased the risk of self-harm or suicide, the jury concluded. Kelly first come to the attention of Lancashire Constabulary late on December 3, after being seen stepping in front of traffic and saying 'I want to die'.
Earlier that day she had drunk two bottles of wine and become upset after arguments with family members including wife Collette Hartigan-Burns. A Grade One response, the most serious, was issued and she was soon found by officers PC Simon Haigh and PC Rebecca Price and was said to be calm but upset.
She was taken to her home on Barley Bank Street in Darwen, only to be arrested on suspicion of assault after her wife Collette Hartigan-Burns told PC Haigh that Kelly had hit her earlier that day. PC Haigh called for more officers, including a female officer, to attend and take Kelly to custody while they carried out the interview with Collette. PC Andrew Sarchet and Special Megan Dawson, a volunteer officer, attended to comply with that request.
The inquest earlier heard that PC Haigh did not ask for more information about a suicide marker which was on Kelly's record and that Special Dawson's notes of the handover included details of a domestic violence incident but not the earlier suicide attempt. PC Haigh did not have any notes completed from the incident or pass on information from Colette which warned Kelly was a risk of self-harming
Kelly was taken to Greenbank Police Station and booked in by Sergeant Jason Marsden without the completion of a full risk assessment despite her having a recorded suicide attempt nine months earlier and in spite of the events earlier that night. Psychiatric medication found during a search of Kelly was not recorded in writing
That meant that Kelly, who was a vulnerable woman who had a history of mental health issues since enduring trauma in her early adult life, was not treated as high risk and she was placed on half hourly checks and not given anti-ligature clothes. Kelly was found unresponsive in her cell around one hour later at 1.27am. She was taken to the Royal Blackburn Hospital but died the following day.
More than five years on, her family have continued to fight for answers. The jury today concluded a short term conclusion that Kelly died of a "self-applied ligature of unknown intention" but was damning of Lancashire Constabulary in its longer form conclusion.
Its foreman said: "The absence of both PNC warning markers and PVP reports relating to the multiple episodes of attempted self-harm and suicide attempts evidenced via numerous previous ISR logs seriously contributed to Kelly's death. The lack of training in 2016 by Lancashire Constabulary Frontline officers concerning in which circumstances a PNC marker should be created contributed to the lack of PNC markers on the system thus contributing to the death of Kelly.
"Whilst attending this serious grade 1 "threat to life" incident the senior attending officer who was first on scene should have requested more information from the control room regarding the known suicide marker. There is no evidence to suggest that the senior attending officer informed the special sergeant who was part of the transportation team of any of the circumstances relating to the initial grade one incident nor any potential risk of self-harm or suicide in relation to Kelly.
"This is an extremely serious omission which contributed to the death of Kelly as the transportation team were not able to pass on this critical information to the custody sergeant at Greenbank Custody suite. Whilst at Barley Bank Street there was a conversation between Kelly's wife and the senior attending officer regarding concerns relating to Kelly's wellbeing and safety whilst in custody.
"This was not communicated to the transportation team, and therefore could not be passed onto the custody sergeant. Failure to communicate this information contributed to the death of Kelly."
The foreman continued to say that the "management of Kelly within the Greenbank custody suite... significantly contributed to an increased risk of self-harm or suicide." He said she was agitated but compliant but the speed and manner in which she was treated and failure to explain the process or build rapport made her more agitated and non-compliant, "therefore increasing the risk of self-harm or suicide whilst in custody".
He added: "In addition, further enquiries using all systems available to the custody sergeant would possibly have resulted in more information being available to support a more comprehensive risk assessment leading to a higher-level care plan being applied or potentially a refusal to detain.
"However, based on the information exchanged at the informal handover and the information recorded on the whiteboard in addition to scheduled care-plan visits it would not be expected for a custody sergeant to immediately perform a re-assessment of Kelly's risk post-handover.
"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."
At the opening day of the inquest, June Hartigan described Kelly as the "first of my two beautiful children” She described her as “beautiful, clever and resourceful”, adding that ‘everyone that met her immediately liked her’.
She said: “I miss my friend, stylist, holiday buddy more than anyone will ever know. That pain will never go away.”
