Failings on day of Sheffield man's police cell death - inquest

Matthew Terrill's family thanked the jury for their findings

There were "fundamental failures" in areas of training, documentation and communication on the day a man died in a police cell, a inquest jury found.

Matthew Terrill, 46, died at Shepcote Lane custody suite in Sheffield in 2020 after having a cardiac arrest.

He had been put under "Level 4 constant supervision", but jurors said the training for officers was "inadequate".

They also found that paperwork was "unclear and poorly structured" and communication was "ineffective".

The inquest heard Mr Terrill had been arrested on suspicion of assault on 22 April and was handcuffed while he lay on the ground in a park, with police officers assuming he was asleep.

The hearing was told he had taken a cocktail of drugs, including cocaine, heroin and spice.

During the arrest an associate of Mr Terrill's claimed his lips had turned blue and an ambulance was called for by PC Sian Ahmed. However, the ambulance was later cancelled when a colleague said his lips had not changed colour, and he was taken to the police station.

Matthew Terrill died while in police custody at Shepcote Lane Police Station in 2020

On arrival he began to self-harm and was restrained and put on the highest level of supervision, with two officers assigned to watch him.

A form detailing what the role should consist of was signed by PC Ahmed, but she admitted she had only "skimmed through it".

Giving evidence, she said she had sat outside his cell door from 12:16 until 13:28 when he was found to be unresponsive. He was pronounced dead 20 minutes later.

PC Ahmed said she had not attempted to rouse him during her observations as she could see his chest moving and thought he looked "comfortable and snoring".

She added that while she could not see his face from where she was sitting a colleague had gone into the cell to check on him.

Mr Terrill is thought to have died more than an hour into the observations, the inquest heard.

At the conclusion of the inquest assistant coroner Alexandra Pountney said Mr Terrill's death had been the result of a cardiac arrest and returned a narrative conclusion.

She said as well as issues around training, documentation and communication the jury had also found there had been a "missed opportunity" to medically assess Mr Terrill on arrival due to "a lack of integration of health care professionals with police staff".

Speaking after the hearing Mr Terrill's family said they were "exceptionally grateful" to the jury for its findings.

"It has been a rollercoaster three weeks, however we 100% agree with the fundamental failings the jury have highlighted," his sister, Janine Aspinall, said.

"We feel very strongly that this could have all been avoided if the ambulance had not been cancelled and Matthew would have been taken to A&E."

Ms Pountney said she would be sending a prevention of future deaths report to South Yorkshire Police.