Lloyd Butler

West Midlands Police response to Regulation 28 Report relating to Lloyd Edward
Butler (deceased)

Purpose of Report

This report has been prepared on behalf of the Chief Constable. It details the West Midlands Police (WMP)
response to the, ‘Regulation 28 Report to Prevent Future Deaths’, relating to Lloyd Edward Butler (deceased)
issued by the Senior Coroner for Birmingham.

Introduction

The inquest touching the death of Mr Butler concluded on 24 June 2014. The Regulation 28 Report arising
from the inquest lists three ‘Matters of Concern’, summarised as:

4) Alack of professionalism and leadership in the custody suite
2) Insufficient guidance and training for custody staff on what constitutes acceptable behaviour

3) That the poor practice evidenced by the CCTV footage in the case of Mr Butler is representative of the
general approach and culture within the custody suites.

WMP accepts that the behaviour exhibited by the officers and staff responsible for the care of Mr Butler fell
far below the standard required and expected of them. As such misconduct procedures were instigated
against the officers and staff concerned and they each received a disciplinary sanction. The Independent
Police Complaints Commission (IPCC) has also identified a number of points of learning arising from their
investigation. A copy of the WMP response to the IPCC recommendations is attached to this report for
information. it details a number of specific actions that have been undertaken by the force, which have not
been listed below to avoid unnecessary duplication.

Response to ‘Matters of Concern’

WMP takes its duty of care to detainees and the obligations placed on the force under the Police and Criminal
Evidence Act 1984 (PACE) extremely seriously. As the Regulation 28 Report notes, detainees often have
complex medical and social issues requiring proper assessment, monitoring and management during their time
in custody. It is vital that the medical and, as far as possible, the emotional needs of detainees are catered for
and the force is fully committed to adhering to the standards of ‘Safer Detention’ in this regard.

1) Alack of professionalism and leadership in the custody suite

Since 2010, management of custody facilities and staff has been brought under a central force department,
Central Justice Services (CJS) and the number of custody suites reduced from 21 to 11. The creation of this
department has allowed for greater accountability and clearer leadership. WMP recognises that Custody
Sergeants have a key role in ensuring that proper standards are implemented on a day to day basis and
recognises how the lack of front line leadership shown in the care of Mr Butler would give cause for wider
concern.

WMP has invested in ensuring that there is a culture of professionalism, not only in all of the custody facilities,
but more widely across the workforce. In June 2013, WMP launched the ‘Pride in our Police’ campaign. This
internal campaign aims to promote a culture of high professional standards and personal responsibility across
the organisation. The areas of focus are identified by panels of first and second line supervisors and are then
addressed at a local level, supported by an internal media campaign and with oversight by the Head of
Professional Standards. The campaign has already covered topics including uniform and appearance, personal

West Midlands Police response to Regulation 28 Report relating to Lloyd Edward Butler (deceased)

standards and behaviour, and driving standards, and is now incorporating the force’s adoption of the national
Code of Ethics.

The local implementation of the Code of Ethics, overseen by the Deputy Chief Constable, will underpin WMP’s
continued focus on professionalism amongst our staff. The principles within the Code are being incorporated
into all WMP training courses, including those relating to custody. All first and second line supervisors,
Sergeants and Inspectors, are attending one day training courses, which have already commenced, covering
the Code and its requirements. This commitment of resources hopefully evidences the force’s determination
to promote a positive culture of professionalism within the organisation.

2) Insufficient guidance and training for custody staff on what constitutes acceptable behaviour

WMP agree that training and guidance for custody staff is a crucial part of maintaining high standards in the
custody environment and it is unfortunate that insufficient evidence was presented at the inquest to offer
reassurance of our commitment in this regard. All new custody officers and staff, since 2010, have undertaken
a specific lesson entitled, ‘The Role of the Custody Officer’, as part of their training for their role. This lesson
incorporates key aspects from the force values, including acting with, ‘integrity, compassion, courtesy and
patience’, and explores what is meant by ‘duty of care’ in the custody environment; emphasising the
importance of being attentive towards the needs of detainees and having due regard for their human rights. It
also covers the practical application of these principles to the custody role, such as ensuring that initial and
ongoing risk assessments are conducted, cells are inspected for damage and cleanliness, and that adequate
meals, clean clothing and bedding is available. In addition to this initial training, all custody staff receive one
day’s continuous professional development every 20 weeks. These one day courses refresh staff knowledge
on custody procedure and policy, make staff aware of new guidance and legislation, provide an opportunity for
operational learning to be disseminated, and help to reinforce the professional standards expected of all
custody staff.

3) That the poor practice evidenced in the CCTV footage in the case of Mr Butler is representative of
the general approach and culture within the custody suites.

While recognising that evidence given at the inquest suggested that the conduct evident in the case of Mr
Butler has not necessarily been eliminated entirely, WMP believe that it is not representative, in any way of
the general conduct or culture of WMP Custody Sergeants, officers and staff today. This position is based on
the governance structures now in place, the training and guidance provided to staff, the systems and
processes that have been implemented, and the culture of WMP as a whole.

It is recognised that staff, other than dedicated custody staff, have roles and responsibilities in the custody
environment, such as bringing detainees into custody, interviewing and processing them following their arrival
and, on occasion, having specific duties to conduct observations on detainees to ensure their welfare; as was
the situation in Mr Butler’s case. It is noted in the force’s response to the IPCC that since August 2010 WMP
has sought to primarily use custody trained staff to conduct observations on detainees. The percentage of
custody staff conducting constant observations compared to non-custody staff is monitored on a monthly
basis to ensure our performance in this area is maintained, with figures showing that, on average, over 80% of
watches were conducted by custody staff between January and June 2014. In our largest custody facility,
Birmingham Central, Custody Officer Assistants (COAs) have been recruited to provide additional capacity. On
the rare occasions that non custody staff conduct the observations, Custody Sergeants are required to fully
brief the officer involved, utilising Observation Briefing Sheets (copies attached), and an entry recording that
the briefing has taken place is made on the custody record. These briefings are designed to remind staff of the
importance of their role and the need to conduct themselves in a focussed and professional manner.

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West Midlands Police response to Regulation 28 Report relating to Lloyd Edward Butler (deceased)

Clear guidance has also been given to officers on the proper process to deal with persons arrested for being
drunk and incapable or who are arrested for other offences but are so intoxicated as to be unable or walk or
talk. This guidance clearly states that the individual should be treated as a medical emergency and
transported directly to hospital and not to a custody facility. This learning has been embedded with frontline
officers, control room staff and in custody, to provide a number of checks through the system to help ensure
compliance. WMP are able to evidence the impact of the changes made since 2010 by analysis of the statistics
concerning the number of people arrested for being drunk and incapable and held in custody facilities.
Between 2010 and 2012 the number of detainees brought into custody for being drunk and incapable fell
significantly and since December 2012 no persons have been brought into custody for this offence.

Conclusion

It is hoped that the measures detailed above will offer reassurance that WMP has addressed the ‘Matters of
Concern’ since 2010 and continues to do so. Whilst recognising the potential for under-reporting, the level of
complaints made by detainees is relatively low; with only 71 complaints being made in relation to detention in
custody in 2013-2014 out of approximately 65000 people who were detained. Nevertheless, to ensure the
quality of care provided to those in custody, CJS managers are expected to dip sample custody records and,
where appropriate, CCTV.

It is never possible to vouch for the actions of all individuals in a large organisation at all times but WMP
considers that the culture and systems that have been developed will, as far as possible, eradicate the type of
behaviour revealed in the case of Mr Butler and ensure that it is not repeated in the future.

Assistant Chief Constable (Operations)

1 August 2014