PFD report

Lloyd Edward Butler · Prevention of Future Deaths report

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Issued 25 Jun 2014•Birmingham and Solihull

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
5

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
10

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised5

  1. Failure to control custody staff behaviour
  2. Failure to maintain a professional and safe custody-suite culture
  3. Lack of leadership by custody sergeants
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.6

  1. Action

    Incorporate the national Code of Ethics into all training courses and deliver associated training to supervisors, Sergeants and Inspectors.

    Stated by West Midlands PoliceStated plannedThe respondent said that this action was planned when they made their response on 25 June 2014.
  2. Action

    Require Central Justice Services managers to sample custody records and, where appropriate, CCTV to monitor the quality of custody care.

    Stated by West Midlands PoliceStated completedThe respondent said that this action was complete when they made their response on 25 June 2014.
  3. Action

    Provide all custody staff with one day of continuous professional development every 20 weeks to refresh procedures, disseminate learning and reinforce standards.

    Stated by West Midlands PoliceStated completedThe respondent said that this action was complete when they made their response on 25 June 2014.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    Poor practice shown in the case is not representative of the general conduct or culture in current custody suites.

    Stated by West Midlands PoliceDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to control custody staff behaviour

Wider context from the report

“(1) The lack of professionalism and leadership in the custody suite was striking. There was no leadership by the custody sergeant and no control of the behaviour of any of the staff. Evidence heard at the inquest indicated this sort of banter and practice was common and continuing. Many detainees in the custody block are vulnerable, often have mental health difficulties and other social problems and may be in varying degrees of intoxication. The custody staff are responsible for those detainees and should carry this responsibility out in a professional and disciplined manner. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to maintain a professional and safe custody-suite culture

Wider context from the report

“(3) There was evidence at the inquest that the CCTV footage of Mr Butler’s time in custody was representative of the general approach and culture within custody suites in the West Midlands. West Midlands Police should consider how this culture might be addressed and changed. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of leadership by custody sergeants

Wider context from the report

“(1) The lack of professionalism and leadership in the custody suite was striking. There was no leadership by the custody sergeant and no control of the behaviour of any of the staff. Evidence heard at the inquest indicated this sort of banter and practice was common and continuing. Many detainees in the custody block are vulnerable, often have mental health difficulties and other social problems and may be in varying degrees of intoxication. The custody staff are responsible for those detainees and should carry this responsibility out in a professional and disciplined manner. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Insufficient guidance and training for custody staff on acceptable behaviour

Wider context from the report

“(2) There was insufficient evidence at the inquest that any guidance or training had been conducted for custody staff regarding what was acceptable behaviour in a custody suite following the events in question. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure of custody staff to behave professionally and with discipline

Wider context from the report

“(1) The lack of professionalism and leadership in the custody suite was striking. There was no leadership by the custody sergeant and no control of the behaviour of any of the staff. Evidence heard at the inquest indicated this sort of banter and practice was common and continuing. Many detainees in the custody block are vulnerable, often have mental health difficulties and other social problems and may be in varying degrees of intoxication. The custody staff are responsible for those detainees and should carry this responsibility out in a professional and disciplined manner. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Incorporate the national Code of Ethics into all training courses and deliver associated training to supervisors, Sergeants and Inspectors.

Verbatim wording from the response

“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.”

Source location

2014-0281-Response-by-West-Midlands-Police
Page 2 · response
Published 25 June 2014

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Require Central Justice Services managers to sample custody records and, where appropriate, CCTV to monitor the quality of custody care.

Verbatim wording from the response

“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.”

Source location

2014-0281-Response-by-West-Midlands-Police
Page 3 · response
Published 25 June 2014

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Provide all custody staff with one day of continuous professional development every 20 weeks to refresh procedures, disseminate learning and reinforce standards.

Verbatim wording from the response

“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.”

Source location

2014-0281-Response-by-West-Midlands-Police
Page 2 · response
Published 25 June 2014

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Implement the Pride in our Police campaign to promote professional standards and personal responsibility across the organisation.

Verbatim wording from the response

“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”

Source location

2014-0281-Response-by-West-Midlands-Police
Page 1 · response
Published 25 June 2014

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Provide new custody officers and staff with the Role of the Custody Officer lesson covering duty of care, detainee needs and custody standards.

Verbatim wording from the response

“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.”

Source location

2014-0281-Response-by-West-Midlands-Police
Page 2 · response
Published 25 June 2014

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Centralise custody facility and staff management under Central Justice Services and reduce the number of custody suites.

Verbatim wording from the response

“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.”

Source location

2014-0281-Response-by-West-Midlands-Police
Page 1 · response
Published 25 June 2014

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Poor practice shown in the case is not representative of the general conduct or culture in current custody suites.

Verbatim wording from the response

“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.”

Source location

2014-0281-Response-by-West-Midlands-Police
Page 2 · response
Published 25 June 2014

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.4

  1. 1

    Recruit Custody Officer Assistants at Birmingham Central to provide additional custody observation capacity.

    Stated by West Midlands PoliceStated completedThe respondent said that this action was complete when they made their response on 25 June 2014.
  2. 2

    Direct officers to treat severely intoxicated or drunk-and-incapable detainees as medical emergencies, transport them to hospital and apply embedded system checks.

    Stated by West Midlands PoliceStated completedThe respondent said that this action was complete when they made their response on 25 June 2014.
  3. 3

    Brief non-custody staff conducting detainee observations using Observation Briefing Sheets and record each briefing on the custody record.

    Stated by West Midlands PoliceStated completedThe respondent said that this action was complete when they made their response on 25 June 2014.
  4. 4

    Primarily assign custody-trained staff to detainee observations and monitor monthly the proportion of observations conducted by custody staff.

    Stated by West Midlands PoliceStated completedThe respondent said that this action was complete when they made their response on 25 June 2014.

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Recruit Custody Officer Assistants at Birmingham Central to provide additional custody observation capacity.

Verbatim wording from the response

“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.”

Source location

2014-0281-Response-by-West-Midlands-Police
Page 2 · response
Published 25 June 2014

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Direct officers to treat severely intoxicated or drunk-and-incapable detainees as medical emergencies, transport them to hospital and apply embedded system checks.

Verbatim wording from the response

“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 to 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.”

Source location

2014-0281-Response-by-West-Midlands-Police
Page 3 · response
Published 25 June 2014

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Brief non-custody staff conducting detainee observations using Observation Briefing Sheets and record each briefing on the custody record.

Verbatim wording from the response

“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.”

Source location

2014-0281-Response-by-West-Midlands-Police
Page 2 · response
Published 25 June 2014

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Primarily assign custody-trained staff to detainee observations and monitor monthly the proportion of observations conducted by custody staff.

Verbatim wording from the response

“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.”

Source location

2014-0281-Response-by-West-Midlands-Police
Page 2 · response
Published 25 June 2014

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026