A woman who died after being arrested and put in a police cell was “known to police as being at risk of suicide”, and inquest has heard.
Former Canon Slade pupil from Bolton Kelly Hartigan-Burns, 35, died in 2016 after being arrested and put in a Blackburn police cell while in a mental health crisis.
An inquest, which has been running for five weeks at County Hall in Preston, heard how the Kelly had been visited by police on five occasions that year because of mental health episodes.
She was seen by a woman in a taxi in Bright Street, Darwen, in her pyjamas threatening to take her own life at around 11pm on December 3, 2016.
Kelly’s family described her as a “bright and positive” person. Although her mental health was impacted by the sudden and traumatic death of her father when she was a teenager, she went on to get a degree and help people with substance misuse issues.
Her mother, June Hartigan said: “It’s been a long time waiting. It has been five and a half years. It’s been terrible.”
Before leaving the house that night, the inquest heard Kelly had an argument with her civil partner Colette Hartigan-Burns and drank two bottles of wine during the afternoon and early evening.
Kelly had an alcohol dependency and struggled with psychosis, and had been previously diagnosed with emotionally unstable personality disorder.
The passenger in the taxi who saw Kelly called 999, with officers told by the dispatcher to attend on the highest alert and that Kelly had threatened her life.
PC Simon Haigh and PC Rebecca Price, who was completing her training, attended and found Kelly sitting behind a church clearly upset but “calm”.
Officers spoke with her before checking with dispatch who told her there was a marker on her file for risk of suicide.
Neither of the officers asked for further clarification on this marker to see how severe or recent it was, something which Chief Inspector James Black, lead for Lancashire Constabulary’s custody suites, said he would have expected “any officer to check” and that it would be a “short radio message”.
Coroner Dr James Adeley said: “PC Haigh said he did not ask for further information at this time as Kelly was safe and well, although PC Haigh explained he was not letting Kelly out of his sight because of the report from that evening that she had tried to kill herself.
“He considered her a vulnerable person and Kelly was now safe as she was in the company of two police officers.”
The officers took her to the home she and Colette shared on Barley Bank Street, however Colette told PC Haigh that Kelly had hit her, leading to an arrest for assault.
To allow a statement to be taken from Colette, PC Haigh radioed for more officers, including a female officer, to attend and take Kelly to custody.
This led PC Andrew Sarchet and Special Sgt Megan Dawson, a volunteer officer, to attend, who spoke with PC Haigh about the events.
Notes recorded by Dawson from the handover said it was a domestic violence incident, that Colette has been hit on the head, and that an arrest was taken by PC Price.
Dawson said she was not informed about any mental health or suicide risk or the call earlier of Kelly attempting to take her life.
Dr Adeley added: “Had she been provided with any information relating to the earlier events that evening, she would have written it down in her notebook.”
After arriving at the custody suite in the early hours of December 4, custody sergeant Jason Marsden “failed to engage” with Kelly, not asking her name until just before she was taken into a cell.
While being checked in, Special Dawson and Mr Marsden were discussing the reasons for the arrest before another custody sergeant attempted to remove her hair bobble and rings.
However, they said the rings could not be removed and when moving her arm, the sergeants believed that Kelly was attempting to hit them, so they restrained her.
The four-minute check-in process was described by Christopher Hampshire, a temporary inspector who has been involved in a national enquiry into deaths in police custody, as being “totally unacceptable”.
After her check-in, Kelly was taken to a cell and it was agreed she would be checked on hourly under level one, the lowest level taken in the custody suite.
Mr Marsden said had he been aware of her previous attempts, and her attempt earlier that night to take her own life, he would have placed her in an anti-ligature suit and would have put her in a cell with monitored CCTV.
During Mr Marsden’s handover, he told other custody sergeants a few details including that she had a tag of suicide on her file from earlier that year and was on mental health medication.
She was checked shortly after by another custody sergeant, CEO Miller, who checked on Kelly and shook her awake.
In another check at around 1.30am, Kelly was found having attempted to take her own life.
An ambulance was called and Kelly was taken to Royal Blackburn Hospital and put on life support, but she died on December 5, 2016.
Originally from Bolton, Kelly lived in Darwen with Colette who died in 2020 before learning the full details of what happened to Kelly.
A police misconduct hearing which concluded on October 11, 2021, found that custody sergeant Jason Marsden did breach professional standards, and this was gross misconduct.
Mr Marsden, 51, retired just under a month before the hearing. The sanction for gross misconduct, in this case, would have been dismissal without notice, had he still been in post. He has been barred from working in the police in future.
A jury has now retired to consider the evidence and return its conclusion.
Lancashire Police will provide a comment when the jury has reached a conclusion.
Anyone struggling with their mental health can reach out to services such as the Samaritans’ free helpline on 116 123.