The mother of a loving and caring 35-year-old Devon man who died in police custody as a result of failings and errors says she has been left heartbroken that his death was preventable.
Last week a jury inquest was heard in Plymouth into the death of John Coysh, of no fixed address, who was detained at Torquay Police Station after he failed to attend court.
John died after 15 hours in police custody on September 14, 2016, while going through alcohol withdrawal.
An investigation was carried out by the Independent Office for Police Conduct (IOPC) which concluded there were some procedural errors made by custody staff, and a number of recommendations were made which have all been since implemented.
During the inquest it was heard how it took police nine hours before John’s mum Susan, from Newton Abbot, was informed that her son had died in custody, despite being his next of kin.
The inquest lasted for five days and included harrowing CCTV footage of John suffering a medical episode in his cell which led to his death, and showed how there had been a delay before anyone became aware he had stopped breathing.
Susan said she has been left disappointed by the outcome of the inquest and believes her son’s death could have been prevented.
She said: “I’m disgusted with the injustice of it all. The whole thing was shocking and I just feel beside myself.
“I’m in no doubt that had John been sent to hospital he would still be here today.
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“I don’t think it was a fair inquiry. I was asked if I wanted to say anything at the end of the inquest but I couldn’t find any words. I was speechless that one of the health care professionals did not get reprimanded.
“In her evidence she admitted she could not properly use the new system that had been put in place so did not have access to his records. It was just unbelievable.
“There were several occasions when John should have been sent to hospital. There were many missed opportunities to save his life. Even early on in custody his pulse rate was high. He should have been put on a heart monitor and if that was done in hospital they would have had access to his medical records.
“I believe John’s death was preventable because had been in hospital three times before with heart problems when withdrawing from alcohol. On one of those occasions he stopped breathing for 16 minutes and they managed to bring him around.
“I was also upset that it was not admitted during the inquest that the new custody processes now in place have directly been caused by John’s death. It would make me feel better in that he didn’t die for nothing.
“It has taken four years for his inquest to be heard so it has been a long time for it to be hanging over us. I was hoping the inquest would give us closure, but now I feel worse than ever.
“I have never received any apology from the police, G4S or anyone else. We have not had justice for John.”
This week, Devon and Cornwall Police have sent their condolences to Susan and her family for their loss.
Temporary deputy chief constable Jim Nye said: “This was a very tragic incident and our thoughts and condolences remain with the family and friends of John Coysh.
“We accept there was a delay in notifying John Coysh’s next of kin. We would like to apologise to his family for that, and we would also like to reassure them that we have learned from this.”
Last week a police statement following the inquest was issued by the then deputy chief constable Paul Netherton.
He said: “Following John Coysh’s death, a mandatory referral was made immediately to the Independent Police Complaints Commission (IPCC), now the Independent Office for Police Conduct (IOPC).
“The force co-operated fully with the IPCC’s independent investigation and subsequently with the IOPC.
“The IPCC made seven specific recommendations following his death which the force has taken action on. The force has learned lessons, adapted working practices and introduced further measures to custody procedures.
“The changes have been made in order to ensure that the force’s custody centres are a safe place for detainees to be. These practices and procedures are ever evolving and there will always be improvements that can be made.”
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When asked what she thinks about the changes that have been put in place by Devon and Cornwall Police since John was detained in custody, she said: “It certainly has improved.”
In her statement read out during the inquest, Susan told how her son had led an active life despite being diagnosed with chronic asthma after being born in Torquay. She described him as a keen sportsman with a ‘big circle’ of friends, and having had a passion for nature and travelling.
She recalled he had wanted to join the Marines, but due to his health had instead obtained a degree in landscape architecture at Manchester University.
It was at university she said he began drinking and had previously struggled with the loss of his father who died when he was 17.
Regarding John’s drinking, she recalled how he had sought help and had periods of being sober, but had begun drinking again in 2014.
Speaking this week she said: “I didn’t even know he was in custody when he died which was John all over because he never liked to cause a fuss. He was a very quiet and likeable person. Even the police who dealt with him in custody said so and that he was very engaging.
“At the time of his death I thought he was actually trying to get a little bit better. I always hoped that. One of his friends told me he was attempting to pull through it all.
“At one point he had a great future. He was very bright and intelligent, had always played rugby and had a degree. It was when he started at Manchester University that he started drinking heavily. Alcohol was so cheap up there and I remember him saying it was only £1 a pint.
“No alarm bells rang at the time as a lot of students do drink. After university he moved to Ireland. I used to visit him and those around him were all heavy drinkers. He was a musician and played the guitar so it seemed like he could not get away from drink because it’s so much part of our culture. His father also drank as well. Whether it’s hereditary or not I don’t know?”
For a period of time, John moved in with Susan when she was living in a remote part of North Devon 10 years ago. John helped landscape the yard surrounding her barn and says he was very happy living there and stopped drinking.
She said: “There were a lot of wild spaces so John would take his tent and go walking for a few days.”
When she moved to Newton Abbot John began drinking again as alcohol was readily accessible. He had periods of not drinking and two years before he died, Susan discovered he took drugs.
She said: “I didn’t know he took drugs until I found paraphernalia, including needles, in his room one day. He was not drinking so he must have been using heroin as a substitute. After I mentioned what I had found he decided not to come home again and I believe he was living in a caravan on a friends farm in Totnes.
“It’s all very sad. It does not matter what background someone has; it does not seem to make a lot of difference.”
Susan last saw John two weeks before he died. He came to her house with some friends and she said she had no concerns about him.
“We had a lovely day. We had tea in the garden and a hug. He looked well as he’s always been into his food and knew a lot about foraging. I never understood how he managed to abuse his body as he did and look so tremendous. He still had a rugby player physique.
“His death was absolutely out of the blue to me.”
A post mortem examination confirmed the cause of his death was cardiac arrhythmia during alcohol withdrawal in a man with a past medical history of intermittent cardiac arrhythmias.
The jury recorded a conclusion of alcohol related-death.
When John was taken into police custody on September 13, 2016, a risk assessment was undertaken on arrival where it was noted he had alcohol and drug dependencies and had declared an undiagnosed heart condition.
He was placed in a cell with observations to be carried out every 30 minutes. During his detention he was also seen four times by two healthcare professionals who deemed him fit to remain in custody and treated him for alcohol withdrawal.
One of the health care professionals (HCP) who assessed Mr Coysh said in her evidence that had she known of his previous history and had been able to consult his previous medical and custody records the treatment he received would have been different.
It was not known by the HCP that Mr Coysh had been admitted to hospital from custody in 2015 suffering from palpitations while withdrawing from alcohol.
At around 5.40am the following day, Mr Coysh was found to be unresponsive and he died in an ambulance en route to hospital.
Susan has said the family do not wish the pursue the matter anymore following the outcome of John’s inquest.
She said: “We have the option of taking it to crown court if we can afford it, which we can’t. The inquest was so harrowing that I don’t think I have the strength to take it further.”