Jury criticises police action concerning vulnerable women’s death in a cell at Southampton Central police Station

11.03.16 | |

Central Hampshire District Coroner’s Court, Winchester

Before Senior Coroner Grahame Short


Following an eight day inquest which concluded late yesterday afternoon, a jury returned highly critical findings concerning the death of Martine Brandon at Southampton Central Police Station.


The jury found that on 1st November 2014 Martine was found in her cell having committed suicide.  She had removed and swallowed her underwear causing an obstruction to her airway.


Martine was a French national who had lived in England for over 10 years.  Although she had no history of mental illness, on the morning of 31st October 2014 she was found in the street with a large knife, saying that an invisible demon and also her sister wished to kill her and her family.  Police officers decided to arrest Martine for a criminal offence, rather than detain her under section 136 of the Mental Health Act 1983 and take her to a place of safety where her mental health could be properly assessed.  She was taken to Southampton Central Police Station and after 18 hours in police custody she was found dead in her cell.


The jury recorded serious failings in the care provided to Martine, including that insufficient steps had been taken to observe and monitor her welfare.  The jury criticised a failure of communication between arresting officers and custody staff (including healthcare staff) concluding this influenced the risk assessments and care plans put into place.  The jury found that Martine had been caused avoidable distress by having been left in her own faeces for six hours, and by the fact that communication with her by custody staff had been inadequate.


Martine’s mental health crisis followed a series of difficult and stressful personal events.  During the inquest, evidence was heard that during her detention Martine had been treated as someone who had been drunk, rather than someone suffering a mental health crisis.  Welfare checks claimed to have been conducted were shown not to have taken place.  A check said to have been conducted at 6.11am recorded Martine breathing and asleep on the bench, when at this time Martine was laying unresponsive on the floor of her cell.


In concluding the case, the Senior Coroner for Hampshire, Mr Grahame Short, indicated his intention to issue a report recommending clear guidance and training for police officers as to when it is appropriate to detain someone under the Mental Health Act 1983 rather than arrest for a criminal offence.  He commented that once the knife had been removed from Martine he did not consider that Martine "was a real danger to anyone but herself", and detention under the Mental Health Act 1983 "would have been a better way to establish the cause of her problems".


Martine’s husband, Barry Brandon, and her son, Jerome Coquerelle, made the following statement:


We know that nothing can bring Martine back.  Our sole intention was to make sure that nobody else in the future would be treated the way that Martine was treated.   We hope that these critical conclusions made by the jury will ensure that change happens.


Deborah Coles, Director, INQUEST:


This is a tragic and shocking case.  It is clear from the evidence that Martine was a highly vulnerable woman in serious mental health need.  A police station is the last place she should have been taken to. Rather than criminalising a woman in mental health distress she should have been taken to a hospital where she could have received specialist care. Instead she was left in appalling conditions alone in a cell. Martine is the first person to have committed suicide in a police cell since 2009. She will not be the last unless there is national learning from this tragic case. She and her family deserve nothing less.” 


INQUEST has been supporting the family of Martine Brandon. The family is represented by INQUEST Lawyers Group members Michael Oswald from Bhatt Murphy Solicitors and barrister Sam Jacobs of Doughty Street Chambers.


More information is available from the Guardian.

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