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The Independent Police Complaints Commission has published the main findings from its investigation into the death of Istiak Yusuf at Luton Police Station.
Mr Yusuf was arrested at around 8.45am on Saturday 13 June 2015 and taken to Luton Police Station, where he was booked in, searched and then at 9.40am placed in a cell. Shortly before midday a detention officer conducting checks on the condition of detainees found Mr Yusuf in need of medical assistance. First aid was given by officers and a health care professional, before paramedics attended at 12.03pm. An air ambulance also attended but at 1.05pm Mr Yusuf was pronounced dead in the cell.
In the cell a number of items were found and forensic tests later identified the presence of cocaine and cannabis on them. A toxicology test indicated that Mr Yusuf had cocaine, MDMA, alcohol and cannabis in his system.
The IPCC investigation found evidence suggested:
A total of five police officers and two custody detention officers were investigated for potential misconduct, while a further detention officer was investigated for potential gross misconduct.
The investigation recommended the two arresting officers had a case to answer in respect of the handover they provided to colleagues who transported Mr Yusuf to the police station. It also recommended that the three detention officers had a case to answer for misconduct in respect of the cell checks they undertook.
Following receipt of the report Bedfordshire Police delivered management action in respect of the two police officers. The force also held misconduct hearings for the detention officers in which two of them had the cases against them proven.
Associate Commissioner Guido Liguori said:
"Following Mr Yusuf's death last year his family have acted with great dignity during what has been an extremely difficult time for them. Our thorough investigation was concluded in six months and I hope it has been able to provide them with the answers they were looking for about their loved one's death.
As well as looking at the actions of individuals at Bedfordshire Police who had contact with Mr Yusuf, the investigation identified learning that we hope will improve the standard of custody care. This learning was provided both during and following the investigation, and included making guidance concerning cells checks clearer, developing a more robust line management structure within custody, as well as providing refresher training for staff."
The findings have been published after the conclusion of the inquest into Mr Yusuf's death on Tuesday 10 May 2016, and the IPCC's investigation report will be published in due course following consultation with all interested parties concerning potential redactions.
Deputy Chief Constable Mark Collins said: "It is tragic that a young man lost his life in our care and our thoughts remain with Mr Yusuf's family and friends. We are committed to continue to improve the standard of our service provided in custody. We cooperated fully with the Independent Police Complaints Commission (IPCC) to ensure that a full and transparent investigation was completed and we welcome their recommendations.
"Five police officers and three detention officers were served misconduct notices following the IPCC investigation. Of those, two detention officers were found to have a case to answer for misconduct in respect of the checks made whilst Mr Yusuf was in custody and have been served with a 12-month written warning. Two police officers received management action and the remaining three police officers and one detention officer were found to have no case to answer.
"Bedfordshire Police is dedicated to protecting people and we have taken learning from this sad death. The safety of those in our custody is paramount and we have taken action to review our procedures in order to ensure all of our officers and staff give the best possible service to those in our care.
"We would like to thank the family of Mr Yusuf for their patience while the circumstances around his death were investigated and express our deepest sympathies to them at this sad time."