Recommendations - Leicestershire Police and Mitie, October 2025

Leicestershire Police · Ref: 2023/193778

Recommendation date: 6 October 2025

Response due: 1 December 2025

Published: 2 December 2025

Custody and detention Death and serious injury

We identified organisational learning following an independent investigation into a death in custody. A man was detained and placed on checks every 30 minutes. During the interval between two checks, the man covered himself with a blanket, improvised a ligature and used it to take his own life.

View on IOPC website

Recommendations (5)

Recommendation 1 Accepted

Recommendation

The IOPC recommends that Leicestershire Police should, in collaboration with the Leicestershire Office of the Police and Crime Commissioner (OPCC), establish a regular process for assuring themselves that the contracted provider of custody detention officers (DOs) is meeting their responsibilities … Read moreThe IOPC recommends that Leicestershire Police should, in collaboration with the Leicestershire Office of the Police and Crime Commissioner (OPCC), establish a regular process for assuring themselves that the contracted provider of custody detention officers (DOs) is meeting their responsibilities with respect to the training of their custody DOs. This recommendation has arisen following an independent investigation into a death in custody. A man was detained and placed on checks every 30 minutes. During the interval between two checks, the man covered himself with a blanket, improvised a ligature and used it to take his own life. Over the next 11 hours, DOs continued to conduct checks on the man, failing to notice he had not moved position. Some DOs recorded he was asleep and breathing. The alarm was raised after the man was requested to leave his cell for a call, 11 hours after he was last seen to move. During the investigation, it was identified that the force has a contracted provision of DOs via a contract arranged by the OPCC. The contract details the responsibilities of the provider, which include ensuring DOs are appropriately trained to carry out the duties specified in the contract, and for ensuring staff maintain the necessary knowledge and skills to complete their duties. The contract also states the provider must assess competency in the workplace using recognised tools linked to a recognised qualification and that the customer can request specific competency tools to be used. However, the contract lacks any mechanism for the force and/or OPCC to assure themselves of the quality of the service provision. Some of the DOs in this case had not received training for several years, which was highlighted during the course of our investigation. APP is the official guidance for policing, which officers and staff are expected to take it into account when carrying out their duties. Clear rationale is required to justify not complying with APP. College of Policing Authorised Professional Practice (APP) for detention and custody states: All custody officers and staff have undergone appropriate and adequate training. Police, contract and healthcare professionals (HCPs) understand their role and their legal responsibilities, and are operationally competent and Forces must ensure that there are appropriate governance and accountability arrangements in place for contracted and commissioned staff. Show less

Force Response

Accepted Action taken:

Recommendation 2 Accepted

Recommendation

The IOPC recommends that Leicestershire Police should create guidance for custody staff to support them in implementing the College of Policing Authorised Professional Practice (APP) when conducting cell checks. The guidance should include the length of cell checks, actions to … Read moreThe IOPC recommends that Leicestershire Police should create guidance for custody staff to support them in implementing the College of Policing Authorised Professional Practice (APP) when conducting cell checks. The guidance should include the length of cell checks, actions to be taken and what should be observed, what to do if a detainee’s face is obscured (for example, by a blanket), and that consideration should be given to the result of previous checks. This recommendation has arisen following an independent investigation into a death in custody. A man was detained and placed on checks every 30 minutes. During the interval between two checks, the man covered himself with a blanket, improvised a ligature and used it to take his own life. Over the next 11 hours, detention officers (DOs) continued to conduct checks on the man, failing to notice he had not moved position. Some DOs recorded he was asleep and breathing. The alarm was raised after the man was requested to leave his cell for a call, 11 hours after he was last seen to move. Where some DOs recorded the man as asleep and breathing, some checks lasted for only a second, which is not long enough to ascertain if a sleeping detainee is breathing. The checks also did not take into account APP guidance to adjust a blanket if it is covering a sleeping detainee’s face to enable a clear view. APP is the official guidance for policing, which officers and staff are expected to take it into account when carrying out their duties. Forces are expected to support their officers and staff to implement APP or to justify where local policy or guidance does not comply with APP. This is usually done through local guidance developed by each force. Our investigation found that Leicestershire Police did not have local guidance to support their custody officers and staff to implement the guidance in APP. If the man had been observed for an appropriate length of time during the checks or the blanket had been adjusted, it is likely the DOs would have discovered he was dead much sooner. Show less

Force Response

Accepted

Recommendation 3 Accepted

Recommendation

The IOPC recommends that Mitie should work with Leicestershire Police to review their initial custody training to ensure it aligns with national standards for police custody, including how to conduct cell checks and what should be done if a detainee … Read more

Force Response

Accepted Action taken:

Recommendation 4 Accepted

Recommendation

The IOPC recommends that Mitie should, in collaboration with Leicestershire Police, develop and implement a mechanism for informing their custody detention officers (DOs) of updates to national and local policies and legislation relevant to police custody, including updates to the … Read moreThe IOPC recommends that Mitie should, in collaboration with Leicestershire Police, develop and implement a mechanism for informing their custody detention officers (DOs) of updates to national and local policies and legislation relevant to police custody, including updates to the College of Policing Authorised Professional Practice (APP). This recommendation has arisen following an independent investigation into a death in custody. A man was detained and placed on checks every 30 minutes. During the interval between two checks, the man covered himself with a blanket, improvised a ligature and used it to take his own life. Over the next 11 hours, detention officers (DOs) continued to conduct checks on the man, failing to notice he had not moved position. Some DOs recorded he was asleep and breathing. The alarm was raised after the man was requested to leave his cell for a call, 11 hours after he was last seen to move. Where some DOs recorded the man as asleep and breathing, some checks lasted for only a second, which is not long enough to ascertain if a sleeping detainee is breathing. The checks also did not take into account APP guidance to adjust a blanket if it is covering a sleeping detainee’s face to enable a clear view. APP is the official guidance for policing, which officers and staff are expected to take it into account when carrying out their duties. During the investigation, it was identified that the DOs had gaps in their knowledge, including of APP relevant to police custody. We have made a separate recommendation to ensure new recruits to the DO role have completed relevant training in the previous 12 months and that annual refresher training is completed by all DOs. However, updates to policies and legislation can happen at any time so annual training alone may not be sufficient to ensure DO knowledge is consistently current and up-to-date. As contracted staff, the DOs noted they did not have the same access to resources force-employed custody officers/staff have to maintain their knowledge, so another mechanism is required to plug this gap. Show less

Force Response

Accepted Action taken:

Recommendation 5 Accepted

Recommendation

The IOPC recommends that Mitie review the training process for custody detention officers (DOs) to ensure new recruits have completed relevant training in the previous 12 months and that annual refresher training is completed by all custody DOs. This refresher … Read more

Force Response

Accepted