Additional reporting by Alex Jee

Kent Police has pledged to make changes after a mother-of-four died in a custody cell.

An inquest and police investigation found that welfare checks were not carried out properly on Debbie Padley on the night before she died at Tonbridge Police Station.

She had been arrested the evening before her death on the afternoon of July 24, 2021, on suspicion of assaulting her estranged husband, Stephen Padley, outside the home of a mutual friend in Bedwell Road, Tunbridge Wells.

Mrs Padley was just 43 when she died from complications arising from a liver infection that led to sepsis. Custody officers did not pick up that she was ill until she was found unresponsive in her cell at 12.55pm.

An inquest into her death partly backed her family’s belief that the police should have recognised that she was ill and done more to secure medical attention for her before it was too late – while an investigation by the Independent Office of Police Conduct (IOPC) concluded there were multiple performance issues associated with her monitoring.

At the multi-day inquest at County Hall in Maidstone, a jury of six men and five women heard evidence from officers including DS Gabriel Chandler, who was the custody sergeant at Tonbridge when Mrs Padley was booked in.

He said that the standard shift in the custody suite was for a sergeant and three dedicated detention offices, but at this time, during the Covid crisis, they were one staff member short and all the personnel were male – and “budget restrictions” meant there was no nurse on site, with the suite having to share one with North West Kent.

Under questioning from Matthew Turner, a barrister representing Mrs Padley’s family, DS Chandler, who had three years’ experience as a custody sergeant, said: “It would have been my preference to have both a female officer and a nurse on site, but that’s the luck of the draw.”

DS Chandler said that Mrs Padley, although not very drunk, was intoxicated and emotional when booked in.

For that reason, he took the decision that she should not be interviewed over the allegation until she had sobered up and he assigned her to a cell and authorised observation checks on her every 30 minutes.

The inquest heard that there were four levels of observation checks that a custody sergeant might assign to a prisoner. Level 1 was a visual observation through a spyhole in the cell door, either every 60 minutes or every 30 minutes.

Level 2 was a check every 30 minutes, in which the prisoner was also woken up and spoken to, if they were not clearly conscious on observation. Level 3 involved a constant check on the prisoner via CCTV in the cell.

Level 4, used if the prisoner is considered at risk of suicide or self-harm, involved an officer sitting outside the door, maintaining a constant vigil.

DS Chandler assigned Mrs Padley to 30-minute Level 1 check – without the rousing.

He conceded that this was contrary to the standards of Authorised Professional Practice as issued by the College of Policing that require that anyone who was intoxicated to any degree should be subject to the Level 2 regime that involved rousing the prisoner.

DS Chandler said that had not been the routine in the Tonbridge custody suite at the time and blamed the training he and colleagues had received. He said: “There had been a misunderstanding.”

Mr Turner pointed out that a general email had been issued to all Kent Police custody suites by an Inspector Fisher on July 9, two weeks before Mrs Padley’s death, following an adverse inspection. That email had pointed out that the expectation was that prisoners should be regularly roused until they were considered sober.

DS Chandler said the wording of the email wasn’t clear. He had interpreted it as a requirement for those already on a rousal routine, not expanding the number who should be subject to such a regime. He said that in any case: ”The discretion remains with the custody sergeant.”

Mr Turner said that following Mrs Padley’s death, the events in the Tonbridge custody suite that night had been reviewed by an experienced police inspector, who had himself previously run the suite – and who had branded the situation “chaotic”.

That was strongly denied by DS Chandler, who said: “I respectfully disagree with the inspector’s report. I do not run a chaotic custody.”

Mr Turner also suggested that DS Chandler had been subject to a disciplinary process after the sad death, but Matthew Holdcroft, a barrister representing Kent Police, quickly corrected him.

DS Chandler had received a form giving guidance on his performance, which did not count as disciplinary action.

I do not run a chaotic custody

Before being booked into custody, Mrs Padley had been in a holding cell escorted by two police officers. Mr Turner said that the transcript from the cell’s CCTV recorded that she had eight times told the officers: “I’m in pain.”

DS Chandler said he was not made aware of that at the booking-in desk and said that if he had been, he would have called the nurse to come and visit the station.

He pointed out that his own medical training as a police officer was one day a year.

The inquest also heard from a Dedicated Detention Officer (DDO), Damien Santana. DDOs are known as police civilians. He carried out some of the observation visits to Mrs Padley’s cell the night before her death.

The court was shown footage from two such visits. In both, DDO Santana peered through a spy hole into the cell for no more than a few seconds.

The court was then shown CCTV footage of Mrs Padley in her cell. At times, she would lie quite still and quiet as though asleep. Then she would moan and call out and writhe about on the bed, clearly in distress.

DDO Santana agreed the footage was “distressing” and said that if he had been aware of her exhibiting such behaviour that night, he would have sought medical assistance for her. However, he insisted that at no time did she exhibit such behaviour during his checks.

Mr Holdcroft asked DDO Santana about other visits he had made to the cell that night, in addition to the 30-minute welfare checks.

DDO Santana said that on five occasions, responding to a request from Mrs Padley made over the intercom in her cell, he had taken her a drink of water, which he passed through the hatch in the door. On each occasion she had got off her bunk and come to the door to take the water and at no time did she mention to him being ill, nor did she ask for help.

The court also heard evidence about the way that observation checks were carried out. Each cell is fitted with both a spy hole and a larger observation flap.

The current police guidance is that the flap should be used to give a wider view of the room. However, DDO Santana carried out his checks through the spyhole, which was common practice at Tonbridge at the time.

But under questioning from Mr Holdcroft, DDO Santana explained that because of the particular geography of Mrs Padley’s cell, the spy hole gave a better view of the detainee.

I believe her life could have been saved

The view from the flap was partially blocked by a partition that gave privacy to the toilet, so that if that was used for observation, the officer couldn’t fully see an inmate if he or she were lying on the bed.

Outside the courtroom, Mrs Padley’s mother, Carole Butler said: “Debbie was clearly ill, she looked ill and if they had treated her as a person and used their brains, things could have been a lot different.”

She said: “They must have seen how unwell she was, I believe her life could have been saved if she had been taken to casualty.”

The inquest ended today with the conclusion that while Ms Padley gave contradictory reports of her condition, her death was probably contributed to by the absence of medical intervention at least five hours prior to her death.

In a release after the conclusion, IOPC regional director Mel Palmer said: “Our thoughts are with Debbie Padley’s family, including her four children, following her tragic death.

“When someone dies in police custody it’s important that an independent investigation is carried out to investigate the actions of custody staff and the level of care the person received.

“While it’s clear from the evidence that custody staff were unaware of Mrs Padley’s medical condition before she died, early on in our investigation we had concerns about the conduct of cell checks for persons under the influence of alcohol or other substances.

“This led to an immediate recommendation being issued to Kent Police, who agreed to implement the learning.”

Detective Chief Superintendent Sam Price, of Kent Police’s Criminal Justice and Custody Command, said: “Kent Police acknowledges and accepts the findings of Debbie Padley’s inquest and we again extend our sympathy to her family and friends.

“On Friday July 23, 2021, Mrs Padley was taken into custody at Tonbridge Police Station following an arrest for assault. Her welfare was consistently monitored with a total of 35 checks to her cell in 17 hours, including seven occasions when Mrs Padley was offered meals and drinks.

“On Saturday, July 24, these ongoing welfare checks included Mrs Padley being roused and spoken to, shortly before a welfare check at 1pm which found her to be unresponsive. Despite immediate medical care Mrs Padley was sadly pronounced deceased at the scene. A subsequent post-mortem examination found she had an underlying acute medical condition.

“This has clearly been a very difficult time for Mrs Padley’s family and friends and we hope the inquest brings them some closure.”