Daniel Ryan, 50, died of pneumonia, alone in police cell with insufficient welfare checks

Daniel, of Hendon, Sunderland, Tyne and Wear, was found dead in his police cell on the morning of 12 November 2023 during a scheduled welfare check by a detention officer, the inquest at City Hall, Sunderland, was told.

Welfare checks had been reduced from half-hourly to hourly, coroner Abigail Combes was told, following a risk assessment on 11 November 2023.

The jury concluded that his condition had deteriorated overnight, and he died from acute bronchopneumonia.

The jury at the three-day inquest into Daniel’s death concluded on Wednesday 15 July 2026 that due to insufficient welfare checks, medical care was not obtained for Daniel.

The coroner determined that Article 2, the right to life was engaged, requiring an enhanced investigation into Daniel’s death. 

Daniel had been arrested on 11 November 2023 and taken to Southwick Custody Suite in Sunderland. Daniel was booked in and put on level 2 observations, which required rousing checks every 30 minutes. This was changed at just before 3.30pm to level 1 observations, which required checks every hour. 

Daniel was seen by a healthcare professional at 4.23pm and offered an alcohol withdrawal assessment which he declined. When he arrived at the police station Daniel reported symptoms of covid, saying that he had been “really unwell” over the past week, and he asked for a mask. The jury’s conclusion considered that Daniel was not showing signs of illness but mentioned having covid. The court heard that the initial risk assessment did not include these details and that Daniel was put on level 2 checks because he appeared to be intoxicated. 

An emergency medicine consultant who reviewed the case considered that Daniel's condition rapidly deteriorated during the morning of 12 November. 

The court heard that welfare checks for Daniel happened every 60 minutes but saw CCTV evidence that they were brief. CCTV footage played to the jury showed Daniel groaning and coughing in his cell when welfare checks were being conducted and officers were stood outside. The court heard evidence from police staff that it may be difficult to hear coughing in the corridor when stood outside a cell.  Police staff also confirmed that there was no expectation for CCTV of Daniel’s cell to be viewed whilst he was on level 2 or 1 observations.  

The healthcare professional confirmed that had she been made aware Daniel was coughing and wheezing when he arrived at the station and had suspected covid and then deteriorated to a point where he was groaning, she would have assessed him and called an ambulance and/ or administered oxygen and fluids if required. 

CCTV evidence showed that Daniel became acutely unwell at approximately 4am. CCTV footage showed that Daniel suffered a medical episode at 10.29am, after which he did not appear to move again. A welfare check was conducted at 10.51am and the detention officer reiterated that he believed Daniel was breathing at this time. A medical expert gave evidence that Daniel had probably died by this point, and that had an ambulance attended up to approximately 10am Daniel would have had a chance of survival.

Daniel was found unresponsive during a scheduled welfare check at 11.41 am. At no point before this time was medical care obtained for Daniel.

The court heard that at 10.15am a sergeant’s review indicating that Daniel was awake and had been spoken to was entered on to the custody system. The evidence from the officer was that he had not actually had that interaction with Daniel when he entered the record and no subsequent interaction took place between them.. This entry was made after 10am which was after the period it was considered that medical treatment could have saved Daniel’s life.

The evidence heard at the inquest made clear that no one actually spoke to Daniel from 6.45am on 12 November 2023 up to the time of his death.

The jury gave a narrative conclusion:

Daniel Gregory Ryan was a 50-year-old man who died from acute bronchopneumonia whilst detained in police custody at Southwick Police Station on 12 November 2023. Daniel was found unresponsive during a scheduled welfare check by a detention officer. Daniel’s death was confirmed at the scene by attending paramedics

Daniel Ryan was arrested by Northumbria Police for breach of bail and transported to Southwick Police Station. Upon arrest Daniel was not showing signs of illness, but mentioned having covid. Upon being detained, Daniel’s condition throughout the early morning of 12th November 2023 suddenly deteriorated whilst in custody Daniel died of natural causes from Acute Bronchopneumonia and was declared dead at 12:23 12th November 2023. Due to insufficient welfare checks, medical care was not obtained for Daniel. 

The coroner stated her intention to request further information from the College of Policing about the clarity of its APP guidelines about cell checks so that she can decide whether to make a prevention of future deaths report. The coroner has also requested more information on how welfare checks are conducted by police officers to satisfy them of a detained person’s welfare. 

Representatives for Mitie Care & Custody Limited confirmed that a missive had been circulated, reminding their healthcare staff to ensure they are carrying out ‘fitness for detention’ assessments before confirming this on a detainee’s records. 

Following the inquest conclusion, Daniel’s family issued a statement.

Daniel’s sister Terri Ryan said:

“The inquest has been the end of a journey that no family should ever have to endure. For nearly three years we have lived with the pain of losing Daniel, while fighting to understand how a man who walked into police custody never walked back out.

“The coroner’s findings have finally recognised what we have believed from the very beginning. Daniel died whilst he was in police custody, reliant on those responsible for his care. The jury found that inadequate welfare checks by Northumbria Police led to medical care not being obtained. The coroner found that Article 2 was engaged and is querying whether a Prevention of Future Deaths report is necessary.  

“Nothing can ever take away the heartbreak of losing my brother Daniel, who was also a son, uncle and father. Daniel wasn't just a name in a court case. He was loved beyond words. He had his struggles, but he deserved dignity, compassion and proper care, just like every other human being. Instead, he was let down at the time he needed help the most.

“We hope today's findings mean that lessons will finally be learned. No family should have to spend years fighting for answers or live with the thought that their loved one may still be here if things had been done differently.

“We now expect Northumbria Police to accept the findings of the jury, to acknowledge where they failed Daniel, and to make the changes needed to ensure no other family has to suffer the pain that ours has.

“Daniel deserved better in life. We will make sure his legacy is that others are better protected because of him. He will never be forgotten.

Daniel’s family were represented at inquest by Leigh Day human rights team partner Leanne Devine, with trainee solicitors Ted Richards and Myfanwy Worman. Barrister Caroline Finney, 7 Bedford Row, was instructed. 

Leigh Day partner Leanne Devine said:

“Daniel’s inquest laid bare the very traumatic circumstances of his death in a police cell, becoming seriously ill without anyone being aware. 

“It was a strong and meaningful outcome which vindicates Daniel’s family’s concerns about the failure to treat him with the dignity he deserved while he was in police custody.”

"The representation of bereaved families in proceedings where state bodies are involved is vital to ensure parity and fairness.  In this case, the family were without legal aid funding to attend hearings for 18 months. As a result, both we and Counsel and ourselves attended fivePre Inquest Review hearings at risk of no funding.  After numerous requests for reviews, appeals and finally a threat to challenge the Legal Aid Agency in the High Court, funding was granted 12 days prior to the final inquest hearing.  The focus for families should be on the proceedings involving their loved ones not fighting to secure legal representation when the state authorities have legal teams funded by the public purse.”