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

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.

Notes for editors


• The majority of INQUEST’s police related cases over the past five years have involved the death of vulnerable individuals in some form of mental health crisis.  Following an eleven year low of 11 police deaths in 2013/14, the number of deaths in or following police contact rose sharply to 17 in 2014/15.  8 out of those 17 deaths were of people identified as having mental health concerns.  5 were restrained. This marks the continuation of a trend in mental health related deaths where in 2012/13 of the 15 people who died in or following police custody, almost half (7 individuals) were identified as having mental health concerns.  In 2013/14 of the 11 people who died, 4 were identified as having mental health concerns.   See IPCC annual statistical report here.


• In February 2016 the Home Secretary announced an independent review, conducted by Dame Elish Angiolini QC, into Deaths in Police Custody.  INQUEST Director Deborah Coles has been appointed special advisor to the review. https://www.gov.uk/government/consultations/independent-review-of-deaths-and-serious-incidents-in-police-custody

• See INQUEST’s written submission to the 2014 Home Affairs Select Committee review of policing and mental health here

Please refer to INQUEST the organisation in all capital letters in order to distinguish it from the legal hearing.

For further information, please contact: INQUEST on 020 7263 1111

INQUEST provides specialist advice on deaths in custody or detention or involving state failures in England and Wales. This includes a death in prison, in police custody or following police contact, in immigration detention or psychiatric care. INQUEST's policy and parliamentary work is informed by its casework and we work to ensure that the collective experiences of bereaved people underpin that work. Its overall aim is to secure an investigative process that treats bereaved families with dignity and respect; ensures accountability and disseminates the lessons learned from the investigation process in order to prevent further deaths.

Please refer to INQUEST the organisation in all capital letters in order to distinguish it from the legal hearing.

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