Police not at fault over Christopher Shapley's death
Police involved in the arrest of a man who was later found dead in his prison cell have been cleared of any fault in relation to his death.
Christopher Shapley, 43, was arrested at home in Aberdare last September and charged with assaulting his mother.
An investigation found South Wales Police had followed risk assessment procedures and care plans correctly.
But it noted a form detailing concerns about Mr Shapley was lost between the police station and HM Prison Cardiff.
The Independent Police Complaints Commission (IPCC) said it would never be known if the loss of additional information about Mr Shapley would have made any difference but it found "no evidence of misconduct" and commended the actions of one officer.
However, it said a Person Escort Record form, which is used when transferring people from police custody to prison to record any concerns about the risk of self-harm, was not fit for purpose and needed a fundamental redesign.
Investigators found the police carried out all the correct procedures about the risk assessment and had ticked a box to record concerns but did not have room to write them all down, and had attached a piece of paper giving more information.
The additional piece of paper was lost at some point.
IPCC Commissioner Jan Williams said: "The loss of this additional risk information was most unfortunate for Christopher, and we will never know what might have happened if it had not gone astray.
"This is a very sad series of events that had a tragic conclusion, and the last year has clearly been a most distressing time for Christopher's family and friends."
Mr Shapley was arrested on 17 September and taken to Merthyr Tydfil police station and charged with common assault and remanded in custody.
He appeared before Pontypridd Magistrates court two days later and was transferred to HMP Cardiff.
Prison officers found him dead in his cell on 20 September.
The investigation found South Wales Police officers had spoken to Mr Shapley and his family to assess his risk of self-harm.
It also praised one police constable who took into consideration his welfare and his parents' desire to get him help when deciding to charge him with common assault.
Ms Williams added: "Christopher's death has highlighted the need for an informed and thorough risk assessment of an individual's risk of self-harm, and a robust means of communicating this information to all authorities with responsibility for people in custody."
A Prison Service spokesperson said: "The sharing of information between agencies is a crucial part of keeping prisoners safe, and we are currently reviewing how the Person Escort Record form can be improved.
"We are committed to reducing the numbers of self-inflicted deaths in custody.
"All deaths are subject to investigation by the police and the Prisons and Probation Ombudsman and a coroner's inquest, and strenuous efforts are made to learn lessons from these processes."
Chief Supt Tim Jones, head of professional standards with South Wales Police said the force would support the development of a new form as recommended by the IPCC.
"Our thoughts are with the family of Mr Shapley and we remain committed to embedding any learning that comes from this tragic incident," he said.