Man took own life after Bedfordshire Police custody release
Concerns about police training after a man killed himself days after telling officers he was "on top of the world" have been raised by a coroner.
David Bird, 51, died in August 2018 after being released from Bedfordshire Police custody despite requests from another force for his assessment.
Custody officers interpreted a response when asked how he felt as literal rather than ironic, a report said.
The force said "learning" from the inquest would be in future training.
In her report to prevent future deaths, coroner Emma Whitting said failure to arrange a medical assessment "possibly contributed to his death".
The report details how the Bedfordshire force submitted a Vulnerable Adult Referral for Mr Bird on 18 August when officers became aware he had seemingly been preparing to take his own life at his home.
He was arrested on 19 August after further concern for his welfare and interviewed under caution by Northamptonshire Police who requested that he undergo a medical assessment before being released from custody.
Mr Bird, from Bedford, was released at about 01:30 BST on 20 August without assessment, despite the request being made three times, the coroner said.
He was found dead on 21 August at 15:45.
Ms Whitting said she had concerns about whether the training of custody officers to interpret the behaviour and demeanour of detainees and to formulate a suitable care plan was adequate and that "action should be taken to prevent future deaths".
When Mr Bird was asked how he was feeling on being booked in, both custody sergeants interpreted his "on top of the world" response as literal when this "might be interpreted as having an element of irony requiring further exploration".
As well as not being assessed, Mr Bird was also released despite being identified as vulnerable and being tearful and distressed during his interview.
At an inquest in May, Ms Whitting said that while Mr Bird intentionally took his own life, "the failure to arrange a medical assessment prior to his release from police custody the previous day possibly contributed to his death".
A Bedfordshire Police spokeswoman said the force was "committed to ensuring the care and safety of those in our custody and continually look for ways to improve our procedures".