False entries were made in the custody record of a man who died after being refused medical aid while detained by police, a watchdog has found.
Stephen Berry died in hospital in 2013 from the effects of alcohol withdrawal after spending two days in a police cell in Washington, Tyne and Wear.
The Independent Office for Police Conduct identified "serious failings" leading up to the 43-year-old's death.
It said two detention officers accepted misconduct and received warnings, while two Northumbria Police sergeants were found to have a case to answer for gross misconduct but both retired before action was taken.
Separate from the inquest proceedings the watchdog carried out its own investigation into what happened with Mr Berry at Washington police station on 28 March 2013.
It said he was assessed as requiring half-hourly checks, during which he should have been be roused.
Inquiries from CCTV footage, witness accounts, police custody logs and statements from officers and staff found:
- Six false entries and other inaccuracies in the custody record relating to checks made on Mr Berry
- Mr Berry asked to be taken to hospital but this was refused
- A detention officer reported concerns for Mr Berry's welfare to a custody sergeant, but these were ignored or dismissed
- A custody sergeant contacted a doctor but told him Mr Berry's condition was not urgent
IOPC interim regional director David Ford said: "Our findings make for difficult reading, not least because they recount the obvious distress Mr Berry was in during his detention.
"Our evidence demonstrates there were, overall, serious failings in the care afforded to Mr Berry. Thankfully, such incidents are rare - the vast majority of police officers and staff understand their responsibilities and uphold the highest professional standards."
The Crown Prosecution Service decided in 2015 not to prosecute the sergeants involved.
Northumbria Police said its custody procedures had changed since 2013, with a "management information system" in place to closely monitor the welfare of people in custody.