The Independent Police Complaints Commission has announced disciplinary action following its investigation into the death of Tony Davis on 12 October 2004 after his detention in custody at Poole Police station, Dorset.

The investigation was carried out by Hampshire Constabulary officers under the management of the IPCC. An inquest jury in Bournemouth today decided that Mr Davis died of hypothermia and that essential procedures to monitor and protect his health, when in custody, were not complied with.

During the morning of 12 October members of the public raised concerns to the police about 51-year-old Mr Davis' welfare after he was seen lying in a foetal position in a seaside shelter by the Mowlem Restaurant, Shore Road, Swanage.

IPCC Commissioner Ian Bynoe said: "This was a tragic case and my condolences go to Mr Davis's widow and other members of his family and to his friends."

The police control room despatched a police unit and requested an ambulance. The officers attending cancelled the ambulance and arrested Mr Davis and took him into custody at Poole Police station.

Mr Davis had been found on the seaward side of the shelter and his clothes had been soaked by sea spray - the weather was described as very cold.

"The chain of events that led to Mr Davis being left in a police cell in wet clothes without any medical examination was set in train by his arrest and subsequent detention at Poole police station. However, it was only after his arrival at Poole that matters began to go wrong," Mr Bynoe said.

"Dorset Police's own custody procedures require that a risk assessment be completed by the custody sergeant before someone is detained. If the person is incapable of answering questions then a medical opinion should be sought as to whether they are fit to be detained. This did not happen in this case."

At 10.30 a.m. officers placed Mr Davis in a cell. He was left in wet clothing in breach of Dorset Police custody policy, which dictates that under no circumstances will a detained person be left in a cell wearing any form of wet clothing.

The IPCC investigation has concluded that police officers and staff in the custody centre failed to carry out their duties in respect of the supervision, treatment and care while in detention as required by the Police and Criminal Evidence Act and Dorset Police procedure.

"Had these officers and staff properly fulfilled their duties of care the likelihood is that Mr Davis would have been taken to hospital at a much earlier stage during his detention," Mr Bynoe said.

"I want to make it clear that this may not have led to Mr Davis' recovery from hypothermia, but at least it would have given him an earlier chance of medical intervention.

"Civilian custody staff also made false entries in the custody record and following our investigation three detention officers will each face a disciplinary hearing for gross misconduct. The duty inspector and one of the two custody sergeants involved will each face a misconduct hearing while the other sergeant will receive a written warning."

The investigation also included a number of detailed recommendations to Dorset Police designed to improve its custody procedures and practice and the training given to police officers and staff.