A jury returned a unanimous verdict of accidental death on Monday following a three-day inquest into the case of a 27-year-old Sydenham woman who died while in police custody.
Recovering heroin addict Tammy Jordan, of Hasting Fields, died at Leamington police station on August 11 2004, after being arrested for failing to attend court on motoring charges.
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The jury at Leamington Town Hall required four hours to reach a decision, reappearing in coroner's court midway through that time to ask how much detail it could record regarding the unusual circumstances of the case.
It gave 'methodone and alcohol poisoning, in association with other prescription and non-prescription drugs' as the cause of death, but decided Miss Jordan had not died as a direct consequence of drug dependency, one of the remaining possible verdicts after Warwickshire coroner, Michael Coker, had earlier ruled out suicide, unlawful killing and involuntary manslaughter.
The foreman expressed his "condolences in a sad and distressing story", sentiments echoed by Mr Coker. He said: "Whatever decisions this court has made, you have lost your daughter in circumstances which were tragic and there is not much more to add. I hope the last few days have answered some, if not all, of your questions."
The findings of an independent Police Complaints Commission investigation into the death are expected to be released shortly.
MONDAY AFTERNOON: Coroner Michael Coker summarised the two day inquest and instructed the jury on what they had to decide. He also ruled out suicide, unlawful killing and involuntary manslaughter verdicts as a possibility.
He said: "It is my view that you could not come to any of these conclusions. There is no gross negligence or any intent shown."
He added this also included no evidence of intent from Miss Jordan herself.
He said: "It is quite obvious that she hoped to be on the verge of a new life. So it would be completely out of character with what she wanted to do."
The inquest is at Leamington town hall, and could last up to four days, to examine the circumstances surrounding the death of Tammy Jordan while she was in police custody in August 2004.
The 27-year-old had been taken into custody a day earlier after failing to attend court on driving charges.
END OF DAY TWO: Forensic scientist Brian Johnson, who took samples from Miss Jordan's body, told the hearing he found "high levels" of drugs including amphetamines, painkiller diazepam and heroin substitute methadone in her blood, which also contained more than half the amount of alcohol needed to push someone over the drink-drive limit.
He said: "The diazepam, methadone and mirtzapine could have made a significant difference to her death."
Mr Johnson explained that mixing methadone and alcohol can be fatal - and that Ms Jordan may have taken amphetamines shortly before her arrest.
He also claimed that Ms Jordan could have suffered from alcohol intolerance.
* Consultant Home Office pathologist Dr Peter Acland conducted Ms Jordan's autopsy - and also believes drugs were likely to be responsible for her death.
He told the inquest: "It is difficult to work out the contibution that drugs had to her death as they affect people in different manners.
"People bulid up a tolerance to them, but can lose it too. These drugs affect the brain and they slow down the breathing. The reason for the delay from the time she took them to the time she was in custody was that she was still absorbing them."
Dr Acland found Ms Jordan's liver to be twice the size it should have been. Her body was also bruised, suggesting drug injections. She was seen to turn in her sleep, showing her brain to be active, but Dr Acland believes the cocktail of drugs she had allegedly ingested led to respiratory failure.
He said: "I had originally believed Ms Jordan's cause of death to be methadone poisoning but, upon understanding the full report, I now believe it was due to a combination of methadone and alcohol."
* The policewoman who found Ms Jordan dead had not been warned that the 27-year-old was vulnerable, the inquest heard.
Pc Samantha Oakley started her shift at 7.40am, assuming there would be no problems. She told the inquest: "There was no indication anything was wrong with her - no-one had said anything.
"When I conducted my review at 7.50am, all was well."
Pc Oakley looked in on Ms Jordan with a medical student with whom she was walking around the cells.
Pc Oakley said: "We looked only through the hatch of the door, and I could see Ms Jordan was still breathing, indicated by the movements of her shoulders.
"But the medical student said Ms Jordan did not look well, so I went back in to check. I tried talking to Ms Jordan, who had a blanket over her, but there was no response."
Pc oakley told Pol Sgt Rupert Atkinson that she thought Ms Jordan had died, and to call a doctor urgently. With colour and warmth still in Ms Jordan's face, the pair tried to resuscitate her. An ambulance was called at 8.20am, but she was officially pronounced dead minutes later.
* No action will be brought against the officers at the police station when Ms Jordan died.
Lisa Edwards from the Independent Police Complaints Commission told the inquest: "The police carried out everything correctly."
LUNCHTIME ON DAY TWO: Medical experts believe the way Tammy Jordan was cared for in police custody was "appropriate" given the conditions she suffered from at the time she died.
The jury heard that alcohol and drug addict Miss Jordan had been "keen to address her substance misuse" before relapsing in 2004, the year she died in police custody where she ended up after failing to appear in court on a traffic charge.
The 27-year-old, who suffered from depession and anxiety attacks, drank heavily and smoked and injected heroin, for which she was prescribed methadone, a drug which suppresses narcotic withdrawal for between 24 and 36 hours.
But her drinking - she sometimes consumed up to a bottle of vodka per day - put her at "high risk" of dying and the jury heard that she was lucky to be alive.
Dr Ashraf Khan said: "She had been drinking while she had been taking methadone and didn't realise the severity of that.
"There was a risk of withdrawal from both drugs.
"She may have taken this high risk combination of drugs in the past and been lucky not to have the effects, but eventually it would take its toll.
"It is clear from the report that the medical attention she received was appropriate.
"Certainly, by taking the amount of alcohol she had been with the methadone, she was putting her life at considerable risk.
"She was lucky to be alive at the time of her death, anyway."
On the day she died, Miss Jordan was given diazepam at 1.34am.
The drug is used to relieve anxiety, muscle spasms, and seizures and to control symptoms for alcohol withdrawal.
It is believed this is the reason why Miss Jordan slept soundly that night and why officers, who checked her progress at half-hourly intervals, did not notice any symptoms of alcohol withdrawal.
But the contribution of the three drugs she had in her body - alcohol, diazepam and methodone - could all have contributed to her death, the jury heard.
Miss Jordan, who took her daily dose of methadone orally and under the supervision of a pharmacist, had not been to take it the day she was admitted to the police cell.
Dr Helen Liley, of the south Warwickshire primary care trust, who regularly saw Miss Jordan since June 2003, became tearful as she recounted the last time she had met her on July 15, 2004.
She said: "I would have expected to have seen some withdrawal symptoms.
"She told me that she had not used heroin for eight weeks and seemed keen to address her substance misuse.
"She suffered from panic attacks and depression but she was suitable for a detox programme and I had arranged for her to see a clinical team the next day. I felt Tammy was relatively positive."
END OF DAY ONE: After lunch on day one of the inquest into the death of Tammy Jordan the jury of four men and four women were told of the events following the 27-year-old's arrest.
Miss Jordan was arrested on Warwick Street, Leamington the day before her death after failing to attend court to face driving charges and was taken to Leamington police station.
Insp Stephen Pace explained to the inquest that Miss Jordan was "in drink" when she arrived at the station and she had notified him that she had been prescribed methadone and diazepam. He added that she admitted she had attempted suicide ten years earlier and as a consequence was put in a paper suit.
He said: "I conducted a lengthy booking process and spoke to her for 30 minutes. During that time no issues were raised other than the previous issues of self harm, the fact that she was in drink and requiring methadone and diazepam. I called the doctor who would give me the appropriate medical advice."
Despite earlier evidence produced by Miss Jordan's doctor that she was not being prescribed diazepam, Miss Jordan had two tablets of the drug in her purse at the time of her arrest and told the police officers and later the police surgeon that these were prescribed drugs.
Dr Paul Miller, who happened to be Miss Jordan's doctor before she moved away from Kenilworth, visited her at the police station. Giving evidence at the hearing on Thursday he said: "She was able to give me a good history and I was able to leave the room unattended. She was drunk but I felt that for someone with her alcohol capacity, the toxicity would decrease in a couple of hours."
He prescribed diazepam and also medication to alleviate the withdrawal symptoms from methadone. But speaking of the incorrect information he was given, he explained that he would not have allowed Miss Jordan to have the tablets she had brought in with her. Instead he would have prescribed the drugs from the station's own medicine cabinet.
Describing the dose given to Miss Jordan, despite not previously being prescribed it, Dr Miller said it was "reasonable" and Miss Jordan had not caused him any exceptional concern.
Members of the jury then heard evidence from three officers who were on duty at the time Miss Jordan was in the cells.
PS Ian Roberts said: "Police have to take on board what the person is saying to them. If they are saying false information there is nothing to stop them. It is a sad reality that the person coming into custody does not always tell the custody sergent the truth."
He added that the mechanisms were not in place to check prisoners' medical records and prescriptions.
The inquest continues.
THURSDAY LUNCHTIME: The father of a 27-year-old woman who died while in custody in a Leamington police cell has spoken of his "caring, friendly and humorous" daughter at the opening of an inquest into her death.
Tammy Jordan of Hastang Fields, Sydenham died at Leamington police station in August 2004 after being arrested for failing to attend court over driving charges.
Her death prompted an Independent Police Comp- laints Commission investigation and a report is expected to be released after the inquest.
Speaking at Leamington Town Hall yesterday (Thursday), father Gerry Jordan explained to the jury that his daughter had been through some hard times but her outlook was positive.
He said: "She was caring, friendly, humorous and she was liked and loved by many. She was very outgoing and was the life and soul of the party. Tammy's love of children was one of her great pleasures in life and was a proud aunt to her two nieces.
"She was looking forward to going back to college and her thoughts for the future were very positive.
"She had been addicted to heroin but as far as I was aware she wasn't at the time. I had spent 11 to 12 days with her going cold turkey and she had done very well with that. The drug rehabilitation team themselves seemed to be happy with her progress."
Evidence was also heard on Thursday from Matthew Standley, who was Miss Jordan's boyfriend at the time of her death.
Unable to attend the hearing, Mr Standley's statement was read to the jury by Warwickshire coroner Michael Coker.
It stated that the couple had been together for three weeks following a chance meeting on the Parade in Leamington and detailed the day of Miss Jordan's arrest.
It read: "I got a text from Tammy saying 'Bye'. It seemed strange but I thought nothing of it. Shortly afterwards I got a phonecall from the police telling me that Tammy was in custody and would be kept in and put before the court the next day. I asked if she had cigarettes and said I would bring some down.
"I started to think about her being in custody and started to panic about her alcohol problem, her drugs and being in a closed space."
Standley added that he visited Leamington police station with a friend to ask if he could pass on cigarettes and a letter to Miss Jordan but was told this was not possible. He also told a police officer at the desk of his concerns for his girlfriend's health.
Inquiry officer Glen Wright informed the inquest that Mr Standley concerns had been passed onto the custody sergeant.
The inquest continues.
Reports from the inquest will appear here regularly throughout the four-day hearing.