Ryan was a 20yo man with learning disabilities who was also diagnosed with depression. He was arrested and collapsed in the police van, complaining of chest pains. The police took him to hospital where signs of recent self-harm were found. However, the hospital did not investigate his mental state, despite NICE Guidelines which give clear instruction on doing so, and Ryan was released into police custody.

(The NICE Guidelines referenced in the PFD report appear to have been superseded in 2022.)

The Liaison and Diversion Service attended the custody suite, but failed to record his mental state, nor was he given a mental health assessment. Ryan expressed a desire to self-harm, but custody officers dismissed this as "attention-seeking". They released him to his father, but gave the father no information about what they had seen of Ryan's mental state.