Inadequate training for police and ambulance crew on acute behavioural distress
Association of Ambulance Chief Executives received 5 coroners' reports about this hazard between 20 Mar 2015 and 2 Feb 2026.
They came from 5 different coroners in 4 coroner areas. A similar concern was raised again 4 times after the first warning.
A published response was found for 4 of the 4 earlier reports, stating 6 specific actions.
The story, report by report
Spacing grows with the time between reports.
“it was clear from the inquest that there was a lack of understanding of how to treat someone with an acute behavioural disturbance.”
Original on judiciary.uk ↗ Association of Ambulance Chief Executives responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗
“My concern is that this has not been rolled out nationally and therefore many other forces will not understand the implication of this condition and how best to treat it. | suggest contact is made with Chief Inspector | Og WMP for full information on the changes made in the West Midlands Area”
Web search (Tavily): No evidence found either way
Acute Behavioural Disturbance: preventing future deaths - Mental health - Patient Safety Learning - the hub ↗“We have made a recommendation to the National Education Network for Ambulance Services leads (NENAS) that each trust considers including, if not completed already, the education of front line staff and control room staff in acute behavioural disturbance to raise awareness of the condition and how it can present in a patient.”
Stated timescale: November 2015
Web search (Tavily): No evidence found either way
Acute Behavioural Disturbance in Emergency Departments ↗- 4 years 7 months laterIdentical hazardConfidence 0.86 · higha different coroner
“During the iInquest evidence was heard that: i. Acute Behavioural Disturbance (ABD) is a term used to describe the presentation of a spectrum of behaviours, signs and symptoms which create an immediate risk to life, especially at the severe end of the spectrum.”
Original on judiciary.uk ↗ Repeated from the earlier report:AcuteBehaviouralDisturbance
Association of Ambulance Chief Executives responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗
“providing additional Continuous Professional Development training around Acute Behavioural Disturbance”
“We will address each of your concerns, insofar as we are able.”
Web search (Tavily): No evidence found either way
Association of Ambulance Chief Executives (AACE) ↗ - 1 year 11 months laterClosely relatedConfidence 0.85 · higha different coroner
“insufficient or inadequate instruction of both police and ambulance crew about the critical issues of recognising and responding to a medical emergency and the effects of restraint including positional asphyxia.”
Original on judiciary.uk ↗ Association of Ambulance Chief Executives responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗
“The revised guidance includes wording to highlight that the police officer on scene should call the local ambulance service and include in the information passed whether the patient is being actively restrained and if so how, and if acute behavioural disturbance (ABD) is suspected. Ambulance trusts will assign a Category 2 response to patients detained under S136 and suspected of having ABD unless there are other immediately life-threatening clinical features that would warrant a Category 1”
Stated timescale: recently revised
Web search (Tavily): No evidence found either way
“EEAST's Mental Health team have also been working on updating the guidance documents for our partners in relation to managing s.136 patients within the community setting. This document 'Requesting Conveyance for Patients Detained under the MHA' will be sent to you once the review and update has been completed in December 2021.”
Stated timescale: December 2021
Web search (Tavily): No evidence found either way
A brief guide to Section 136 for Emergency Departments ↗ - 4 months laterIdentical hazardConfidence 0.96 · higha different coroner
“Acute Behavioural Disturbance (ABD) is an umbrella term to describe a presentation which usually includes abnormal physiology and/or behaviour. ABD is not a diagnosis or a recognised syndrome, but rather a term used to describe a combination of signs and symptoms of aggression and agitation with physiological abnormalities”
Original on judiciary.uk ↗ Repeated from the earlier report:AcuteBehaviouralDisturbancetermdescribepresentation
Association of Ambulance Chief Executives responded.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
- 4 years laterClosely relatedConfidence 0.90 · higha different coroner
“Special Constables are a valuable resource for police forces and may often be first on scene as in this case and should receive the same training in the potential recognition and alert of potential life-threatening conditions.”
Original on judiciary.uk ↗ Association of Ambulance Chief Executives responded.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
- All reports to Association of Ambulance Chief Executives
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2015 → 2019Douglas Oak4 years 7 months after Kingsley Burrell · different coronerIdentical hazardConfidence 0.86 · high
Identical hazardConfidence 0.86 · highBoth reports highlight insufficient knowledge about managing acute behavioural disturbance leading to risks during restraint.
Kingsley Burrell · 20 Mar 2015
“it was clear from the inquest that there was a lack of understanding of how to treat someone with an acute behavioural disturbance.”
Original on judiciary.uk ↗ Douglas Oak · 24 Oct 2019
“During the iInquest evidence was heard that: i. Acute Behavioural Disturbance (ABD) is a term used to describe the presentation of a spectrum of behaviours, signs and symptoms which create an immediate risk to life, especially at the severe end of the spectrum.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“We have made a recommendation to the National Education Network for Ambulance Services leads (NENAS) that each trust considers including, if not completed already, the education of front line staff and control room staff in acute behavioural disturbance to raise awareness of the condition and how it can present in a patient.”
2019 → 2021Leon Briggs1 year 11 months after Douglas Oak · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight gaps in training for recognizing and managing acute behavioural disturbance/medical emergencies involving restrained individuals.
Douglas Oak · 24 Oct 2019
“College of Policing issued a training package at the end of 2016 to all Police Forces on ABD.”
Original on judiciary.uk ↗ Leon Briggs · 4 Oct 2021
“insufficient or inadequate instruction of both police and ambulance crew about the critical issues of recognising and responding to a medical emergency and the effects of restraint including positional asphyxia.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“the College will work with police stakeholders through the NPCC First Aid Forum and the national clinical governance panel to reflect this learning outcome in Module 2, the refresher training module for front line staff. This will ensure that this training is given to all front line officers. This amendment will be made as part of the wider scheduled review of the FALP following the release of updated guidance by the UK Resuscitation Council in 2020.”
2015 → 2021Leon Briggs6 years 7 months after Kingsley Burrell · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports address gaps in training regarding recognition and response to behavioral/medical emergencies during restraint.
Kingsley Burrell · 20 Mar 2015
“lack of understanding of how to treat someone with an acute behavioural disturbance”
Original on judiciary.uk ↗ Leon Briggs · 4 Oct 2021
“insufficient or inadequate instruction of both police and ambulance crew about the critical issues of recognising and responding to a medical emergency and the effects of restraint including positional asphyxia.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“We have made a recommendation to the National Education Network for Ambulance Services leads (NENAS) that each trust considers including, if not completed already, the education of front line staff and control room staff in acute behavioural disturbance to raise awareness of the condition and how it can present in a patient.”
2019 → 2022Adam Stone2 years 3 months after Douglas Oak · different coronerIdentical hazardConfidence 0.96 · high
Identical hazardConfidence 0.96 · highBoth reports concern Acute Behavioural Disturbance (ABD) as a set of behavioural and physiological signs indicating imminent risk of death requiring urgent management.
Douglas Oak · 24 Oct 2019
“Acute Behavioural Disturbance (ABD) is a term used to describe the presentation of a spectrum of behaviours, signs and symptoms which create an immediate risk to life, especially at the severe end of the spectrum”
Original on judiciary.uk ↗ Adam Stone · 27 Jan 2022
“Acute Behavioural Disturbance (ABD) is an umbrella term to describe a presentation which usually includes abnormal physiology and/or behaviour. ABD is not a diagnosis or a recognised syndrome, but rather a term used to describe a combination of signs and symptoms of aggression and agitation with physiological abnormalities”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“providing additional Continuous Professional Development training around Acute Behavioural Disturbance”
2021 → 2026Scott Taylor4 years 4 months after Leon Briggs · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight a lack of adequate training for frontline personnel in recognising and responding to medical emergencies linked to restraint. The earlier report focuses on police and ambulance crews, while the later report stresses the need for Special Constables to receive equivalent training.
Leon Briggs · 4 Oct 2021
“insufficient or inadequate instruction of both police and ambulance crew about the critical issues of recognising and responding to a medical emergency and the effects of restraint including positional asphyxia.”
Original on judiciary.uk ↗ Scott Taylor · 2 Feb 2026
“Special Constables are a valuable resource for police forces and may often be first on scene as in this case and should receive the same training in the potential recognition and alert of potential life-threatening conditions.”
Original on judiciary.uk ↗ 2015 → 2026Scott Taylor10 years 10 months after Kingsley Burrell · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports address inconsistent handling of acute behavioural disturbance across ambulance services.
Kingsley Burrell · 20 Mar 2015
“lack of understanding of how to treat someone with an acute behavioural disturbance”
Original on judiciary.uk ↗ Scott Taylor · 2 Feb 2026
“in some ambulance localities the required response is allocated Category 2 and in others Category 1. This means that there is not a national standard for response Acute Behavioural Disturbance with active restraint.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“We have made a recommendation to the National Education Network for Ambulance Services leads (NENAS) that each trust considers including, if not completed already, the education of front line staff and control room staff in acute behavioural disturbance to raise awareness of the condition and how it can present in a patient.”
Stated action
“My concern is that this has not been rolled out nationally and therefore many other forces will not understand the implication of this condition and how best to treat it. | suggest contact is made with Chief Inspector | Og WMP for full information on the changes made in the West Midlands Area”
What happened next: No evidence found either way
No source confirms or denies a national rollout of the suggested contact with Chief Inspector Og WMP.
“In December 2022, [name redacted] died after experiencing Acute Behavioural Disturbance (ABD) and a complex disturbance in normal physiology.”
“PERF releases new report on avoiding restraint-related deaths** PERF members, Use of force continues to be the defining issue in policing.”
No evidence found does not mean the action did not happen.
Stated action · timescale: November 2015
“We have made a recommendation to the National Education Network for Ambulance Services leads (NENAS) that each trust considers including, if not completed already, the education of front line staff and control room staff in acute behavioural disturbance to raise awareness of the condition and how it can present in a patient.”
What happened next: No evidence found either way
The Association of Ambulance Chief Executives has not publicly confirmed or denied the November 2015 recommendation regarding frontline staff education on acute behavioural disturbance.
“All EDs should have a locally agreed strategy for the management of cases of ABD. 4. All EDs should have an identified area suitable to provide verbal and environmental de-escalation of ABD cases when required”
“There is no widely accepted definition of ABD but it is characterised by a combination of:** * Delirium * Severe agitation and aggressive behaviour * Autonomic dysfunction, e.g.”
“AACE supports the UK's statutory ambulance services in implementing national policies and acts as a key interface between members and stakeholders.”
No evidence found does not mean the action did not happen.
Stated action
“providing additional Continuous Professional Development training around Acute Behavioural Disturbance”
What happened next: No evidence found either way
The organisation's website lists resources related to acute severe behavioural disturbance but does not mention any specific training provision or commitment to deliver additional CPD in this area.
“The **purpose** of this guide is to provide fellows and CPD Program participants with information, suggestions and resourcing support specific to each of the programs activities”
No evidence found does not mean the action did not happen.
Stated action
“We will address each of your concerns, insofar as we are able.”
What happened next: No evidence found either way
The Association of Ambulance Chief Executives describes its role in supporting ambulance services and facilitating coordination, but no source confirms it carried out the promised action of addressing concerns.
“The Association of Ambulance Chief Executives is a membership organisation established in 2011 to provide UK NHS ambulance services with an organisation that can support them in the implementation of nationally agreed policies.”
No evidence found does not mean the action did not happen.
Stated action · timescale: recently revised
“The revised guidance includes wording to highlight that the police officer on scene should call the local ambulance service and include in the information passed whether the patient is being actively restrained and if so how, and if acute behavioural disturbance (ABD) is suspected. Ambulance trusts will assign a Category 2 response to patients detained under S136 and suspected of having ABD unless there are other immediately life-threatening clinical features that would warrant a Category 1”
What happened next: No evidence found either way
The Association of Ambulance Chief Executives has not published recent revisions to police guidance on detaining individuals under mental health legislation.
No evidence found does not mean the action did not happen.
Stated action · timescale: December 2021
“EEAST's Mental Health team have also been working on updating the guidance documents for our partners in relation to managing s.136 patients within the community setting. This document 'Requesting Conveyance for Patients Detained under the MHA' will be sent to you once the review and update has been completed in December 2021.”
What happened next: No evidence found either way
The organisation said the guidance would be sent in December 2021, but no source confirms it was delivered or that the deadline was met.
“When a patient is brought to the ED under section 136 of the Mental Health Act; the nurse in charge and a senior clinician should review the patient with the police and ambulance crew to assess their medical needs and review their risks to self and others.”
“The 24-hour clock, and when it can be extended Someone detained under Section 136 can be held for up to 24 hours while a Mental Health Act assessment is arranged.”
No evidence found does not mean the action did not happen.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to Association of Ambulance Chief Executives at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2015 → 2019 | 0.63 | 0.25 | Identical · 0.86 | different |
| 2019 → 2021 | 0.69 | 0.09 | Closely related · 0.85 | different |
| 2015 → 2021 | 0.68 | 0.06 | Closely related · 0.85 | different |
| 2019 → 2022 | 0.80 | 0.29 | Identical · 0.96 | different |
| 2021 → 2026 | 0.76 | 0.09 | Closely related · 0.90 | different |
| 2015 → 2026 | 0.66 | 0.28 | Closely related · 0.85 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.