Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Kingsley Burrell · 20 Mar 2015 · Louise Hunt, Birmingham and Solihull
“it was clear from the inquest that there was a lack of understanding of how to treat someone with an acute behavioural disturbance.”
judiciary.uk/prevention-of-future-death-reports/kingsley-burrell
What was promised
Stated action 1 · response to Kingsley Burrell (20 Mar 2015) · stated timescale: none stated
“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”
judiciary.uk/…/2015-0472-Response-by-Metropolitan-Police.pdf
Stated action 2 · response to Kingsley Burrell (20 Mar 2015) · stated 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.”
judiciary.uk/…/2015-0472-Response-by-Association-of-Ambulance-C…
Stated action 3 · response to Douglas Oak (24 Oct 2019) · stated timescale: none stated
“providing additional Continuous Professional Development training around Acute Behavioural Disturbance”
3 further stated actions are listed on the full chain page.
What recurred
- 24 Oct 2019 · Douglas Oak · Rachael Griffin · Identical hazard · confidence 0.86 (high)
- 4 Oct 2021 · Leon Briggs · Emma Whitting · Closely related · confidence 0.85 (high)
- 27 Jan 2022 · Adam Stone · Emma Brown · Identical hazard · confidence 0.96 (high)
- 2 Feb 2026 · Scott Taylor · Sonia Hayes · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · 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”
Later · 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”
What happened next
No evidence found either way · stated action 1
“In December 2022, [name redacted] died after experiencing Acute Behavioural Disturbance (ABD) and a complex disturbance in normal physiology.”
Acute Behavioural Disturbance: preventing future deaths - Mental health - Patient Safety Learning - the hub · pslhub.org/…/acute-behavioural-disturbance-preventing-future-de…
“PERF releases new report on avoiding restraint-related deaths** PERF members, Use of force continues to be the defining issue in policing.”
PERF releases new report on avoiding restraint-related deaths · policeforum.org/trending20sep24
No evidence found does not mean the action did not happen.
No evidence found either way · stated action 2
“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”
Acute Behavioural Disturbance in Emergency Departments · rcem.ac.uk/…/Acute-Behavioural-Disturbance-in-Emergency-Departm…
“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.”
Acute Behavioural Disturbance - RCEMLearning · rcemlearning.co.uk/reference/acute-behavioural-disturbance
“AACE supports the UK's statutory ambulance services in implementing national policies and acts as a key interface between members and stakeholders.”
AACE: Association of Ambulance Chief Executives · aace.org.uk
No evidence found does not mean the action did not happen.
No evidence found either way · stated action 3
“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”
Acute severe behavioural disturbance (ASBD) in the adult patient - ANZCA & FPM CPD Program resources - Library resource guides at Australian and New Zealand College of Anaesthetists (ANZCA) Library · libguides.anzca.edu.au/cpd/emergency/asbd
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “We will address each of your concerns, insofar as we are able.”
“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.”
Association of Ambulance Chief Executives (AACE) · uk.linkedin.com/…/association-of-ambulance-chief-executives-aace
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “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”
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.
No evidence found either way · stated action: “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.”
“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.”
A brief guide to Section 136 for Emergency Departments · westyorkshire-pcp.gov.uk/…/appendix-c-a-brief-guide-to-section-…
“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.”
Section 136 & Health-Based Places of Safety Explained · learnsignal.com/…/section-136-mental-health-act-places-of-safet…
No evidence found does not mean the action did not happen.