Brian Ringrose
The coroner's concerns
1. positional asphyxia risk
“Inadequate application of police restraint training”
2. reassessment failure
“Failure to apply the National Decision Model”
3. unmonitored breathing deterioration
“Ineffective welfare monitoring”
4. silence on improper restraint
“Failure of officers to "speak up and speak out"”
5. information gap on restraint duration
“Inadequate communication and handover”
6. welfare ignored during FLACS application
“Inappropriate prioritisation of transport over welfare”
7. assessment inability due to unresponsiveness
“Inadequate Assessment”
8. unvoiced clinical concern
“Failure to Escalate Concerns”
9. reliance on verbal communication
“Unsafe Communication Practices”
10. risky discharge suggestion
“Inappropriate Discharge Recommendation”
11. policy references missing form
“Non-existent Documentation Referenced in Policy”
12. document misinterpreted as official discharge
“Misleading Discharge Documentation”
13. delayed final review decision
“Inadequate Discharge Review Process”
Responses
2025-0399-Response-from-Central-and-North-West-London-NHS-Foundation-Trust.pdf ↗· Central and North West London NHS Foundation Trust
Stated action · one hour
“We have revised our approach to ensure that referrals are accepted even when patients are not yet medically cleared. This enables earlier engagement, risk planning, and support. A key performance indicator for the HLT is timely response to referrals. In the past six months, over 95% of ED referrals have been responded to within one hour.”
2025-0399-Response-from-Milton-Keynes-University-Hospitals.pdf ↗· Milton Keynes University Hospital
2025-0399-Response-from-Thames-Valley-Police.pdf ↗· Thames Valley Police