Kingsley Burrell
20 Mar 2015 · Coroner Louise Hunt · Birmingham and Solihull
A similar concern from this report was raised again 3 times later. See the linked reports.
The coroner's concerns
1. prolonged restraint and struggle against restraint
“lack of understanding of how to treat someone with an acute behavioural disturbance”
2. inconsistent police response to mental health crises
“police now only attend a mental health ward if there was a patient who is threatening staff or there is disorder on the ward”
Linked reports
Identical hazardConfidence 0.86 · high
This report
“it was clear from the inquest that there was a lack of understanding of how to treat someone with an acute behavioural disturbance.”
Later report
“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.”
Closely relatedConfidence 0.85 · high
This report
“lack of understanding of how to treat someone with an acute behavioural disturbance”
Later report
“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.”
Closely relatedConfidence 0.85 · high
This report
“lack of understanding of how to treat someone with an acute behavioural disturbance”
Later report
“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.”
Responses
2015-0472-Response-by-Association-of-Ambulance-Chief-Executives.pdf ↗· Association of Ambulance Chief Executives
Stated action · 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.”
2015-0472-Response-by-Department-of-Health.pdf ↗· Department of Health and Social Care
2015-0472-Response-by-Metropolitan-Police.pdf ↗· Association of Ambulance Chief Executives
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”