Leon Briggs
4 Oct 2021 · Coroner Emma Whitting · Bedfordshire and Luton
This report repeats 2 earlier warnings, and was raised again 2 times later. See the linked reports.
The coroner's concerns
1. lack of communication and miscommunication
“A lack of communication and miscommunication throughout, in particular by Bedfor”
2. inadequate monitoring of detainees subject to restraint
“inadequate continuous risk assessments and monitoring of [the deceased] resulting in a failure to recognise when [the deceased] became in need of urgent medical attention in the cell”
3. insufficient training for police and ambulance crew
“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.”
Linked reports
Closely relatedConfidence 0.85 · high
Earlier report
“lack of understanding of how to treat someone with an acute behavioural disturbance”
This 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
Earlier report
“College of Policing issued a training package at the end of 2016 to all Police Forces on ABD.”
This 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
“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.”
Later report
“There was an evident lack of knowledge and/or concern on the part of the attending officers of the requirements of the Mental Capacity Act (MCA) 2005, particularly when it came to the decision to use force against and restrain [the deceased].”
Closely relatedConfidence 0.90 · high
This 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.”
Later report
“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.”
Responses
2021-0330-Response-from-Association-of-Ambulance-Chief-Executives_Published.pdf ↗· Association of Ambulance Chief Executives
Stated action · 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”
2021-0330-Response-from-Bedfordshire-Police_Published.pdf ↗· Bedfordshire Police
Stated action · this year
“A revised policy is due to be signed-off this year.”
Stated action · 29 October 2021
“The Chief Constable met with the National Lead for restraint's team, headed by Deputy Assistant Commissioner , on 29 October 2021.”
Stated action
“The College of Policing has issued updated Authorised Professional Practice (APP), and provides 'College Learn' (formerly NCALT) with regards Officer [name redacted], First Aid and Mental Health Awareness.”
Stated action · July 2021
“The National Lead for Mental Health informed Bedfordshire Police that at the NPCC National Forum in July 2021, an update was provided by Chief Superintendent of South Yorkshire Police, who is working alongside Dr (Medical Director for West Yorkshire Metropolitan Ambulance Service, and Consultant in Emergency Medicine and pre-hospital care at Mid Yorkshire Trust) on a national ABD policy.”
2021-0330-Response-from-East-of-England-Ambulance-Service_Published.pdf ↗· Association of Ambulance Chief Executives
Stated action · 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.”