An inquest recently concluded in south London in to the death of a Canadian musician, Fraser Moore. Mr Moore had recently travelled to the UK for professional reasons and within 24hrs of his arrival was electrocuted on the live line of London Bridge train station, having jumped from a platform after fleeing the police. The Southwark coroner has indicated an intention to issue a Preventing Future Deaths report, both to Network Rail and to the police and I will update this post if / when it emerges on the Chief Coroner’s website.
Mr Moore was travelling on a train which happened to contain two off-duty Metropolitan Police sergeants who had concerns about him, given he was wearing no upper clothes and three pairs of trousers. Having talked to him, they established that he was willing to go to hospital for help and the officers stated they expected him to be helped to hospital, based on this and that he was non-violent. Two British Transport Police officers turned up, including a sergeant and almost immediately handcuffed Mr Moore and arrested him. It was whilst he was being escorted from the train that he fled and ended up on the railway line, tragically killed after coming in to contact with the live line.
The Coroner has been critical of the BTP officers and of the Metropolitan Police call handler who took a 999 call. Reading between the lines of coverage, it seems the nature of the call to the Metropolitan Police may have been at odds with the observations of the two off-duty sergeants who were actually there – the call handler had recorded that Mr Moore was accused of exposing himself, but the media coverage of the inquest states this was found to be incorrect – I’d love to know more detail about that, quite honestly. The BTP officers having turned up with that 999 allegation in mind but without knowledge of the observations by the off-duty officers, they acted extremely quickly to detain, handcuff and then arrest Mr Moore.
MORE THEN MINIMALLY
When assessing contributory factors to a death, His Majesty’s Coroners use a ‘more than minimally contributed’ test. In this case there are a number of factors listed which have been thought to meet that threshold: the failure to use the National Decision Model, inappropriate handcuffing and a failure to supervise Mr Moore appropriate after arrest, which allowed him to flee. The handcuffing aspect, for the avoidance of doubt, follows an assessment by the court that handcuffing was entirely unjustified because he had not been violent and because the off-duty Met officers could have offered information to influence decision-making that was simply not sought. Had it been, I assume they believe the handcuffing and arrest may well have not occurred.
This is a very sad case and it does highlight the impact of policing on vulnerable people in crisis. We know that uniformed officers turning can be enormously impactful, esp if they feel the need to become coercive – and I do include situations of where it would be legally quite reasonable to become coercive, as well as where it would not. It reminds of the need to proceed slowly and softly where we can and I’m left wondering why the off-duty officers were not spoken to first. There may be reasons, but we’re left to assume the Coroner mustn’t have been satisfied with them, giving the findings.
I’ve said a number of times that some of the problem we need to be fixing is the fact that police are expected to be the social agency to respond to mental health crisis – we need far more police-free options for the public, precisely because the impact of policing cannot be predicted until it’s too late to remove that impact. But in fairness to everyone, a half-naked man in crisis on a public transport system, amidst an suggestion or allegation (made for whatever reason) of a criminal offence and it’s hard to think how that could not involve the police.
So then the quality of the police response needs to be right and that’s what the Coroner appears to be highlighting on this terribly sad occasion.
Winner of the President’s Medal, the Royal College of Psychiatrists.
Winner of the Mind Digital Media Award

All opinions expressed are my own – they do not represent the views of any organisation. (c) Michael Brown, 2023
I try to keep this blog up to date, but inevitably over time, amendments to the law as well as court rulings and other findings from inquests and complaints processes mean it is difficult to ensure all the articles and pages remain current. Please ensure you check all legal issues in particular and take appropriate professional advice where necessary.
Government legislation website – www.legislation.gov.uk