I spent February 2021 engaged as an expert witness in a police contact death inquest which was sitting in Milton Keynes – the inquest after the death of Leon Briggs in Bedfordshire in 2013. When those proceedings concluded, His Majesty’s Senior Coroner for Bedfordshire requested a discussion with me to help formulate the Preventing Future Death report, she intended to issue, as she had said she would during open proceedings. I was aware, as the Briggs inquest was coming to an end, another mental health police contact death had happened in Milton Keynes, a short distance from where the inquest was sitting and cruel irony of timing was not lost on me.
From the start, the horrible sounding incident felt all too familiar –
Last week, the inquest in to the death of Brian Ringrose concluded and the outcome is a rare one: it has been found by the jury that his death was an unlawful killing as a result of unlawful act manslaughter by a police officer, contributed to by the neglect of the arresting officers, other police officers present and NHS staff. The officer at the centre of the events, whose use of force was found to be excessive by both a disciplinary hearing and now an inquest, has already been dismissed from service for gross misconduct by Thames Valley Police. As a result of the inquest, there will now be a review of the case by the Independent Office for Police Conduct and potentially, by the Crown Prosecution Service, given the court’s overt reference to something which amounts to a criminal offence.
Let’s go back to the beginning –
ARRESTED
Mr Ringrose was arrested (reason given only as a domestic incident) in late January 2021 and because of concerns he had overdosed on prescribed medication for his mental health he was taken directly to hospital in Milton Keynes. After some time spent there, he was wrongly deemed fit for discharge by NHS staff – the jury found this conclusion was neglectful – and the police then intended to remove him to custody in connection with his arrest. We now know from the inquest, he was still suffering the effects of drug toxicity and that the NHS decision was not appropriate, but officers having reached their police vehicle after a significant restraint, they turned things around and went back in to the ED because they had concerns.
It was the physical force used in removing Mr Ringrose from the Emergency Department to the police vehicle which was the focus of IOPC concern and you can see some of the footage shown to the inquest jury on the Channel Four News coverage.
Be aware: it’s distressing content and I’m not going to analyse it very much because there’s really no need. Observing it for the first time I just exclaimed “what are you doing?!” in a tone of sheer bewilderment and that sums it up really. It’s not just that it had obvious potential to cause injury to Mr Ringrose – and it did – it’s just it was a weird thing to do and nothing I’ve ever seen or heard in police personal safety training related to what we can see. I also couldn’t believe the NHS was asking the police to remove him and then standing as passive observers as the officers did what they did.
Let me put it this way: if we had seen someone presenting to the police in the street in the way Mr Ringrose was presenting to the officers in ED, I’d have been arguing a need for legal detention in order to remove him to ED and my concern would be around acute behavioural disturbance. So why he was thought fit for discharge, I’ve no idea at all. Obviously, I wasn’t there, but the finding of neglect against NHS staff perhaps asks us to contextualise it.
MISCONDUCT
For the record: I’ve not seen those words “acute behavioural disturbance” written in connection with this and I’m all too aware of the controversial discussions around “ABD”. But if you look at the resources in the hyperlink just used, you’ll find there is plenty of “medical” material showing the debate is far from settled so I’m not yet ready to be totally dismissed by those who argue it’s “not a thing” or “group of things” – it strikes me the clinical discussion about whether ABD is a recognised medical condition or a syndrome or something else entirely is misleading. Every doctor, paramedic and nurse I’ve ever discussed this with seem to be in agreement: if you’re presenting in a way which would cause those questions to arise, there’s something going on that needs consideration in ED whether we call it ABD or not.
It’s not the police to make those judgements but it then becomes really awkward to realise in this case – as in the Leon Briggs case – NHS staff to whom the police are so often told to defer because of “expertise” seem to be making decisions which don’t survive contact with scrutiny. Not is it the first inquest to have to look at difficult issues where agencies are present together and their distinct professional decisions are affecting the other agencies – indeed, the Leon Briggs inquest was a good example of the complexity which emerges about who is a lead decision-maker or who takes primacy. It looks like we’ve got this here, too:
NHS decision-making to discharge Mr Ringrose as the background to the use of force; NHS decision-making to standby and not interject or object to the treatment. The NHS is currently declining to state whether any staff members are subject to professional practice or disciplinary processes and this case is something Dr David Baker from the University of Liverpool noted in his 2016 book on Deaths After Police Contact (2016): NHS background or context to police contact deaths. There have been a large number of them and again, the inquest for Leon Briggs is another example. As are the deaths of Sean Rigg (2008), Seni Lewis (2010), Kinglsey Burrell (2011), Kevin Clarke (2015), David Stacey (2017) and Nigel Abbott (2018) – and that’s just to name a few and intends no disrespect to others.
HISTORIC VERDICT
So again we have to wonder what will be done and what will be learned in partnership, about this latest tragedy. This stuff is literally the business of the PhD I’m now undertaking so no doubt it will be one of many cases studies and examples I have to use in the next few years, not least because of the unique verdict in a mental health PCD.
Finally, there’s something to be said here for the lack of coverage this particular case has received – the inquest finished days ago and it only made its way to the BBC News website on 28th April.
I remember press releases during the Leon Briggs inquest by the campaign from Inquest who made observations about ‘unlawful killing’. You may not be aware, the law changed a few years back on the standard of proof required for juries to be able to return such a conclusion. Previously, unlawful killing required the criminal standard of proof – beyond all reasonable doubt. Now, it requires the civil standard – on the balance of probabilities. Inquest pointed out, if the Briggs jury had returned a verdict of unlawful killing it would have been the first under the new standard. Perhaps I’m wrong but I don’t recall any other unlawful killing verdicts since the inquest for Mr Briggs so is this the first one?
It’s not just for that reason I would have expected to see more coverage of this but by way of example, the redoubtable Simon Israel from Channel Four News has covered this hearing as he often does cover controversial PCDs but there was no BBC coverage of the inquest outcome, for example – at least not at the point of publication and I can’t find press released from Inquest or from Bhatt Murphy (the family solicitor).
PRESS RELEASE – THAMES VALLEY POLICE: 24/04/25
The police have a habit of taking down press releases from their website after a short period, so what follows is a cut-paste so it can be read to see context to what is above.
Today (24/4) following a jury inquest a narrative conclusion has been given in relation to the death of Brian Ringrose. The inquest concluded unlawful killing unlawful act manslaughter by a former Thames Valley Police officer. This was contributed to by neglect by one officer who was involved in the restraint. Two other officers and medical staff who were also present contributed by neglect, as they did not intervene to ensure the welfare of Mr Ringrose.
On 27 January 2021, Mr Ringrose, who was aged 24 at the time, was medically discharged into the custody of our officers at Milton Keynes hospital. Officers then attempted to take Mr Ringrose back to custody but had to restrain him in the middle of a busy accident and emergency department in the view of medical professionals and the public. After a prolonged period of restraint, officers took him to a custody vehicle; officers then realised he required immediate medical attention. He was taken back into the hospital and placed in an induced coma. He sadly died on 2 February 2021.
Assistant Chief Constable Christian Bunt said: “This was a tragic incident and our thoughts remain with Brian Ringrose’s family and friends.
“We are deeply sorry, and truly saddened, for what happened to Mr Ringrose. It is apparent that Mr Ringrose was still suffering from the effects of drugs toxicity and had been discharged by the hospital to be taken back to custody by officers.
“It is clear that how our officers dealt with Mr Ringrose was not acceptable and did not follow approved training. Mr Ringrose was subjected to excessive force through restraint by a former officer, which was completely unacceptable. The technique used, was and is not, an approved restraint technique and did not follow the force’s operational guidance or approved practices. Additionally, the care and monitoring of Mr Ringrose during the prolonged restraint was wholly inadequate and again did not follow operational training and guidance.
“Following a gross misconduct hearing with an independent chair, the officer who restrained Mr Ringrose, was dismissed without notice, another officer involved was given a final written warning for five years.
“There is nothing that can bring Mr Ringrose back, and we offer our sincerest apologies to his family after he died in these circumstances. Whenever a significant incident happens within the force we will always look to review our policies and training. We have reviewed our current practices alongside the Independent Office for Police Conduct, who have made a number of recommendations, which have been implemented fully.
“We are aware that His Majesty’s Coroner is likely to give further direction to the force and we will of course take any actions required of us”.
A Preventing Future Deaths report was published in August 2025.
Notes to editors
- A referral was made to the Independent Office of Police Conduct (IOPC) following the incident. The IOPC investigated the incident independently and found grounds for gross misconduct.
- Following a gross misconduct hearing on 27 July 2024, in front of legally qualified independent chair Mr Harry Ireland, two officers were proven to have committed gross misconduct.
- A now former PC was found to have breached the Standards of Professional Behaviour with regards to Use of Force and Duties and Responsibilities, in that he restrained Mr Ringrose with his arms above his shoulder, which was not necessary or proportionate. Additionally, he failed to monitor Mr Ringrose properly throughout the restraint. This amounted to gross misconduct. He was dismissed without notice.
- A PC was found to have breached the Standards of Professional Behaviour with regards to Duties and Responsibilities, in that he failed in his duty of care to Mr Ringrose. This amounted to gross misconduct. He was given a final written warning to last for five years.
- Three other officers were given reflective practice in relation to this incident.
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, 2025
I am not a police officer.
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.
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