At the start of this week, an inquest opened in Nottingham after the death in 2022 of 26yr old Kaine Fletcher. Evidence was heard about the cause of his death and has now been adjourned until later in July when evidence will be heard from police officers, paramedics and others who were involved in the incident response which led to Mr Fletcher’s death at the Queen’s Medical Centre, Nottingham. It has been a very distressing inquest and not just for Mr Fletcher’s family and friends – it was reported the jury spokesperson cried as the conclusions were returned and I can see why.
This thing was a mess, I’m afraid.
I had this blog mostly written not long after the inquest began and early stages of evidence had been heard because it included quite a lot of detail. I was waiting for the conclusion to “top and tail” it with detail of the main messages but in the end, two things happened in the final week which caused me to have to delete most of it and do a major re-write –
- The Coroner issued a PFD notice before the evidence was concluded – a rare thing to do, indicative of urgent concerns about the lack of appropriate joint policies and procedures for s136 Mental Health Act processes and the subsequent lack of knowledge of professionals involved in them.
- The jury’s conclusions were far more damning than I had been able to anticipate and they reach from the operational officers who attended right the way up to senior ranks of Nottinghamshire police – after all: whatever the problems of the operational response, it was contextualised and frame by senior officers, as we’ll see.
Mr Fletcher was obviously a well known and hugely popular man. When searching for open-source material to research this post, I couldn’t help notice the countless Facebook posts on the Nottingham Live news feed from people who knew him well or had met or worked with him. They were all very warming messages to read and I hope they bring some solace to his family at what must be a very difficult time: the opening of his inquest is close to the third anniversary of his death, on 3rd July.
INVESTIGATION
Mr Fletcher’s death has been on my database of mental health police contact deaths (MH-PCDs) for a while – a 999 call was made in the early hours of 3rd July 2022 to Nottinghamshire Police by family members who were concerned he “may have taken drugs” and was having a mental health “disturbance”. Officers having arrived, it appeared to have a negative impact on Mr Fletcher’s demeanour and when he left his home address and was outside, officers detained him under the Mental Health Act and restrained him to prevent him causing himself harm. It was reported he was resistant to detention, no doubt frightened and confused, and that he was doing a range of things to hurt himself, from banging his head on the police car window and biting his own fingers.
Having arrived at the Queen’s Medical Centre – a major trauma unit – officers had to remain with him to help NHS staff manage the situation and he deteriorated whilst there until eventually suffering a cardiac arrest and being declared deceased.
The IOPC completed its investigation in to Mr Fletcher’s death in April 2024 and shared their report with his family and with Nottingham Police and the Coroner, stating they will publish their findings at the end of the inquest but as the point of publication, there is nothing on their website. The officers involved were treated as witnesses throughout the investigation, notwithstanding the strength of the jury’s outcome. Now of course, some people question the actual independence of the IOPC whilst many serving officers will argue they are as likely to go after officers disproportionately. It strikes me it is almost impossible to imagine a situation where everyone thinks the IOPC is doing the best job they possibly could so I strongly suspect the second best thing can only be for everyone to think they’re doing a bad job.
This is my own point of emphasis in this post: this is another inquest which seemingly repeats the mistakes of history and it harks back to the kinds of restraint related deaths we saw around fifteen or so years ago. Mental heath and restraint related s136 detention with transport by police vehicle and very sadly, I noticed only this morning the IOPC have launched another independent investigation in to a similar-sounding s136 MHA death in Lancashire earlier this month.
CAUSE OF DEATH
Mr Fletcher’s caused of death was described by the pathologist as “complicated” and was given as –
“The physiological effects of physical exertion combined with the toxic effects of cocaine and other substances.”
The opinion given in evidence by the pathologist was specifically that restraint on its own did not explain Mr Fletcher’s death; drug consumption on its own did not explain his death either. The major thing which struck me, given the cause of death cites physical exertion, is that no-one called an ambulance to the location for thirty minutes.
Now: we know from s136 statistics in Nottinghamshire that –
- Ambulances are not involved in s136 detentions just 12% of the time.
- Of those occasions where a police vehicle was used, 23% of the time it was because no ambulance was available and
- 35% of the time it was because officers did not request an ambulance.
- I did also wonder whether it would be argued in Mr Fletcher’s case that risk assessment would determine an ambulance was inappropriate for safety reasons, because that happened 37% of the time.
It’s worth people in Nottinghamshire looking at this: under-involvement of the ambulance service is amongst the worst in the country but one did turn up after eventually being requested.
EARLY PFD NOTICE
His Majesty’s Coroner for Nottinghamshire took the fairly rare decision to issue a Preventing Future Death report before she finished hearing evidence. It is because of her concern about confusion between Nottinghamshire Police and East Midlands Ambulance Service about agreed procedures for s136 Mental Health Act. In the notice, HM Coroner Alexandra Pountney states –
“The police and the ambulance service do not share an understanding of which policy they are expected to adhere to and whether there is a joint local police … persons detained under s136 of the Mental Health Act 1983 are some of the most vulnerable in society. Their liberty has been removed, and they are reliant upon state agencies to protect their right to life.
I am extremely concerned that there is no joined up thinking, or understanding, between the police and the ambulance service as to which policy and which working standards apply when furthering the protection of that right. I am concerned that this lack of basic understanding of policy and working standards by emergency services, if it persists, poses a risk of preventable future deaths.”
She’s not wrong – reading this, knowing similar failings go back beyond the 2003 police contact death of Michael Powell in Birmingham, are very troubling. Why can’t we learn lessons and make sure hard-won learning is cemented in simple, up-to-date policies and procedures, agreed across the agencies? I don’t actually think it’s hard to do, at all – it just takes a commitment to doing it and I’m left wondering whether someone was asleep at the wheel given a major police force and ambulance trust don’t have a clear, basic agreement about s136 business which should have existed since at least the 1999 Code of Practice to the Mental Health Act.
Someone in Nottinghamshire Police on Monday morning has an awful lot of work to do after a second PFD notice was issued – not many inquests see such things and cumulative impact of both is really quite damning. But one important question will be whether they have the appetite for getting the basics squared away in this “Right Care, Right Person” world.
Awarded the President’s Medal by
the Royal College of Psychiatrists.
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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.
Government legislation website – www.legislation.gov.uk
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