Whenever we listen to families explaining what they want from investigations, inquiries or inquests after police contact deaths, we more often than not hear they just want “lessons to be learned” so other families don’t have to go through what they have been through. Whenever we hear senior police officers (or senior people from non-police agencies) responding to adverse findings after serious, usually fatal incidents, we hear them promise to ensure “lessons are learned”.
It’s almost like two sides of the same coin: families want what senior people promise to deliver so why, in amongst all that, do we keep seeing incidents where it’s perfectly reasonable to wonder if any lessons were really learned? – and if perhaps they were, did the senior officer take the necessary steps to ensure the risk was mitigated in the future, by whatever means? And it’s debatable, isn’t it?!
Regular readers will know the quote which is coming next: said by Deborah Coles, Director of Inquest at the National Police Chiefs Council and College of Policing conference on policing and mental health in 2017 in Oxford. It’s not written down anywhere, except in my iPhone because I made a note of it as soon as she said it –
“You’re not just guilty of failing to learn lessons, you’re repeatedly guilty of failing to learn repeated lessons.”
GROUNDS TO WONDER
Following the inquest after the death of Leon Briggs, the (then) Deputy Chief Constable of Bedfordshire Police gave a press release which was one of the most appalling statements I’ve ever heard from a senior officer. Leon died for two “cause of death” reasons, the first of which was three things taken together.
- Amphetamine intoxication in association with prone restraint and prolonged struggling.
- Ischaemic Heart Disease.
The Bedfordshire Police press release (now long since deleted from the internet) emphasised the drugs Leon had taken and the underlying heart disease without mentioning once the prone restraint and prolonged struggling. Nor did it reference the five different failings which the Preventing Future Deaths report outlined as contributing to Leon’s death and amounting to neglect and which “more than minimally contributed” to his preventable death.
So what learning was taken from that incident? It’s perfectly possible, of course, that internal messaging was different to what we might think was said, given the press release – I can’t say otherwise, obviously. But the response to the Coroner, signed off by the same senior officer, made me wonder whether the inquest had been understood at all.
“It is important to keep in mind that police officers should defer to ambulance staff and clinicians on medical matters because of their specialist training and focus.”
Well, that’s pretty much why the incident went badly awry.
The officers who detained Leon under s136 MHA had a discussion with the lead paramedic who turned up about what they were going to do, and they assumed it would be removal to police custody. The paramedic, who hadn’t undertaken any kind of examination at all and who, it later emerged, had not had specialist training on Acute Behavioural Disturbance, did not contradict that assumption to redirect the officers who naturally assumed it was OK to proceed as planned because otherwise the paramedic would have said so, right?
The expert evidence at the inquest revealed two important things: 1) anyone presenting as Mr Briggs was should be removed to ED, irrespective of the view of paramedics on scene; and 2) had he been removed to ED he would most likely have survived.
So the formal response, after a promise of lessons learned, showed the lessons had not been understood to start with and they were then actively rejected by a senior officer who made public assumptions about what police officers should do and about how non-police professionals are trained.
COPYCAT INCIDENTS
Leon’s death was not the first police contact death to follow a very similar pattern –
- Mental health crisis – however caused – leading to a 999 call for the police.
- Officers attend and either arrest or detained MHA
- Restraint, potentially for an excessive period involving aspects in the prone position.
- Police vehicle conveyance to custody – usually no ambulance attendance.
- Detention in a cell, rapid deterioration and a 999 call for an ambulance.
- Rapid transfer to ED and eventually, the person declared deceased.
Various cases follow this kind of pattern and others are closely similar – Michael Powell, Sean Rigg, James Herbert, Toni Speck, Leon Briggs, Terry Smith, Douglas Oak. Other cases with enough similarities to make us think about lessons learned include Seni Lewis, Kingsley Burrell and Kevin Clarke.
This is, I suspect, what motivates Deborah Coles’s comment at the NPCC / College conference – Michael Powell was the first of those listed above to lose their life in police contact and Kevin Clarke was almost fifteen years later. I remember a senior Metropolitan Police officer on BBC Panorama after the inquest in to Kevin’s death returned a damning verdict of both police and mental health services. He was at pains to point out the Met would sit down and look at the Coroner’s outcome to ensure lessons are learned and they would work with national bodies like the College of Policing to ensure best practice.
I remember sitting at home watching that at the time and thinking, “But Kevin’s incident was meant to be one of those where the lessons from Sean Rigg’s death were learned: this was the one where we were meant to see the change.”
SO WHAT’S GOING ON?
My PhD research is ongoing – and it will be until early 2031 at least, the first point at which I can submit a thesis and so far, I have details of +220 police contact deaths confirmed with another dozen or so where I’m still working to confirm details and almost exactly half of them have a Preventing Future Death report and twenty of those confirmed PCDs are still yet to reach an inquest, so we will see more PFDs, no doubt.
Within this collection of tragedies there are various kinds of similarity, not just the “restraint” paradigm incidents, listed above. There is also the “under-responsiveness” incidents, where the police were contacted about something and their lack of response was a disturbing feature of the inquests (and that appears to have accelerated in recent years).
There are also over-arching themes across different types of mental health police contact death: failure in multi-agency protocols (where the agreements between Chief Constables and “health” either don’t exist when they should or they are sub-standard and missing detail) and in training. How many times to do we see frontline officers ripped apart in Coroners courts over things on which they have no training whatsoever? – too many and Leon Briggs was of those.
My job for the next five years or so is to get even more in to the specific detail of those incidents where I can but also to look towards why we see “lessons learned” commitments being made, but then we see copycat incidents which make us wonder and my job is to figure out why.
Awarded the President’s Medal, by 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.
Government legislation website – www.legislation.gov.uk
Mental Health Cop 