His Majesty’s Coroner for Lincolnshire has issued a new Preventing Future Death report after the death in 2021 of Mr Robert GRACEY. As many of you know, I’m reading a lot of PFD notices at the moment because my ongoing research is examining them and Mr Gracey’s case became the 157th PFD I’ve found for a mental health police contact death (MH-PCD) going back to the year 2000.
NB: by no means do these cases mean the police did anything wrong at all, it merely means there was a mental health related death after contact with the police!
It was especially sad to read for a particular reason – it is the kind of contact death which has historically raised the most concern: one where officers make a detention, they use not-insignificant levels of restraint, not always correctly; they then use a police vehicle to transport the person to a police station and there is a medical consequence during this process which leads to collapse, cardiac arrest and ultimately, the person’s death.
This is the story of Michael Powell, James Herbert, Toni Speck, Sean Rigg, Kevin Clarke and Leon Briggs – to name just a few. Despite efforts made over years to including formal guidance, training and blogging(!) to ensure such situations are recognised as medical emergencies and treated as such, including by the summoning of an ambulance to the location of detention and including transportation to a medical setting, for a range of reasons which shouldn’t really need explaining in 2021 – the year Mr Gracey died.
There is plenty to be found on this website on incidents like this, including a resources page about Acute Behavioural Disturbance. That page contains links to a number of blogs I’ve written, links to deaths like Mr Gracey’s which have involved mention of ABD as well as commentary and guidance documents from medical Royal colleges and so on.
WHY ARE LESSONS NOT LEARNED?
The obvious reason why some things are not adequately learned is the lack of training officers receive on this stuff, including the lack of refreshers and updates – mental health training has never been adequate, despite promises and commitments to the contrary.
One of my additional theories is the reality these matters happen quite rarely and when they do, are scattered across various police force areas. To an individual police force, they seem even rarer still. For example, when entering the sad occasion of Mr Gracey’s case on to my research spreadsheet, it’s the very first time I’ve mentioned Lincolnshire Police at all in those 327 cases leading to what is now standing as 174 PFD notices. At the point of reading this PFD, Lincolnshire had not had ANY mental health related police contact deaths this century, never mind one specifically predicated on ABD issues. (I have since found one other more recent case.)
We might legitimately wonder about the extent to which incidents a force have never experienced before and are unlikely to experience at all are at the forefront of their concerns.
THREAT ASSESSMENT
Of course, when considering the amount of attention to pay to things like this, a force like Lincolnshire might look at a force like Bedfordshire and wonder about the problems which could be created for them if such things go awry. In 2013, Leon Briggs died in highly controversial circumstances, which also involved discussion of ABD issues. It wouldn’t be unfair to say it affected the way that entire police forces was perceived – only at the end of last year, the same Coroner who heard the Leon Briggs inquest in 2021 and issued a PFD, issued another after the death of Andrew McLeary where she lamented the contents of the Briggs PFD appearing unactioned by the time of contact with Mr McLeary.
In that sense, lightening can strike twice and given how such cases can come to dominate headlines and how they emerge every few years, it probably is worth considering such unlikely events on your threat assessment – because the impact can be huge.
And this is what I mean about lessons learned: if forces are relying upon front line officers who in rural forces may come across these matters once a career, how likely is it they’ll remember under pressure the combined impact of the learning from many forces across the country? Is it all synthesised in to something simple and / or brigaded by having specialists who can nudge and advice those who lack experience?
END GAME
All police officers need to realise – whether or not their forces trained this well or even trained it at all – anyone who is thought to be seriously mentally ill, highly affected by use or abuse of substances, and offering significant and ongoing resistance to detention (whether that be under the Mental Health Act or arrest under criminal law), it amounts to a medical emergency.
The NHS issued a “patient safety alert” in 2016 about the need for “post-restraint observations” for several hours after any significant restraint and there are examples within my research of people who have collapsed and died several hours after restraint ended and where everything looked fine as it did conclude.
Joseph Phoung was detained and restrained by the Metropolitan Police and subsequently by the NHS after admission to hospital under the Mental Health Act 1983 – there were inadequate observations of him in hospital after the NHS restraint and he collapsed, then died. Of course, my “observations” it means clinical observations – heartbeat, temperature, blood pressure, etc.. These are things which are often impossible in police contexts, for obvious reasons.
So what are the policies and procedures about determining who should be removed to a healthcare setting for such observations and who shouldn’t? … and if your force hasn’t got any or hasn’t covered this, what are you going to do if you find yourself dealing?!
You’re potentially accountable no matter your training or leadership.
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, 2026
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 