The Deadly Equation

No big introduction, just crack on and read this.  Written by Dr Jenny HOLMES, a Force Medical Examiner and Psychiatrist.  Not all doctors appreciate what she has to say.  Also bear in mind, this recent post by @NathanConstable – how many more deaths will we read about, before the penny drops? 😦

Today I have been at a conference full of eminent people in Manchester, discussing Policing and Mental Health. Police, Doctors, Psychiatric Nurses and many others along with those who have carried out important reports such as Lord Adebowale (who reviewed how the Metropolitan Police deal with mental health in the wake of several deaths and serious incidents). Lord BRADLEY was there to update on the progress of a National Liaison and Diversion service. And Drusilla SHARPLING who produced the HMIC report ‘A Criminal Use of Police Cells’ looking at s136 detentions

Drusilla said that having a person in a Police cell under s136 of the Mental Health Act who had not committed a crime’ was wholly unacceptable. All day we talked about how to make this stop.

The case of 39 year old Leon BRIGGS who died after being taken to a Police cell under a s136 detention by Bedfordshire Police last week was mentioned.  Michael and I went for a drink afterwards to discuss all things Policing and Mental Health then as we parted company and I checked my phone I found out it had happened again via an announcement on Twitter by the IPCC. Yet again a young man of 33, Terry SMITH, detained by Surrey Police under s136 and taken to a Police cell had become ill and died.

Two cases in two weeks. Young men in their 30s. Detained by the Police to get them a mental health assessment and help. Yet somehow dead. We cannot comment or speculate beyond what is in the public domain but here are two tragedies that perhaps could have been prevented and my thought are with the families

It may be oversimplifying things but I have begun to think of these cases as being a deadly combination of factors which contribute to the risk of death:


Looking at these in turn;


Mentally unwell people have poor physical health. We know that someone with a major mental illness such as schizophrenia dies on average 20 years before their peers. This is due to a combination of factors such as heavy smoking (psychiatric patients are some of the heaviest smokers left in society) leading to early emphysema and heart disease. Drugs such as olanzapine can cause people to gain large amounts of weight which can lead to diabetes. Some psychiatric drugs also alter the electrics of the heart making it more likely to stop suddenly.

The mentally unwell often misuse drugs and alcohol leading to further ill-health. Alcoholics can have oesophageal varices, massive swollen blood vessels in the gullet, caused by liver cirrhosis and waiting to burst and cause death at any time. Many people without mental illness also misuse drugs and alcohol.

Disturbed behaviour can arise in the context of intoxication alone, many stimulant drugs such as cocaine, amphetamines and the many ‘legal highs’ can produce symptoms such as a racing heart, raised body temperature, sweating, hallucinations and aggression. By the time the Police get involved the person’s body is often under immense strain, either from chronic illness and/or the acute effects of drugs and/or alcohol


The Police have a situation of risk to deal with. They are trained to deal with people who pose a risk to the public and to a lesser extent those who pose a risk of harm to themselves. They are not trained to assess medical risk. If I as a doctor was faced with this person in the street I could not  fully assess the medical risk either. They are unknown to me, probably in a too agitated state to communicate and I have nothing more to go on than a visual inspection for injuries and obvious physical illness.

When the Police turn up its frightening. One or more blue lights screech up. Officers in protective clothing get out, on their belts they have batons / CS gas / pepper spray and increasingly a TASER.  They approach the person, they do try verbal de-escalation but without success.  Trust me, as a doctor who prides themselves on their verbal de-escalation skills that when I see people like this in Police cells, I often can’t de-escalate it myself.

The Police put a hand on and the person tenses up.  Things can escalate rapidly.  The Police have extensive training on the safe, proportionate and least restrictive use of force but force it still is with pain compliance techniques.  The person is already frightened, many people who experience hallucinations and delusions whilst intoxicated or mentally unwell feel very frightened and paranoid and fear of the Police is often a feature.  Things can escalate rapidly.

What are the medical risks? Well firstly we have a person who we know may be in poor physical health. Acute intoxication carries a risk of sudden death. The restraint process can bring a person from standing to the floor, often with a bang.  NICE guidance states that falls from heights over a metre ( and most people are 1.6 metres at least) carries a risk of serious head injury and a CT scan should be considered. Prone restraint (where the person is lying face down) can be particularly dangerous if prolonged. This is the position people are put in to apply handcuffs to the rear. Add obesity to prone restraint and the risks of asphyxiation are even greater.

The person’s body is absolutely flooded with chemicals such as adrenaline, perhaps through the effects of drugs and alcohol and certainly through fear. The body’s chemistry begins to change, perhaps with the blood becoming overloaded with potassium which can stop the heart. We know acute stress can cause heart attacks. A person who already takes medication that affects the heart’s electricity is doubly susceptible.

As way of comparison when people are restrained by psychiatric staff a nurse trained to Intermediate Life Support is supposed to monitor the medical condition and a doctors review should be sought urgently.


I am no expert in this. But I know that such persons often get transported in caged vehicles for the safety of the officers. By this time the person is controlled but will have handcuffs and possibly leg restraints ( Velcro straps) It can be difficult to maintain a sitting position in a caged vehicle and the person may get into further awkward positions aggravating the risks of positional asphyxia. Particularly if they are drunk. The worst near miss I saw of positional asphyxia was a drunk teenager, overweight, who had fallen asleep on the toilet with his head slumped forward, this had obstructed his airway and he was blue ( we woke him up and he was fine).

There is no ability to monitor medical condition in Police transport and no one trained to do it and it is usually a quick trip to the Custody Suite. In rural areas the distances can be substantial increasing the risks.


Once the person gets to Custody hopefully the restraint will be removed and things get a little safer. However some damage may be done; injuries sustained during restraint, a heart under strain, abnormal blood biochemistry. Custody Suites do have nurses and access to doctors. Some Custodies have a nurse there all the time: with most it is a mobile service with a response time of up to an hour in a City and much longer in rural areas. The Custody nurse comes armed with a blood pressure machine, a temperature, a saturation monitor, a blood glucose machine and that’s it. There might be some oxygen available and all suites should have a defibrillator which custody staff are also trained to use. We can’t do blood tests/x-rays/ECGs (heart tracings)/CT scans etc. We can’t drill holes in someone’s skull to remove the blood clot that is about to kill them, caused when they fell to the floor.  We are not an Accident and Emergency Department. And if we decide to transfer the person to hospital we have to wait for an ambulance involving more delay.


I have blogged before about how these cases, if not starting as a medical emergency, can rapidly become one. The two deaths tell us that alone. November 2013 should never happen again. The answer is simple to me – get Health into the pathway right at the early stages.

I met PC Alex Crisp today who is rightly proud of the new Leicestershire Street Triage Scheme. He would argue that if he had turned up with a psychiatric nurse that the situation may have been different and they could have de-escalated it and kept things safe. That may be right but I know from years as a Police Doctor (FME) that many of these cases cannot be quickly verbally de -escalated. I have spent many a long night trying to engage a highly agitated, intoxicated person in a cell.

I do have doubts about the street triage model because of the physical ill health risks and was glad to hear that Alex would have no hesitation in summoning a paramedic to assist in these cases.

These cases must have a rapid paramedic response at scene and Health transport supported by the Police as necessary. I believe they should all then go to Health Based Places of Safety and hope this blog illustrates why: even without taking into account Drusilla SHARPLING’s views that from a legal and ethical perspective a cell should never be used

In eighteen months’ time my eldest son hopes to go to University.  The late teens is a time of risk for men’s mental health and also a time when they can drink excessively and experiment with drugs.  If my son is found one night in a highly agitated and intoxicated state in the middle of the road by a Police Officer I would be grateful if they applied discretion and applied s136 instead of arresting him, perhaps jeopardising his future career.  I will jump in my car and drive through the night to pick him up from a hospital and take him home and look after him.

I don’t want to arrive at the hospital and be directed to the mortuary – let’s stop this deadly equation ever happening again.

IMG_0053IMG_0052Winner of the President’s Medal from
the Royal College of Psychiatrists.

Winner of the Mind Digital Media Award.


11 thoughts on “The Deadly Equation

  1. When are the legistlators and the NHS going to get it? Ive had a near death in custody in the transport phase of a 136. I had all my kit seized and was told the incident was being referred to the IPCC. All I wanted to do was get them help at a 136 suite and my career is on the line….

  2. Billions is available for failed banks but mental health assessments are still being carried out In prison cells. Isn’t there a human rights issue here?

  3. I just want to say thank you for these posts. I was a chaplain to the police in Warwickshire and sad to say rather oblivious of all this. No one ever told us and no one ever spoke about it. Ignorance was not bliss. Having relied early from ministry on grounds of ill health with quite severe clinical depression from which I am hopefully emerging, should the opportunity to go back to chaplaincy ever arise again I would concentrate so much more on the mental welfare of the police. The only “good thing” to emerge from this which has had a huge impact on my family is that one day I will be able to use this experience to help others. Brian Jones, Coventry 07587187049

    Keep up the good work.

    Sent from my iPad


  4. I am Alison Orchard and my son, Thomas, who had schizophrenia, died in October last year after being arrested by police in Exeter city centre and being restrained inappropriately.

    I am devastated about the two deaths this week. Nothing can bring Thomas back but we are determined to do all we can to stop it happening again. However, the investigative and legal processes are taking so long and are so wearing.

    We are starting a blog (it’s very basic compared with yours!). Do search for ‘Justice for Thomas Orchard’. We expect to be announcing what charges the CPS are considering in the next couple of weeks but we know that a decision won’t be made until the spring of next year.

    Thank you for caring and bringing these issues to the public attention. Thank you, thank you.

    1. The desire to do something to prevent these deaths is very strong in all of us who have lost loved ones. I am Tony Herbert, father of James Herbert, who in June 2010 was detained under Section 136 of the Mental Health Act and restrained. James died and you have mentioned his death in some of your articles.

      I join Alison in giving you my profound thanks for caring and for providing such clear insight through your Blog. The recent deaths of Leon Briggs and Terry Smith have filled us with despair. More families going through the same agony. As you said last week “Here we go again”.

      Your compassion, intelligence and spirit are really important to all death in custody families. You speak the truth and you do it from a well-informed perspective.

      Thank you.

      1. I thank you both for your comments, truly and for the courage it must take to write them publicy on a police blog after all you’re going through.

        I can only imagine how hard it must be to hear of yet more terrible events that must trigger the most profoundly dreadful emotions – I say that as a parent who can only fear what you have been through. I have the questions that you have and only hope here to help others find answers that reduce risk.

        Some of these answers will be “police” answers – some “NHS” and some about society as a whole but there is much that individuals can do.

        I thank you both, again.

      2. I don’t see myself as a courageous person! But I do like to think of myself as an honest and kind person! I want the truth to come out about how Thomas died and I can only hope that the IPCC and CPS are doing a good and thorough job to get to those truths. If there have been offences committed, I want them to be addressed with transparency and fairness; the police should not be above the law how ever hard their job is.

        At the moment, however, I don’t care whether individuals are convicted or not (I reserve the right for that view to change once I’ve seen the evidence), More than anything, I want these deaths to stop; it’s the only thing I can now do for Thomas and his memory. There have to be lessons learnt. I am convinced we will get nowhere if we create an ‘us’ and ‘them’ division because the two sides just retreat into opposite and extreme positions, communication is defensive and the most vulnerable in our society continue to be the victims of the fall out.

        Again, thanks for bringing the issues out for discussion.

      3. Having met many families who have lost loved ones in State Custody, they seem to me to feel very much as Alison has expressed. We want mistakes acknowledged and police officers and the forces held FAIRLY accountable for their actions but most of all we need the lessons to be learned. James was a Section 136 detainee who died as a result of his struggle against restraint. Our genuine experience of the police force up to and including his inquest was that they simply would not acknowledge catastrophic errors, despite the evidence. The IPCC are now reinvestigating and there are hopeful signs coming from the police force that they are prepared to REALLY face what happened and to learn from it, but our experience mirrors that of many families over the years. A failure to learn the lessons and the fact that vulnerable people are still being restrained to death is something that I find incredibly difficult to tolerate.

        You are the courageous one in that you do not go along with the pack but have thought deeply about a subject that you really understand and you express your ideas honestly, clearly and in a way that helps your colleagues. Your blog really gives me hope that we ( the State) will stop killing vulnerable people. I just wish it could stop now and it has been an awful two weeks. Rest in Peace Leon and Terry.

    2. Thank you, Alison – please see just below, my comment to both you and Tony HERBERT. I’d be grateful for the opportunity to support your blog if be kind enough to let me publicise it a bit on here and other social media?

  5. It would be great if a mental health crisis could be seen as a medical crisis needing police support. The NHS usually seem to see it as a police problem which they reluctantly have to get involved in. Then you get into the debate with MHS about is it a mental health problem or just people being annoying which MHS seem to think gets them off the hook altogether.

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