Six Missed Chances

I want to ask you to put all your preconceptions to one side for the five minutes it will take to read this and for a short while afterwards. If you use the links below and read the Six Missed Chances report from the IPCC, which is published today and follows the death of James Herbert in Somerset in 2010, your instinct may be that some of it is not practical. I fully and freely admit, that was my instinct when I read a draft copy of it last year and I’ve had to really think about this because it’s challenging us to think again about whether we can think differently. I suspect and do understand some officers may wonder whether the IPCC actually understand police work at all or live in the real world – social media shows these questions are emerging as people read the media coverage that is coming out. I would suggest they read the report instead, because it’s not the longest thing of this type you’ll ever see.

A man died here – the report merely asks the service to think again about whether we could think or act differently: in how we respond to crisis incidents and consider or undertake restraint as a tactic. I admit I don’t think it’s a big ask and would argue we all owe it to James and all those who have been affected by his death to think again about whether it’s possible for us to think differently about the use of force in handling a mental health crisis.


Tony Herbert, James’s father, spoke earlier this month at the NPCC / College of Policing conference on mental health. I admit to sitting there, watching this man speak for his dead son to an audience of people doing the same job as those who were with him in the hour or so prior to his death. I sat there thinking about Harrison, my “nearly-13” year old son, simply unable to conceive of any situation where he has already lived more than half of his life and not with us in another 13 years – I admit I dream some non-specific dreams about the life he may be able to lead.  And there was Tony, having lived that nightmare, saying out loud that he doesn’t think officers acted maliciously and that he is absolutely confident no officer came to work that day aiming to hurt anyone. But regardless, James died in police custody and it appears there were lots of complicated reasons as to why he did. These issues are not just about frontline police officers: it is about senior police officers and their responsibilities around policies, joint protocols and effective training; it’s also about healthcare partners who must be able to deliver on their side of the deal: the ambulance service, the emergency departments and the mental health system.

The report is about trying to help the police understand how those various factors combine and need to be addressed in their totality – unless I’ve entirely missed the point. It’s about asking whether the police – at all levels – can think differently, given that James’s death is not the most recent death in police custody involving someone in mental health crisis and the lessons it offers are not unique to James’s circumstances. You can look at the death of Thomas Orchard in Devon in 2012, Sean Rigg in London in 2010 and many, many others and see similar issues: this is about frontline police officers, but it’s not JUST about them – it’s about creating a context in which they stand a chance of thinking that the ideas in this report are possible.

  • As long as they believe it’s unlikely an ambulance can turn up at all, the more likely they are to think we should “get on with it” by conveying people in police vans.
  • As long as they are told by joint protocols that people who are resistant, challenging or even violent should be detained in custody, they are more likely to go to custody.
  • As long as they hear that “A&E is not a place of safety”, the more likely they are not to take someone there who needs it for emergency psychiatric reasons to which published medical guidelines relate.

We could go on.  Last night, I did some Google searching of MH trust websites, in an area of England where I know the ambulance service will not agree to comply with the Crisis Care Concordat requirements for ambulance services, where Place of Safety services still insist that anyone who is intoxicated, aggressive or under 18yrs old still cannot access the NHS Place of Safety and where A&E are openly resistant to the idea of anyone going there purely in preference to custody. So the toxic circumstances that existed in Somerset in 2010, still exist in some parts of England in September 2017. Just imagine if there was another death in custody where officers had used a police vehicle to convey someone to custody?!


The report itself says what it says: it doesn’t necessarily say what the media are purporting to have it say. Read it for yourself, if you’re going to get in to the discussion: it’s less than 40 pages so anyone with a specific interest in this won’t have to spend too much of their time – and if you do just you want a summary, read the IPCC press release, because it covers the salient points. But what this report does NOT say, contrary to the BBC News headline, is that “the police should not restrain people in custody with mental health problems”.

No, no … the report simply did not say that!

It acknowledges in various places that the police have difficult judgements to make and that restraint when it is used, merely needs to be proportionate to the situation. All over social media this morning, officers are putting up hypotheticals about scenarios they’ve dealt with, then reflecting on the (inaccurate) BBC headline that restraint should not be used as if to ask, “So what do they want us to do here, then?!”  This is why it’s important to take time to read this and reflect: the IPCC are not saying officers should never restrain: but to justify inflicting a fatal restraint on someone, you need to be managing a pretty serious level of risk and threat to justify that as proportionate.

We need to remember this: a man died here and a family’s life is still in turmoil as processes connected to this concluded only this month, more than seven years down the line. My own view is we owe it to James’s parents and family to take a small amount of time to think again about whether we can think differently. We absolutely need to accept, if nothing else, that the strategic and partnership context in which the operational decisions were taken, was inadequate. I was formally commissioned by the IPCC a few years ago to review the multi-agency s136 policy in play at that time. It is correct to say, as mentioned in the report, that if any police force had asked my advice about the policy, I would have advised against signing it.

No-one is saying that the ideas in this report will make a difference in every case, because this is complex stuff with fast-moving factors and no-one is saying it is never relevant for officers to use force and we know, when we do, that is sometimes on people who are medically very unwell. But we do need to show we’ve not just defensively rejected the ideas amidst an immediate sense that it’s not practical and then, this may make a difference to just one or two families who will not have to experience the utter trauma of losing a son and perhaps that can afford Tony and Barbara a small measure of peace.

I just think we owe all them at least a small amount of our time to think on it.


And what is there to disagree about?! —

  • Prioritise safety and wellbeing.
  • Try to de-escalate things to prevent or reduce the use of force.
  • Aim to contain, rather than restrain, wherever possible.
  • Ensure robust, effective local protocols across police / NHS so we know what to do and when.
  • Proactively share and better disseminate information about vulnerable people to influence all of the above.

I’m not sure we’re allowed to disagree with this, are we?!  Most of it is the just law of the land in operation and it always has been but it will be really easy to look at this report and say, as Avon and Somerset Police has: much has changed since 2010. New national guidelines for the police on mental health, new training packages, new national standards; a Crisis Care Concordat, some street triage and liaison and diversion; nurses in control rooms, nurses in police cars, nurses in A&E departments, greater collaboration – LOTS of meetings. My biggest fear is that most of those things don’t actually address the key issues which emerge during incidents which can lead to deaths in police custody (or suicide following contact) incidents: if a police officer believes they must get ‘hands on’ with a vulnerable person, how do we bring everyone together in quick time and what are the pathways we’re choosing from?

This is what was missing in 2010 (and in 1998, when I joined), this is what is still missing in too many areas today – this is what street triage won’t touch because, frankly, they will almost usually not be there to take a view on what is necessary. And faintly, whether or not an NHS service provider does or does not agree or aspire to what the Crisis Care Condcordat sets out, the legal responsibilities for police officers remain. Where s136 of the Mental Health Act, assuming all attempts to de-escalate have been tried, someone presenting like James needs to be removed only to an A&E department because his presentation to the police was such that any number of things could have been going on, medically, and as a police healthcare doctor once said, “Officers seem too keen to try and medically manage challenging patients in custody that no junior doctor would go anywhere near without bleeping for a consultants.”

We have a first aid-certificate – we are police officers – we have limits. It’s not illegal to call for an ambulance – it’s not illegal to take someone to A&E if that’s genuinely where you believe they need to be. Seek help – both for the patient you’ve detained and yourself because you will usually lack the skills needed to know what’s right. And if the worst does happen, you can look Mr Herbert in the eye and promise him you did nothing less than your very best.

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, 2019

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 –


7 thoughts on “Six Missed Chances

  1. Society is going to have to come to terms with some cold hard realities. If people want to be nurtured from cradle to grave then they are going to have to be prepared to fund these services from their taxes.

    Increasingly people expect the state to pick up the ball and the state is underfunded, mismanaged and trying to be all things to all people whilst tiptoeing around ridiculous PC and multicultural agendas.

    All these issues exist while the BBC deliberately preach dependence and ignorance as if they were cardinal virtues, is it any wonder there are unfortunate victims where the system ‘fails’. In reality everyone is only one bad decision away from a mortuary slab, no ‘system’ can prevent people from making bad choices.

    The police face an impossible task, they are expected to be a Swiss army knife of social interactions and yet be exemplars in every discipline all at once. I meet a fair amount of front line police and almost all of them are very nice people doing a tough and largely thankless job with scant resources, are they sometimes out of the depth? Certainly yes. What else can we expect, Theresa May wants everything done for tuppence by the least qualified person they can find to bear the responsibility. Until this thinking from central government is reversed things will not improve.

  2. I’m not sure this helps. At all. The decisions are still with the officers and whichever ‘option’ they choose they are liable for criticism. The safest would seem to be to take the patient /prisoner to A&E and have them tell you they can’t or won’t help. Then at least you can tell the Coroner / IPCC that you did. Sadly I was doing exactly this in 1990 in South London.

  3. I have some strong views about the IPCC, but found this report to be quite reasonable.
    It is hard to argue with their points. Each one has its challenges but with help and multiple agencies involved they are not insurmountable. As police alone we can’t manage to do it. But the reality or the perception is that we are the only ones trying.
    And while we try, we are doing so while demoralised, tired and understaffed. This harms critical thinking and numbers reduce options and flexibility.

  4. Having read the IPCC report with an open mind, I don’t disagree with much of its contents. I will however pick up on the recommendation about officers de-escalation skills. There seems to be a focus on James’ mental ill health and lack of comment on James’ use of psychoactive substances on the day in question. As an experienced custody officer I all too often see this toxic combination and how notoriously challenging it is to de-escalate a situation where someone is try to harm themselves whilst “high” let alone when they are mentally unwell in addition. I cannot recall a time from personal experience when verbal reasoning alone has been successful in such circumstances to prevent harm to the individual. I hope that as we gain understanding of the effect of these substances then we will also become more adept at dealing with those people who choose to take them.

    1. We (James’ family) don’t believe that the substances would have stopped James from responding to deescalation,had it been tried. You will have read in the report how James came into contact several times during the day with police officers and responded to them. Only half an hour previous to his detention, he had been in conversation with a PCSO who could not engage with him half an hour later and we know that James had not taken any substances between the encounters or just before the first. The kind of psychotic episode James was having was not unfamiliar to his family– and with perhaps ten or twenty minutes of talking he would normally come around. I do not dispute for a moment what you are saying about your experiences as a custody officer, only that in James’s particular case, we really don’t believe that the substances he had been taking made him high at the time of his detention, that in using the substances, he was self-medicating his underlying illness. We think it likely that the last time James had taken any of the psychoactive substance was quite early in the morning of 10th June 2010 and that he was not intoxicated when he was detained. The toxicologist at his inquest, could not really throw any light on that either way.

      Sadly, we will never know whether our analysis is right but working it the other way, had the drugs been directly seen to be directly affecting James;s behaviour in the way you describe, then perhaps the officers might have approached him differently, as the police officers said in their statements that it had not occurred to them that James was high on drugs when they were restraining him.

      It is very clear to me from your thoughtful reply to Michael’s article that you already carry out the type of thinking that he is advocating. Thank you for that.

  5. Second hand, but someone I know found deescalation attempts a bit of a two edged sword especially after the first couple of times. They knew what was going to end up happening, so the longer the waiting took the more worked up they would get. Also the imperative to harm themselves would increase. Sometimes worked better, but certainly sometimes delays just made things worse.

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