The Angiolini Review

Theresa May, as Home Secretary, commissioned an independent review in 2015 on deaths following police custody or contact and appointed Dame Elish Angiolini QC, former Lord Advocate of Scotland, to lead it. Deborah Coles, chief executive of Inquest, was appointed as special advisor to the review and it has finally been published today, along with a full thirty-page response by the Government. The review came about, in part, because of meetings Theresa May had as Home Secretary with the families of Seni Lewis and Kingsley Burrell, who both died in NHS hospitals whilst detained under the Mental Health Act after the police were called in to the inpatient units where they were held by healthcare staff. That said, the review is not specific to policing incidents related to mental health issues but that is a major theme, as you would expect. Indeed, the report looks not only at policing despite being commissioned by the Secretary of State with responsibility for the police: it also looks at the whole process of post-incident investigation, fully looking at the Independent Police Complaints Commission and the process of Coronial Inquests.

Even ahead of publication, some have said it is “yet another review” and it is certainly one to add to my pile of reviews: two years ago we had the Home Affairs Committee report (2015) in to Policing and Mental Health, that followed the Independent Commission in to Policing and Mental Health’s report (2013) in to these issues in London. We’ve had various HMIC, CQC and Crisis Care Concordat reports, following on from the Bradley Report (2009; five year update in 2014) and obviously, countless Coroner’s hearings in to particular deaths. Non-exhaustively, these include inquests for Joseph Phuoung, Michael Thompson, Kingsley Burrell, Sean Rigg, Seni Lewis, Toni Speck, Rafael Delezuch, Michael Powell.  We are yet to see hear the inquests for Thomas Orchard, Leon Briggs or Terry Smith and there are others pending the conclusion of criminal or misconduct investigations and proceedings.

So what’s going on here?!


The Angiolini Report contains 110 recommendations – yes, really. They cut across many public services and organisations, not just those connected to policing, or post-policing investigation of adverse outcomes. They affect public policy, the law and operating practices of our NHS and local authorities; including the ambulance service, the emergency departments, mental health and learning disabilities providers as well as social services and children’s services. In fact, as was true in the Adebowale Report, if you look at the recommendations in detail, as I have, you will see that out of the 110 recommendations, most of them are not about the police; and those which affect the police are not exclusively in the control of the police. It is for this reason that when the content of the report has been trailed by the media, some officers have wondered aloud whether the call for deaths in custody to be treated like murder inquiries is a principle that will also be extended to unexplained, unexpected deaths in psychiatric care? When I looked at the 38 recommendations which were selected by the Home Office as being about policing and mental health, I opened up a spreadsheet and copied them all on to it. Having then gone through them one by one to make some notes of my reaction, I marked them in different colours —

  • Those wholly about the police where the issues connected to that recommendation are exclusively in our control.
  • Those about the police which are only partly in our control, requiring cooperation or collaboration from other agencies.
  • Those which are about the police where the issues are entirely beyond our control.

38 recommendations about the police: 8 which are about technology like body worn video and CCTV in police vehicles, 6 where we control all the issues; 14 where it would require collaboration and cooperation; the remaining 12 where it is entirely beyond our control. So whilst the police can hope to persuade and influence, the world cannot be as this report envisages unless many non-police organisations see this as a priority.

Of the six issues, all comments about guidance and training on issues related to policing, mental health and the conduct of restraint, I would argue we’ve done five of those six and the other should be finished by early next year (part 2 of the Lord Carlile work on restraint in non-MH or LD settings). Now, it may be that some people think that training and those guidelines are not sufficient and need to be better still – that’s a view which could be taken. The basic recommendation for police training from the College of Policing suggests officers should undertake a minimum of a two-day course on mental health awareness and mental health law, inc suicide prevention. I would personally argue, the extent of the demand we handle connected to mental health, the complexity of it and the risks arising from not getting it right mean we should be doing even more training. We give officers a three week course in driving police cars, not even to advanced driving standards. I would argue the strategic risk to policing that is represented by mental health related demands means we should be giving more than two days, if the risk represented by driving standards means a three week course and even more still for advanced drivers.

I suspect that will be an argument that continues for years to come – how much training is enough training?


So let’s look back at what Lord Adebowale said in his report in 2013 and look at where we are four years later – perhaps this will give us some sense of what could happen beyond 2020 with this attempt to bring change across an unintegrated system of healthcare and criminal justice. His report was insightful, measured and challenging: he issued 28 recommendations, only 9 of which were exclusively about policing. Most of them have been addressed (at least in theory) by the College of Policing’s work in 2016 to published new guidelines and training; most forces have undertaken a lot of work over the last five years or so to improve their responses and their understanding of their local demand. I’m not for one moment trying to put an argument forward that says policing is perfect, far from it. Those with whom I’ve spoken in detail over the last few months will know I have a massive concern about whether the solutions we’ve come up with so far, to the problems we thoughts we faced have actually made things worse, not better. I have wondered aloud, including on this blog, whether the problems we think we’re trying to solve are actually the right problems in the first place.

Whilst that debate continues and whilst I hope to help others push policing in the ’right’ direction, many of the background problems persist and some of the Adebowale recommendations which are about health and social care systems continue. Only last week we saw the inquest outcome after the death of Joseph Phuong which was publicly labelled by a national newspaper to be a death in police custody, when it actually wasn’t. Comparatively little mention (and in some case no mention) of NHS factors which made that incident more difficult to manage for the police and which may, for all anyone knows, have directly contributed to the need for restraint to continue longer than it should have done. Mr Phuong was detained under s136 and no ambulance answered the call to attend; he was turned away from a health-based Place of Safety and then taken to A&E where he was removed after becoming agitated and spent a lengthy period time in police custody, most of it, just awaiting identification of a much-needed inpatient bed where he could receive care. Having eventually arrived in hospital after those problems, he was restrained by NHS staff, medicated and secluded before collapsing within a few hours.

Lord Adebowale said it in 2013 and many have repeated his words with monotonous regularity ever since: yes, mental health is the “core business of the police”, but “the police can’t do this on their own.” Uh, huh …

  • 110 recommendations,
  • 38 of them for policing.
  • 8 relating to the better use of technology (which is all about accountability after adverse incidents and not about preventing them from happening);
  • 6 recommmendations – just 6! – which are in the sole control of the police service, and we’ve done 5 of them already, the last is happening as we react to publication.

If this is not just going to be another report on my shelf, then we actually need to get serious about looking at emergency mental health care and prevention, right across our police-NHS system and how the 999 and acute care integrate all of that, where required. Deborah Coles said this best when I heard her speak at the National Policing and Mental Health Conference in September: all this stuff was said after the death of Roger Sylvester in 1999 – this is nothing new. Yet here we are nearly twenty years later and we still can’t agree on the basic premise of who should go where and when, to access assessment and support. We still can’t agree that highly vulnerable people, even where they exhibit challenging behaviours simply should not bedetained in a cell and need to be treated as a medical emergency, without anybody, anywhere, thinking it’s acceptable to assume someonebody is feigning their own collapse.

Will this will make a massive difference? … or any difference at all?! – I’m not holding my breath because we’ve been here before, more than once.

Winner of the President’s Medal,
the Royal College of Psychiatrists.

Winner of the Mind Digital Media Award


All views 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 –

One thought on “The Angiolini Review

  1. Recommendation 6 is interesting:

    6. The restraint of anyone suffering a mental health crisis should be identified in national policy and training as a high risk strategy giving rise to a medical emergency. Where all else has failed or life threatening circumstances demand, it should be used for the very shortest time possible and an ambulance should be called for immediate transportation to Accident and Emergency.

    What this misses is the level of restraint used and why. Also, a lot of policies dictate that if a certain level of restraint is used then A&E and 126 suites etc. wont accept the person. So back to police custody they go!

    Surely this recommendation goes against what were all trying to do???

    Also, again over reliance on the position of Prone (recommendation 3) as being a problem when research has clearly shown it is NOT the most dangerous position, and some of the most recent deaths in restraint have been in positions other than prone. Why do these types of reports never link up with the relevant research in the particular field they are making recommendations for?

    And good luck with number 2. We’ve been trying to do that in MH services since before the death of David Bennett in ’97 and are still no closer!!

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