Preventing Future Deaths

For a couple of years, I’ve been regularly reading the website of the Chief Coroner, in particular the section on Preventing Future Deaths and I’ve blogged about this before.  I had a discussion with an academic last year about the potential of me undertaking PhD research on PFD issues affecting policing and mental health, not least because of the obvious potential to argue that lessons from these notices are not always fully learned.  To the extent that they are, usually by the organisations directly affected, they are not necessarily learned more widely across agencies and across the country.  In my recent reading, I kept a list of cases with at least some bearing on policing and mental health issues and thought it may be useful to provide links and summary comments about those which stick out, at least for me.


Where a death occurs and a PFD notice is issued to police force X, will police force Y know about this and learn from it?  Will Ambulance Trust Y and Mental Health Trust Y know about this and learn from it if there was also learning for their equivalent services in area X?!  I admit to being unconvinced there is a systemic process in place and we should keep in view at all times that however legitimate it may be to offer criticism of police officers or police services after these tragic events, there is published research out there about how often these tragedies have a broader healthcare context and how often there has been criticism for healthcare services during inquests.

In recent years we’ve seen tragic outcomes and excoriating conclusions to inquests after the deaths of Kevin Clarke, Leon Briggs and several others (see below) but the criticism offered was not just reserved for the police officers or police services concerned.  There are multiple outcomes where ambulance services were found to have “more than minimally contributed” to a fatal outcome by neglect; where mental health services are likewise criticised.  I do realise I’m liable to be over-sensitive on this point because of my own background: but we don’t hear calls for accountability in quite the same way, where health organisations are also found to have failed vulnerable people and we see little which acknowledges the inter-connectedness of this.  Policing doesn’t occur in a vacuum and sometimes, police decisions are a result of context, including healthcare opinion about how things should be handled.

One accusation levelled at all state agencies is that tragedies occur and claims are made of the need to “learn lessons” or even claimed by the time inquests conclude that “lessons have been learned”.  You only have to spend ten minutes on Google and you will find senior people in various kinds of state agencies making these kinds of comments about inquests which concluded in the last year.  But we do seem to have more than one kind of problem:  there are enough cases about to suggest that claims of lessons learned may not be valid claims, because the recent inquests are, in very many important respects, textbook replicas of other incidents a few years further back.  Of course, no two incidents are identical so it would be easy to dismiss the suggestion of a ‘textbook replica’ so it’s probably important that I explain what I mean by this.

Please keep in view: I’m not claiming that any two cases are identical in every regard, but that there are broad themes at play across the multiple events listed below (and others I haven’t listed because the PFD notices don’t appear available online).


So here are various notices, all with hyperlinks to the Office of the Chief Coroner’s website where you can see the notice itself and any responses from agencies.  It should be noted: these are just cases from the last decade which are available online, via that website.  I am well aware of earlier cases which led to other notices not available online.  I’m not in anyway dismissing those cases or denying the learning from them – it’s just that the PFDs are not immediately available to us.

I think a great deal of hard-won learning is within this body of material and I also think far more could be done with it, for this reason:  Deborah Coles is the Executive Director of Inquest and she spoke at the NPCC / College of Policing Mental Health Conference in Oxford in 2017.  She said something in her presentation I’ve heard her say more than once:

You’re not just guilty of failing to learn lessons, you’re repeatedly guilty of failing to learn repeated lessons.”

You’ll have to look at the below and decide whether you’d like to disagree – I can admit that I don’t.

  • Olaseni Lewis, died-2010; verdict-2017 – speaks to issues around ABD and restraint; as well as the medical oversight of police responses in medical settings during police attendance at a disturbance in a mental health setting.
  • Kingsley Burrell d-2011, v-2015 – speaks to issues on ABD / restraint; as well as the street triage as a generic solution when it’s unlikely to have affected this type of incident.  Of note on triage, is the response from the Metropolitan Police Commander who was NPCC lead at the time.
  • Terry Smith, d-2013, v-2018 – speaks to issues around ABD and restraint; as well as the ambulance service interface with the police during MH crisis.
  • Greg Hutchings, d-2017, v-2018) – speaks to the need for unambiguous communication between cooperating agencies and to a clear, joint understand of what ‘street triage’ actually is, inc what telephone triage between nurse and patient can amount to.
  • Eugeniusz Niedziolko, d-2017, v-2018 – speaks to issues on ambulance service responses to police-led healthcare incidents; to consideration of A&E care for drunk people and to the non-use of section 136 MHA in such cases.
  • David Stacey, d-2017, v-2018 – speaks to NHS legal duties and institutional compliance with the Mental Health Act itself (specifically s140 MHA) and the planning for predictable events to which that section gives rise.
  • Darren Cumberbatch, d-2017, v-2019 – speask to issues around ABD, restraint and the use of force, as well as the Probation Service’s awareness of ABD.
  • Sasha Forster, d-2017, v-2019 – speaks to issues of assumptions sometimes found within the health system about what is a police responsibility.  The Coroner’s concern about resources to return patients follow remarks in court by a senior doctor that despite the Code of Practice MHA highlighting the NHS trust’s responsibilities, they preferred the police to do it because they lacked resources.  Also speaks to indifference about the impact of policing on patients known to be fearful of them, as Sasha was.
  • Douglas Oak, d-2017, v-2019 – speaks to issues around ABD and restraint; as well as the ambulance service interface with the police during MH crisis.
  • Nigel Abbott, d-2018, v-2019 – speaks to issues around joint s135 policies, agencies’ perception of others’ policies and responsibilities and urgently required MHA assessment and / or admission / no beds.
  • Kevin Clarke, d-2018, v-2020 – speaks to issues around ABD and restraint; as well as the ambulance service interface with the police during MH crisis, including inadequate clinical assessment and inherent medical risks.
  • Ewan Brown, d-2019, v-2020 – speaks to the need for officers not only to have up to date training, but also refresher training on policing & mental health.
  • Deborah Lamont, d-2019, v-2020 – speaks to issues officers’ understanding MH legislation.  This case involved, amongst other things, non-use of s136 where it may have been considered lawful; also involved risk-taking advice from MH services to police that officers found uncomfortable but where they deferred to perceived expertise even through the MH professionals were not present to assess things in person.
  • Nimo Younis, d-2019, v-2020 – speaks the need for clarity of communication between agencies, to the need for agreements in protocols or at least clear agency procedures where there are no agreements, to ensure police are provided with relevant information when patient’s reported missing.
  • Veronica Biggs, d-2019, v-2021 – speaks to issues culture and risk taking in NHS mental health services.
  • Thiago Araujo, d-2020, v-2021 – speaks to agencies’ perceptions of each others policies and responsibilities, and two-week delays to convene a Mental Health Act assessment for someone at ‘acute risk of suicide’.
  • Levi Pettit, d-2019, v-2021 – speaks to concerns for welfare, referral to MH services and training / awareness of force MH policies.
  • Leon Briggs, d-2013, v-2021 – speaks to the need for clear, effective protocols (s136) as well as training for police officers and greater awareness of post-restraint monitoring of those subject to a use of force.
  • Anthony Preston, d-2020, v-2021 – speaks to issues around voluntary attendance at ED, police not accompanying on the basis of someone not being (able to be) detained MHA and of welfare checks v missing.

Remember what these are: notices from a Coroner to say that unless certain things are changed by organisations with the responsibility to make those changes, then other people may die.

This is serious stuff, to say the very least.

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 OBE, 2021

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 –