Krystian Kilkowski

A jury in Norfolk this week has returned a critical conclusion to the inquest in to the death of Krystian Kilkowski in 2020 –

Mr Kilkowski died on his 32nd birthday after being restrained by the police for one hour amidst officers and the Force Control room ringing the ambulance service no fewer than six times.  The police had been called because of concerns Mr Kilkowski was acting erratically and he then fled from officers upon their arrival.  Following a short footchase, he was detained and restrained, ostensibly under s136 of the Mental Health Act 1983, albeit the jury found that he was not told this was the basis of his detention or why he was being restrained.  Because of a delay in response from the ambulance service, the officers continue to restrain him and he died due to –

  • Multi-organ failure
  • Hyperthermia and Rhabdomyolysis; and
  • Complications arising during restraint of a man with acute behavioural disturbance (ABD) and amphetamine intoxication following a period of physical activity.

So this is another restraint related, acute behavioural disturbance related and drug / mental health related incident where concerns are raised about inter-agency communication and about the suitability of the response.  It’s not an identical incident, but I admit that this did make me think about the death of Leon Briggs in 2013.  As in Mr Briggs’s case, it’s worth noting that amphetamines consumed were not within the fatal range.  This latest, sad case also reminded me of the deaths of Kevin Clarke, Douglas Oak and others covered elsewhere on this blog.  The themes we see across different deaths of this kind include restraint (duration / intensity), response of the ambulance service and communication between the two 999 service agencies.  Those other cases I’ve just mentioned are not the only ones I could have listed, because you could go back to Sean Rigg, Michael Powell or Roger Sylvester and see aspects of similar themes around policing, mental health and restraint.

It raises a particular question about incidents where the ambulance service are non-responsive, for whatever reason.  We know there are problems with ambulance responses for a multitude of reasons and many of them beyond the direct control of paramedics and ambulance managers, but where the police have called for an ambulance and it isn’t appearing over the horizon, how should officers then deal with that situation?  Do they continue restraint in situ, hoping to minimise the impact on the person under restraint if they possibly can; or do officers reach a point where transfer to hospital by police vehicle becomes preferable, to remaining in situ for a potentially unspecified period?


This is a really difficult decision and I’ve covered it on here before.  In summary, though, it would obviously be preferable for those detained to be seen, assessed and cared for by paramedics as soon as possible and for obvious reasons; but given restraint is always risky to at least some degree and that risk only increases as restraint continues or intensifies, how long do you keep someone in situ before deciding the risk is best addressed by police transfer to an Emergency Department?  Not an easy judgement but given concerns around actue behavioural disturbance are always concerns that someone may be experiencing a medical emergency, it’s a judgement that should be faced as soon as it’s apparent the ambulance service may be delayed.

In other cases where police vehicles have been used, we know there has been criticism.  I was always confused why a police vehicle was used to transfer Leon Briggs to custody, when an ambulance was on scene at the point of detention / restraint.  Of course, in some situations the answer to that may be that someone’s resistant presentation means they were considered too volatile for an ambulance – in which case, use the police vehicle by all means, but have a paramedic in that vehicle travelling with and monitoring the person.  The Code of Practice MHA states we should avoid the use of police vehicles for conveyance where possible.  But faced with a potential medical emergency and an ambulance service apparently struggling to ensure a vehicle with clinical staff respond in a timely way, there comes a point where officers may need to think about cracking on regardless.

In situations where officers have done this, there has been no criticism of their decision.  When Leicestershire officers dealing with Rafa Delezeuch realised they were within sight of the Leicester Royal Infirmary ED, they simply didn’t call an ambulance at all.  They rationalised they could get Rafa in to the hospital faster than an ambulance could get to them and no doubt they were right – no criticism offered, at all.  When Metropolitan Police officers decided to transport Nicola Edgington to hospital because she had become agitated and distressed at the mention of police calling an ambulance, the IPCC (as they were then called) offered no criticism at all, because a decision to use a police vehicle was part of respecting Nicola’s wishes and keeping her calm when she was in distress.  Again, no criticism from the IPCC or the Coroner who later examined these matters.


Taking a decision about these matters is therefore unavoidable, because deciding not to use a police vehicle is also a committed decision to remain at the point of encounter until an ambulance arrives, even though you may not know how long that will be. The reaction from the charity inquest, rightly draws attention to recent guidance from the Royal College of Psychiatrists on ABD, which draws attention to the risks of restraint and it’s worth reading, as is the other updated 2022 ABD guidance from the Royal College of Emergency Medicine.

Finally, I remember something said at the NPCC Policing and Mental Health Conference in Oxford, 2017 –

You’re not just guilty of failing to learn lessons, you’re repeatedly guilty of failing to learn repeated lessons.”
Deborah Coles, Executive Director of Inquest.

Further Links to reaction and media coverage

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, 2022

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 –