Source · Prevention of Future Deaths

Leon Briggs

Ref: 2021-0330 Date: 4 Oct 2021 Coroner: Emma Whitting Area: Bedfordshire and Luton Responses identified: 3 / 4 View PDF

The local S136 Multi-Agency Policy is unclear and lacks streamlining. There is insufficient training for first responders on recognizing medical emergencies, the effects of restraint, and monitoring detainees.

Date 4 Oct 2021

56-day deadline 29 Nov 2021

Responses identified 3 of 4

Emergency services related deaths (2019 onwards) Mental Health related deaths Police related deaths

Coroner's concerns

AI summary

View full coroner's concerns

1. Adequacy of the local S136 Multi-Agency Policy Whilst the local S136 guidance has changed considerably since the death of Leon, in my view, it is still not fit for purpose for the following reasons: (i) It requires streamlining and re-formatting (including the use of a larger font) to make it easier for all agencies to follow – it may assist to focus on multi-agency activities ONLY (leaving individual agencies to provide their own specific policies to support the multi-agency interaction) (ii) Reference to other regulations might best be avoided (see for example 3.3) so that it can stand as freestanding guidance for those attending fast moving incidents to apply without delay; (iii) The guidance should closely follow the chronology of a relevant incident i.e. it should start with the decision to detain, followed by the relevant risk assessment, appropriate conveyance, place of safety etc. Information regarding permitted periods of detention and roles and responsibilities could be dealt with at the end. N.B. Whilst it is reassuring to learn that a local ‘task and finish’ group has been set up within the Mental Health Crisis Concordat Strategic Group (MHCCC) to improve the current Policy and that reference is being made to College of Policing training packages, in effecting these improvements, the group might wish to consider engaging with a national expert in this field such as Inspector Michael Brown who provided expert evidence to the Inquest and has experience of effective mental health policy making.
2. Lack of Sufficient Training for Police Officers, Ambulance Crew and other Front-Line Bedfordshire and Luton Coroner Service Tel 0300 300 8383 | FAX

Responders Although, the MHCCC Strategic Group are progressing joint training for all first responders including hospital staff who might need to assess medical fitness and/or treat S136 detainees, it was clear from the evidence heard at the Inquest that there remains insufficient or inadequate instruction of both police and ambulance crew about the critical issues of recognising and responding to a medical emergency and the effects of restraint including positional asphyxia. Consideration, therefore, needs to be given by National and Local Police and Ambulance services as to whether the current individual service training (including refresher training) is adequate (and of similar level to that provided to those working in Mental Health Units pursuant to the Mental Health Units (Use of Force) Act 2018) to ensure the welfare and safety of S136 detainees.
3. Adequacy of Monitoring of Detainees Subject to Restraint The expert evidence of Dr (Consultant Intensivist). Professor (Consultant Cardiologist) and Dr (Forensic Pathologist) highlighted the effect that restraint has on detainees – not only in terms of the potential stress to the heart if the detainee struggles against such restraint but also in view of the continuing metabolic disturbance it creates which continues long after any restraint ceases or is removed. Indeed, they all agreed that metabolic disturbance from the restraint was one of the factors in causing Leon’s cardiac arrest and subsequent death. The evidence of Dr confirmed that the effects of the restraint would, however, have been treatable and that, if appropriate action had been taken, his cardiac arrest would likely have been avoided; indeed, he explained that even if action only had been taken at the point that Leon had become unconscious, the relatively simple steps of placing him in the recovery position in the cell and starting CPR, whilst awaiting emergency help, on the balance of probabilities, would have resulted in his survival. The Jury through their answers to Questions 33-34 of the Jury Questionnaire not only determined that a failure to monitor Leon appropriately in the cell on 4 November 2013 more than minimally caused or contributed to his death but also concluded, in Box 3 of the Record of the Inquest, that “The inadequate continuous risk assessments and monitoring of Leon resulting in a failure to recognise when Leon became in need of urgent medical attention in the cell” was one of the most serious failings by emergency services to provide Leon with adequate support. Since the carrying out of even relatively basic first aid could have made a significant difference to the outcome in this case, it seems critical that the close monitoring of a detainee who has been subject to restraint should be guaranteed in all cases. As the Jury found there were specific failures by the Custody team in this case, consideration could perhaps be given to having additional monitoring in respect of such detainees independent of the Custody team. The NHS England Patient Safety Alert (2015) gives guidance to NHS staff on post-restraint observations: https://www.england.nhs.uk/wp-content/uploads/2015/12/psa-vital-signs-restrictive-interventions-031115.pdf. Although this has been circulated to some police, it may not be widely known about and even though it may not cover all of the situations which the police will encounter in their work, something similar could be of potential benefit to all police forces across the country. Bedfordshire and Luton Coroner Service Tel 0300 300 8383 | FAX

Responses

3 respondents

East of England Ambulance Service NHS / Health Body

22 Nov 2021 PDF

Action Taken

EEAST has approved (November 2021) the National Ambulance s.136 Guidance, is developing and implementing a new mental health care service model, and has developed a specific training session in relation to Acute Behavioural Disorder, including positional asphyxia for frontline staff. (AI summary)

View full response

Dear Ms Whitting

Thank you for your communication regarding the Regulation 28 (Report to Prevent Future Deaths) in respect of the death of Leon Briggs. I would like to offer my condolences to Leon’s family and those affected by this tragic event. I have responded to the points raised in the Regulation 28 report separately below:
1. Adequacy of the local S136 Multi-Agency Policy

Whilst the local S136 guidance has changed considerably since the death of Leon, in my view, it is still not fit for purpose for the following reasons: (i) It requires streamlining and re-formatting (including the use of a larger font) to make it easier for all agencies to follow
– it may assist to focus on multi-agency activities ONLY (leaving individual agencies to provide their own specific policies to support the multi-agency interaction) (ii) Reference to other regulations might best be avoided (see for example 3.3) so that it can stand as freestanding guidance for those attending fast moving incidents to apply without delay; (iii) The guidance should closely follow the chronology of a relevant incident i.e. it should start with the decision to detain, followed by the relevant risk assessment, appropriate conveyance, place of safety etc. Information regarding permitted periods of detention and roles and responsibilities could be dealt with at the end. You also suggested that agencies work with an expert in this field to facilitate these improvements. The National Ambulance s.136 Guidance was recently approved (November 2021) by the National Ambulance Service Medical Directors group (NASMED), which is a working group that reports to the Association of Ambulance Chief Executives (AACE). These changes will now be implemented locally and this work is being led by the Bedfordshire AMHPs (on behalf of the Crisis Care Concordat) and the forum includes representation from both EEAST and Bedfordshire Police. The updated national guidance highlights that the police officer on scene should indicate if ABD is suspected and if the patient is being restrained. Nationally, the agreement is that these patients will warrant a Category 2 response as a minimum. Within EEAST, the decision has been made that patients who are detained under s.136 and being restrained by the police will be treated as Category 1 calls in line with the attached EOC Standard Operating Procedure. The national

East of England Ambulance Service NHS Trust Whiting Way Melbourn Cambridgeshire SG8 6NA

guidance also directs ambulance services to ensure a clinician is involved in the call and highlights the risk of positional asphyxia if the patient is being restrained incorrectly. EEAST’s Mental Health team have also been working on updating the guidance documents for our partners in relation to managing s.136 patients within the community setting. This document ‘Requesting Conveyance for Patients Detained under the MHA’ will be sent to you once the review and update has been completed in December 2021. This will also be shared with the regional police forces and mental health partners through the regional Approved Mental Health Practitioner.
2. Lack of Sufficient Training for Police Officers, Ambulance Crew and other Front-Line Responders.

Although, the MHCCC Strategic Group are progressing joint training for all first responders including hospital staff who might need to assess medical fitness and/or treat S136 detainees, it was clear from the evidence heard at the Inquest that there remains insufficient or inadequate instruction of both police and ambulance crew about the critical issues of recognising and responding to a medical emergency and the effects of restraint including positional asphyxia. Consideration, therefore, needs to be given by National and Local Police and Ambulance services as to whether the current individual service training (including refresher training) is adequate (and of similar level to that provided to those working in Mental Health Units pursuant to the Mental Health Units (Use of Force) Act 2018) to ensure the welfare and safety of S136 detainees.

Since this inquest, EEAST’s Mental Health Team have worked collaboratively with the NHS partner organisations across the East of England to develop and implement a new mental health care service model. The manager’s briefing relating to this new model has been attached with this letter and outlines the changes that have been made. Our chosen service model is to establish an EEAST Mental Health team that is based within the operational setting, working alongside our clinicians and linking with system partners. Through this model we hope to deliver relevant training, identify and improve access to appropriate care pathways and increase the confidence of our staff in the assessment and management of presenting mental health need across the organisation.

EEAST has also developed a specific training session in relation to Acute Behavioural Disorder, including positional asphyxia. The commencement of this training session is planned for 2021/2022 for all frontline staff across EEAST as part of the Essential Care Skills, which is EEAST’s annual clinical update.

In addition to this, in July 2021, the Mental Health Team reviewed and re-published the following pocket guides to all frontline staff: What is s.135/136; Mental state examination; Mental Health Act v Mental Capacity Act. The dissemination of these guides was supplemented by a video for staff to view. Further pocket guides relating to ABD and conveyance of mental health patients are in progress and will be published and shared with all patient-facing staff over the coming months.

I hope this letter demonstrates the steps the Trust is taking to improve our response and care delivery to patients who may be detained and the associated risks that may arise when attending to these patients. Please do not hesitate to contact me should you require a further update.

Bedfordshire Police Police / Law Enforcement

26 Nov 2021 PDF

Action Planned

Bedfordshire Police is updating its local section 136 multi-agency policy, with a revised version due to be signed off this year and is incorporating guidance from a national ABD policy review into existing guidance for relevant policing areas. (AI summary)

View full response

Dear Ms Whitting, Regulation 28 Report – Leon Briggs I write in response to your regulation 28 report to prevent future deaths dated 4 October 2021 (‘the report’) addressed to the Chief Constable of Bedfordshire. This is the formal response of Bedfordshire Police. I start by repeating the apology which I made on 12 March 2021, acknowledging that the Inquest Jury had identified a number of significant failings by police which contributed to the death of Mr Briggs in 2013 and for which we are truly sorry. The Jury recorded their specific findings in the Record of Inquest, including that Mr Briggs’ death was contributed to by neglect. The matters of concern identified in the report relate to the adequacy of the local section 136 multi- agency policy; lack of sufficient training for police officers, ambulance crew and other front-line responders; and the adequacy of monitoring of detainees, subject to restraint. Bedfordshire Police has considered the terms of your report carefully and consulted relevant local and national stakeholders before giving the following response. Adequacy of the local section 136 multi-agency policy As you are aware from the evidence at the inquest, the policy which applied in 2013 had been superseded. The current policy is under a task and finish group. It was reviewed by the current National Lead for Mental Health, Deputy Chief Constable , whose team stated they thought it was comprehensive. Additionally, officers met with partners on 13 October 2021 to review, update and confirm understanding, which took place with the benefit of the concerns you have identified. A revised policy is due to be signed-off this year. I will ask my legal services department to provide you with a final copy as soon as it has been signed off.

Significant learning came out of the Briggs Inquest and resulted in the local multi-agency Mental Health Hub being even more determined to form better working practices with our partner agencies. Despite good working relationships already, there are still challenges for front-line officers including medically-supervised transport; resourcing; making sure ambulance colleagues are leading medical assessments, monitoring and taking responsibility for medical situations brought to their attention; and ensuring there are routes into emergency departments.

Chief Constable , CEO for the College of Policing, confirmed in his meeting with the Chief Constable of Bedfordshire on 29 October 2021, the current College of Policing and National Police Chiefs’ Council (NPCC) Mental Health Leads are the most appropriate sources of guidance and support, and referrals to experts, and will continue to act as consultees in these respects.

Lack of sufficient training for police officers, ambulance crew and other front-line responders

The Chief Constable met with the National Lead for restraint’s team, headed by Deputy Assistant Commissioner , on 29 October 2021. The national position is that officers are not mental health practitioners and that the skills officers have are not the same as those of clinicians and practitioners in mental health units. It is important to keep in mind that police officers should defer to ambulance staff and clinicians on medical matters because of their specialist training and focus.

However, Bedfordshire Police officers do receive training on section 136, mental health awareness and First Aid (see below) and the regular training provided to all officers and meets the standards set out by the College of Policing. If you would like more detail regarding the current training provision, I will ask my legal services department to provide you with all the relevant units and guidance.

The circumstances of Mr Briggs’ death, which again I acknowledge the Jury found was contributed to by neglect in the particular circumstances of his case, is well known to those responsible for training and refresher training, and will have a lasting impact on their provision of training to individual officers.

Adequacy of monitoring of detainees, subject to restraint.

The College of Policing has issued updated Authorised Professional Practice (APP), and provides ‘College Learn’ (formerly NCALT) with regards Officer Safety Training, First Aid and Mental Health Awareness. These packages have been updated significantly since 2013 to reflect learning with regards to awareness of Acute Behavioural Disturbance (ABD) and principles of detainee monitoring.

Our policies around ‘observation and risk assessment’ of a detainee in custody, also provided in Use of Force training, reflect national guidance from the College of Policing, which in turn is reinforced by respective NPCC Leads.

Bedfordshire Police highlighted, in light of your report, the ‘NHS Patient Safety Alert’ to the National Mental Health Lead. Their view was that this document reinforced the requirement for monitoring of ‘vital signs’ for patients post restraint. Monitoring of vital signs, as referred to in a clinical context, is not something officers are trained or equipped to do. However, officers do receive the modern training referred to above (including First Aid) and it was felt that a separate document adapting the

NHS Patient Safety Alert may lead to duplication, or create confusion. On reflection it would be preferable to incorporate any additional guidance into existing guidance for the relevant policing areas such as Use of Force and Custody.

I make clear that all officers involved in the provision of restraint and care to a detainee are required to monitor the detainee. That did not happen appropriately in Mr Briggs’ case. While we cannot guarantee a particular specialist level of additional monitoring in every case, due to the significant variety of circumstances and resourcing challenges, there is in the current training the concept of a ‘Safety Officer’, where possible a supervisor, who will not have a hands-on role in restraint of a detainee but will be observing them and looking for any signs of problems and can give advice to the officers performing restraint.

The National Lead for Mental Health informed Bedfordshire Police that at the NPCC National Forum in July 2021, an update was provided by Chief Superintendent of South Yorkshire Police, who is working alongside Dr (Medical Director for West Yorkshire Metropolitan Ambulance Service, and Consultant in Emergency Medicine and pre-hospital care at Mid Yorkshire Trust) on a national ABD policy. I understand that it is likely that, once completed, a request will be made to the NPCC and College of Policing to incorporate any recommendations from this review into APP, including recommendations being made for officers to formally declare suspected ABD cases as ‘critical incidents’ therefore ensuring they receive immediate management oversight.

Bedfordshire Police are grateful to the Coroner for the opportunity to address the steps which have been, and are being, taken in respect of the matters of concern outlined in the report. And, again, I will ask that you be forwarded the most up to date multi-agency policy as soon as it has been signed off.

Association of Ambulance Chief Executives NHS / Health Body

29 Nov 2021 PDF

Noted

AACE confirms that the national S136 guidance has recently been revised, updated, and issued nationally and that on 1st February 21 they updated the acute behavioural disturbance guidance with wording to emphasise the need for close monitoring of a patient when restraint is used. (AI summary)

View full response

Dear Ms Whitting REGULATION 28: LEON BRIGGS I am writing in response to the Regulation 28 report to prevent future deaths concerning the death of Leon Briggs which you issued on 4th October 2021 to chair of the Association of Ambulance Chief Executives (AACE). Please note that as Managing Director of AACE, I am responding on his behalf. AACE is a private company owned by the English Ambulance NHS Trusts. It exists to provide ambulance services with a central organisation that supports, co-ordinates and implements nationally agreed policy. Our primary focus is the ongoing development of the English ambulance services and the improvement of patient care. It is a company owned by NHS organisations and possess the intellectual property rights of the Joint Royal Colleges Ambulance Liaison Committee UK ambulance service clinical practice guidelines (the “JRCALC guidelines”). AACE is not constituted to mandate or instruct ambulance services however it has national influence via the regular meetings of ambulance Chief Executives and Trust Chairs along with a network of national specialist sub-groups. One of its specialist sub-groups is the National Ambulance Service Medical Directors (NASMeD); this response is from AACE having been informed by NASMeD. With regard to your matter of concern about the adequacy of the local S136 Multi-Agency Policy. We are unable to comment on local S136 policy, but we can confirm that the national S136 guidance has recently been revised, updated, and issued nationally. The revised guidance includes wording to highlight that the police officer on scene should call the local ambulance service and include in the information passed whether the patient is being actively restrained and if so how, and if acute behavioural disturbance (ABD) is suspected. Ambulance trusts will assign a Category 2 response to patients detained under S136 and suspected of having ABD unless there are other immediately life-threatening clinical features that would warrant a Category 1 response. The national S136 guidance highlights that ambulance services must involve a clinician in any call where a patient is being actively restrained so that clinical support can be provided and the patients vital signs monitored. The revision also includes wording to highlight the fact that if a patient is restrained incorrectly there may be an increased risk of positional asphyxia, so it is vital that the patient’s airway and breathing is carefully monitored at all times during restraint. AACE works closely with the police via the National Police Chiefs Council (NPCC) and liaises with them on a regular basis. We have emphasised the importance of direct contact from the officer on scene to the ambulance control and suggested that police forces explore with their ambulance trusts how this can be established if not already in place.

With regard to your matter of concern around lack of sufficient training for police officers, ambulance crew and other front-line responders and the critical issues of recognising and responding to a medical emergency and the effects of restraint. We are unable to mandate the training that is required, nor the depth and degree of training. This is for local ambulance trust determination. However, we are very aware of the need for emphasis on and relevant training in this important area. In the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) UK ambulance service clinical practice guidelines we developed and published a new guideline around acute behavioural disturbance in December 2019. The guideline highlights the importance of trying to minimise physical restraint for fewer than ten minutes and avoid airway or respiratory compromise. We are aware that factors have been proposed as contributory to sudden death in ABD and other types of intoxication such as amphetamines, positional asphyxia secondary to restraint, drug toxicity itself or underlying cardiac disease resulting in cardiac arrhythmias. We suggest that provided there is not an immediate risk to life, verbal de-escalation should be attempted before restraint or pharmacological agents are used. We emphasise that clinicians on-scene are responsible for the clinical safety of the patient at all times and should immediately inform any other personnel on- scene if they believe the patient’s clinical condition is at risk of deteriorating, particularly if there is any restriction to the patient’s airway or breathing. The first healthcare professional on scene should be specifically responsible for monitoring and treating the patient. Any other healthcare professionals or ambulance staff in attendance should be closely liaising with the designated police safety officer. During restraint, clinicians should be prepared for a rapid deterioration in the patient’s condition, including cardiovascular collapse. On 1st February 21 we updated the acute behavioural disturbance guidance with wording to emphasise the need for close monitoring of a patient when restraint is used and that the clinician is clinically responsible for the patient. We have also developed national JRCALC guidance around Mental Health Presentations including Crisis, Distress and Disordered Behaviour. In this guideline, we also have a section highlighting the risks of physical interventions including restraint. I trust that this response addresses your concerns. If I may be of further assistance, please do not hesitate to make contact. On behalf of AACE, I would like to extend our sincere condolences to the family of Leon Briggs.

Report sections

Investigation and inquest

On 5 November 2013 an Investigation was commenced into the death of LEON BRIGGS aged 39. The investigation concluded at the end of the Inquest which was held before me sitting with a Jury from 4 January 2021 to 12 March 2021. The Medical Cause of Death was found to be: 1a. Amphetamine Intoxication in association with prone restraint and prolonged struggling
2. Ischaemic Heart Disease The Conclusion of the Inquest was Narrative Conclusion: “The circumstances of the death of Leon Briggs are described ..[see Section 4. below). The findings of the serious omissions and failures recorded there, result in a conclusion that the death of Leon Briggs was contributed to by neglect.”

Action should be taken

In my opinion action should be taken to prevent future deaths and you have the power to take such action.

Copies sent to

NPCC Lead on Mental Health Deputy Assistant Chief ConstableNPCC Lead on Use of Force/Restraint , HM Chief Inspector of Constabulary

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2021-0330
Date of report: 4 October 2021
Coroner: Emma Whitting
Coroner area: Bedfordshire and Luton

Responses identified

Responses identified 3 of 4

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 29 Nov 2021.

Sent to

Association of Ambulance Chief Executives

Bedfordshire Police

EEAST

National Police Chiefs’ Council

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.