Circumstances of police contact examined after man experiencing ABD dies – Lincolnshire Police, September 2021

A man called 999 shortly after midnight. He spoke to a call handler and a confused conversation followed, with the man doubting he was talking to the police and making references to death. He gave his name and address, and two police officers were sent to the man’s home, arriving minutes later due to the proximity of the man’s home to the police station.

The officers found no signs of a disturbance at the man’s home. They tried to engage with him, but he did not want to speak to them. The man was in the company of another person, and the officers decided to leave and resume their patrol.

A short while later, the man was found outside the nearby police station, banging on the windows. He was agitated and paranoid and officers advised him to return home. The man ran off and out of sight of officers.

Officers followed the man’s direction on foot and in a police van, where they could hear loud banging and shouting. They found the man shouting and screaming as he ran between houses, and an officer took the man to the ground. The man struggled, kicking out with his arms and legs, and appearing to try to bite the officers. Officers used an incapacitant spray to try to control the situation, striking the man on his legs to distract him and applying handcuffs and leg restraints. The man was arrested for breach of the peace, and a number of officers placed the man in the back of the police van as he continued to resist.

The man became unresponsive during transportation to custody, and his breathing became shallow. Officers decided to take him to hospital but had to stop and give the man CPR when his breathing stopped. An ambulance was called and paramedics took the man to hospital. He sadly died soon after his arrival.

We received a death or serious injury referral from the force and decided to independently investigate the circumstances surrounding the man’s death. We examined the actions and decisions of police officers and staff, including whether the use of force during the man’s arrest was necessary, reasonable and proportionate. We also considered if the police may have caused or contributed to his death.

Our investigators went to the scene and obtained initial statements from the officers concerned, recordings of body worn video, incident logs and other relevant documents. Our investigators also went to the man’s postmortem.

Further statements were obtained from officers, paramedics and one of the man’s lodgers.  CCTV from the on-board camera system in the ambulance was also examined, together with telephone and radio transmission recordings.

We concluded there was no indication that a person serving with the police committed a criminal offence or behaved in a manner to justify disciplinary proceedings.

We found that the situation the officers were faced with, made any efforts to reasonably converse with the man extremely difficult. The officers’ actions and decision to physically restrain him were necessary as the man was a danger to himself and the officers, and their use of force was reasonable and proportionate.

The postmortem reported the man’s cause of death as cocaine toxicity induced acute behavioural disturbance (ABD). The police officers did not recognise the man was experiencing ABD. If they had, we found that the outcome of the situation would have been the same as the man was a threat to himself and those present. We found no evidence that the officers caused or contributed to the man’s death.

We did note the lack of awareness that the officers involved had in respect of ABD, and that they did not receive regular training inputs. 

The inquest into the man’s death found that officers’ use of restraint and force probably contributed towards his death, as well as inadequate monitoring and the decision not to treat the situation as a medical emergency.

Lincolnshire Police is working with the East Midlands Police Force Clinical Governance Forum to implement a policy in relation to ABD, developing and aligning practises around response times and restraint practices. This forum includes the East Midlands Ambulance Service, who are producing a joint working policy on ABD.

All operational police officers are required to have training that enables them to recognise a potential case of ABD as a medical emergency and respond accordingly. The core expected action from a front-line officer is to recognise the danger, prioritise de-escalation, minimise the use of restraint, and secure immediate medical help.

We carefully considered whether there were any learning opportunities arising from the investigation. We make learning recommendations to improve policing and public confidence in the police complaints system and prevent a recurrence of similar incidents.

We are in the process of considering learning around awareness of and training in ABD for operational police officers and staff.