Police contact examined after man experiences mental ill health – Devon and Cornwall Police, July 2022

A member of staff in a residential care home called the police to report that a man had broken in and was covered in blood and shouting. The man could be heard shouting in the background throughout the call.

Officers arrived at the care home and found the man had locked himself in a staff toilet. The officers were able to open the toilet door and place the man in handcuffs with his hands in front.

The man lost consciousness, so the officers removed the handcuffs and gave CPR. Paramedics arrived 10 minutes later and gave medical treatment. Sadly, the man could not be resuscitated and died.

The inquest found his cause of death to be heart failure and acute behavioural disturbance associated with drug and alcohol use.

We received a death or serious injury referral from the force and decided to independently investigate the interactions between the police officers and the man.

We examined the police uses of force, the medical treatment and support the officers provided, whether the officers sufficiently considered the man’s behaviour, state of mind and physical and mental health, and whether they complied with local and national policy and procedures. We also considered whether the officers treated the man any differently because of his race.

Our investigators obtained and reviewed call logs and body worn camera footage, as well as CCTV footage from the care home. We also reviewed relevant local and national police guidance and obtained witness accounts from care home staff and officers involved in the incident.

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

We found that officers used force in a restrained manner, and their actions were proportionate, justified and responsive to the situation. Restraint was limited and brief, and officers removed the handcuffs as soon as they noticed medical assistance was needed. We did recommend that officers reflect on sufficiently considering someone’s behaviour, state of mind and physical and mental health, and the need to act urgently when a life is at risk.

We did find that one officer’s performance was unsatisfactory. The evidence we gathered suggested that the officer failed to approach the situation and the man compassionately, adopting a fixed mindset and disrespectful tone, and did not sufficiently consider that the man’s behaviour may have been due to mental or physical illness. Their performance was addressed through the Unsatisfactory Performance Procedures. 

We did not find any evidence that race influenced the officers’ treatment of the man.

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 made recommendations around making sure all police officers and staff are trained in verbal de-escalation as the default response to any incident involving someone with mental ill health, and even if an ambulance is already en-route, updating the ambulance service immediately if a patient’s condition deteriorates.