Investigation into police actions and risk assessments after man experiencing possible ABD dies – Merseyside Police, August 2023

A man called 999 to report concerns for a family member who they believed to be experiencing a mental health episode. Police officers were sent and an ambulance was requested.

Several police officers arrived and found the man in a distressed and disorientated state, displaying erratic behaviour. The officers tried to restrain the man, eventually using leg restraints and handcuffs to try to control the situation.

Officers suspected the man was experiencing Acute Behavioural Disturbance (ABD) and requested ambulance arrival updates. They also requested medical equipment in the absence of an ambulance.

The man was lifted into an ambulance but experienced a cardiac arrest while going to hospital. The ambulance stopped and the crew and police officers gave the man emergency treatment. He was transported to hospital with CPR in progress. The man sadly died in hospital two days later.

We received a death or serious injury referral from the force and decided to independently investigate the nature and extent of police contact with the man before his death, including the decisions, actions and risk assessments made by police officers, and whether the police may have caused or contributed to the man’s death. We also examined whether officers acted in line with local and national policies, procedures, guidance and training.

The man’s stepfather also complained on behalf of the man’s family that they were prevented from engaging with the man, denying them the opportunity to calm him down.

Our investigators conducted a detailed investigation. Witness statements were obtained from family members of the man, independent witnesses, and officers who had direct contact with the man. We examined officers’ body worn video footage and CCTV footage. A forensic post mortem was conducted and forensic samples were examined by experts.

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 officers recognised the man may have been experiencing ABD and acted accordingly. Officers recognised the danger that the man potentially posed to himself, police officers and members of the public, using force and restraint to try to control the situation. Officers monitored the man’s breathing, requesting emergency equipment and re-adjusting restraints and handcuffs appropriately.

We found it was unfortunate that the man’s family could not engage with him when they wanted to, but the risk of doing so was high and there was no evidence it would have altered the man’s mindset.

We did recommend that four officers would benefit from the reflective practice review process (RPRP). This process allows officers to learn from and reflect on what could have been done better. We recommended that some of the officers re-acquaint themselves with police powers on use of force.

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 did not identify any organisational learning in this case.