Restraint and use of force examined after man dies following hospital discharge – Thames Valley Police, January 2021
A man was arrested by the police after his partner reported a domestic assault. The man had warning markers for mental health and suicide on the Police National Computer and presented as someone who had consumed alcohol or another substance. He was unsteady on his feet and his speech was slurred.
Officers believed he had swallowed a large quantity of medication, and he was taken to hospital where he remained under police guard.
The man was later discharged from hospital but appeared to be non-compliant and visibly unwell. Two officers physically restrained him for 18 minutes, using handcuffs and limb restraints, with hospital staff helping to restrain the man at various points. The officers called for support and three more officers arrived at the hospital with a police van.
The man was moved to the police van using a Flexible Lift and Carrying System (FLACS). Officers noticed the man was unresponsive and he was removed from the van, where officers gave him CPR. The man was taken back into the hospital where he was resuscitated and placed in an induced coma. His condition deteriorated over the following days and he sadly died.
We received a death or serious injury referral from the force and decided to independently investigate police contact with the man. We examined the decision to restrain the man and whether this was appropriate, whether the force used by officers was necessary, proportionate and reasonable in the circumstances, and whether officers considered the man’s welfare and mental health during their interactions with him. We also examined whether the officers’ actions or decisions caused or contributed to his death.
Our investigators interviewed the police officers involved, as well as police witnesses, hospital staff, and members of the public. We obtained statements from a medical expert and police trainers in Public and Personal Safety Training. Our investigators reviewed CCTV from the hospital, body worn video footage, hospital records, and police and hospital policies, procedures and guidance.
We concluded there was an indication that the two officers who restrained the man had behaved in a manner to justify disciplinary proceedings. We also found that one of these officers may have committed a criminal offence.
We found that, as the man was under arrest, both officers were ultimately responsible for the man’s wellbeing and to ensure he came to no harm. The actions, demeanour and general presentation of the man were clearly not consistent with someone who was well enough to leave hospital. At no point did the officers question his fitness to be discharged, even as his condition visibly deteriorated.
We found that the officers did not appropriately use the National Decision Making (NDM) model, and the officers’ decision to restrain the man was flawed and not in line with the guidance and the standards of professional behaviour. The officers failed to consider other approaches such as de-escalation through tactical communication. We also found that the use of the FLACS was not compatible with the man’s condition. The officers also failed to consider, or risk assess, the man’s mental health history and did not factor this into any use of the NDM.
We referred the case to the Crown Prosecution Service (CPS). They decided not to pursue criminal proceedings against one of the two officers because the evidence did not present a realistic prospect of conviction for the offence of assault occasioning actual bodily harm.
We found these two officers also had a case to answer for gross misconduct. We shared our report with the force, who agreed. We decided that disciplinary proceedings should be brought against the officers and that they should take the form of misconduct hearings.
The misconduct hearings concluded in July 2024. One officer was found to have breached the police standards of professional behaviour for use of force and duties and responsibilities. These amounted to a finding of gross misconduct, and the officer was dismissed without notice. The other officer was found to have breached the police standards of professional behaviour for use of force and duties and responsibilities. They received a final written warning.
We found that the actions, judgement and assessment of the situation by the three officers who arrived to assist, were not up to the standard that the public would expect. We recommended that these 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.
The inquest into the man’s death concluded in April 2025, where it was found that police neglect and use of restraint contributed to his death.
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 four learning recommendations to the National Police Chiefs’ Council and two to Thames Valley Police. These can be viewed here:
Recommendations - Thames Valley Police, December 2024 | Independent Office for Police Conduct (IOPC)