Lessons still not learnt from Leon Briggs' death in Luton says coroner

Leon Briggs died after falling ill in Luton police station eight years ago - but restraint training which could have saved his life is still inadequate in the emergency services, a coroner has said.

The father-of-two, 39, died in 2013 after being detained at Luton police station under the Mental Health Act, after first being held face-down in the street.

An inquest jury in March found there had been a number of serious police and ambulance failures which led to his death.

Now in a further report, coroner Emma Whitting has said more people could die due to "insufficient" national guidance.

Ms Whitting, senior coroner for Bedfordshire and Luton, said in her Report To Prevent Future Deaths: "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.

"In my opinion there is a risk that future deaths will occur unless action is taken."

Ms Whitting said emergency services workers needed to be clearly instructed and trained to undertake a risk assessment of mental health patients.

Officers had failed to react quickly when he became unresponsive in the cell, she added.

She said: "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.

"It seems critical that the close monitoring of a detainee who has been subject to restraint should be guaranteed in all cases."

Mr Briggs had taken amphetamines and was suffering a mental health crisis when paramedics attended him in Marsh Road in Luton and police used handcuffs and leg restraints to detain him.

Prior to the inquest into his death this year, the East of England Ambulance Service NHS Trust (EEAST) paramedics involved admitted failing to check Mr Briggs' vital signs and didn't take him to hospital in an ambulance for medical treatment.

The inquest jury also found that, although police officers did "reasonably believe" it was appropriate to use force to restrain Mr Briggs while he was suffering a psychotic episode and had taken amphetamines, "inappropriate weight" was used against him "at times".

Officers' failure to recognise that Mr Briggs was in a state of medical emergency or to monitor him in the police van and cell, also contributed to his death, the jury said.

Mr Briggs died at Luton and Dunstable University Hospital about two hours after the restraint,

Responding to Ms Whitting's findings, Bedfordshire Police's Deputy Chief Constable Trevor Rodenhurst said the force was "already working closely with partners to address the issues raised at the inquest and reinforced through this report".

The force had already made "extensive changes" since 2013, he said.

Since the inquest, the force had worked with agencies across Bedfordshire to review and improve its policy and was "developing multi-agency training based on mental health crisis scenarios which will be delivered across the partnership," Deputy Chief Constable Rodenhurst added.

"We have also been reviewing our mental health and custody procedures and will be discussing this at a national level to ensure all the lessons from this tragic case are learned by policing and partners across the UK," he said.

A spokesman for the East of England Ambulance Service NHS Trust said: “We would like to offer our condolences to Mr Briggs’ family and friends and apologise that his medical assessment fell below the standards we expect.

“We have received the Prevention of Further Deaths notice and are working to the timeframes set out by the coroner.”

It says since 2013:

> EEAST now responds to any patient that is being restrained under a section 136 as a category 1 call, with the aim of an ambulance response within seven minutes.

> A month after this incident, in December 2013, the Association of Ambulance Chief Executives (AACE) issued a national protocol on section 136 to all ambulance services.

> In February 2014 EEAST signed up to the Mental Health Crisis Care Concordat (MHCCC), a joint initiative agreed by health, social care, police, justice and local government agencies which set out how public services should work together to respond to people who are in mental health crisis.

>The creation of a Mental Health Street Triage team – a partnership between EEAST, the Police and mental health trust – has been operating in Luton since 2016 and a similar scheme has recently been rolled out in Peterborough.

> Updated guidance on managing patients with potential ABD was issued by the Joint Royal Colleges Ambulance Liaison Committee in February of this year and has been disseminated and embedded across the Trust.

Speaking at the inquest earlier this year Leon's family described him as “a loving, son, brother and father, caring and genuine”.

He had previously worked teaching computer skills to the elderly and as a lorry driver.