Man died after his detention and restraint by police – Norfolk Constabulary, August 2020

In August 2020, Norfolk Constabulary officers attended two locations in Diss, Norfolk following a call from a member of the public relating to a man who needed assistance in the street.

After finding the man, the officers made the decision to detain him under the Mental Health Act and contact the Ambulance Service for assistance.

The officers restrained the man and made repeated calls to the Ambulance Service. Due to high demand and staffing issues, a unit was not immediately available with an approximate wait time of 50 minutes. The man’s condition deteriorated as he became increasingly confused and agitated. The ambulance service arrived at the scene over an hour and a half after the first call from the police.

The man was taken to hospital where he died the next day.

We received a mandatory referral from Norfolk Constabulary following his death. Our investigators were deployed to the scene where forensic and witness enquiries were completed.

We specifically investigated whether officers administered appropriate first aid to the man and whether they made appropriate requests to the ambulance service. We also considered whether local and national policies were followed by Norfolk police officers when detaining the man.

We put out a witness appeal and conducted door to door enquiries. We took statements from police officers and members of the public. We obtained and reviewed body worn video footage and CCTV, in addition to mobile phone footage from the incident. We obtained and analysed expert evidence was obtained, analysed and compared alongside radio and telephone transmissions.

Our investigation concluded in April 2021. We waited for all external proceedings to be complete before publishing our findings.

We found none of the officers present behaved in a manner that would justify the bringing of disciplinary proceedings, nor any indication they may have committed a criminal offence.

All officers provided full and detailed accounts and co-operated fully with our investigation.

An inquest concluded in November 2022, finding that the man died, “a drug related death following amphetamine intoxication leading to acute behavioural disturbance which was exacerbated by a period of physical activity, and further complicated by serious failures in the methods of restraint”.

The jury also found that, “operational failures in the emergency services led to delays in [the man] receiving timely critical care”.

We note the inquest found concerns around the force’s actions and the officers’ efforts to keep him safe while they waited for an ambulance to arrive. While the officers restrained the man, used handcuffs and later applied straps to secure his legs when he became more agitated, our investigation found their actions were proportionate in the circumstances. Throughout the period where they waited for an ambulance, they kept his welfare under constant review and made repeated calls to the ambulance service.

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 identified two areas of improvement which the force accepted. These included bringing to the attention of the relevant agencies apparent contradictions between the local and national guidance on whether individuals suffering from Acute Behavioural Disorder (ABD) can be transported in a police vehicle, if an ambulance is not readily available. In addition, we suggested a policy amendment to allow body worn video to record events in the back of an ambulance.