Police contact with man before his death – Metropolitan Police Service, June 2019

On Saturday 29 June 2019, Metropolitan police officers attended a report of a disturbance on Coldharbour Lane, Brixton. On arrival they identified a man who appeared to be having an asthma attack but who was also alleged to have been in possession of a weapon and committed a violent offence earlier in the day.

The officers could not find the man’s asthma medication and requested an ambulance due to the concerns about his breathing. Based on the allegations made against the man, he was placed in handcuffs to the front of his body and told he was under arrest.

A number of officers continued to monitor the man, encouraged him to focus on his breathing and told him to try to remain sat in an upright position. The officers also reassured the man and told him an ambulance would come to help him. Unfortunately, due to a large backlog, there were no ambulances available.

After approximately 20 minutes of monitoring the man without a change in his condition, he was placed inside a police vehicle to remove him from the heat of the sun. Whilst inside the police vehicle the man’s condition deteriorated and he appeared to stop breathing. He was removed from the vehicle and given CPR by police officers until medical staff were able to take over care of the man.

The man was taken to hospital however he was pronounced dead at approximately 10pm.

A number of police officers who had involvement with the man were treated as witnesses throughout the investigation and provided statements to support the investigation. A large amount of body worn video was available in addition to further video footage from a local CCTV camera, which recorded a significant proportion of the police interactions with the man.

Two officers were asked to provide further witness statements about their first aid training and their knowledge of dealing with people suffering an asthma attack, including the options which might be available to them.

We obtained copies of relevant first aid training materials and sought clarification from a senior first aid advisor, alongside information contained on the police incident log and within radio transmissions.

Our investigation concluded in December 2019. We waited for all associated proceedings to be finalised before publishing our findings.

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

An inquest was held in June 2022. A jury found that his death was caused by acute asthma and situational stress, but that he also died, “…in part because the police officers dynamic risk assessment was not adequate to correctly assess [the man’s] condition without the METDG desk in operation and a clinician was not available due to high demand of ambulances.”

We informed the Coroner that the MPS are dealing with one officer’s performance which is subject to the reflective practice review process.

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 from this investigation.