Recurring concern

Unreliable recognition and communication of restraint-related acute behavioural disturbance risks

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First reported 28 Jun 2017•Latest report 2 Feb 2026

Definition

What this concern includes

Includes dedicated ambulance call-handling, police and paramedic guidance, training and information-gathering controls for recognising acute behavioural disturbance or restraint-related risk, including restraint duration or status, relevant clinical features and communication needed to inform response categorisation and immediate safety decisions.

Not included

Excludes ordinary restraint application, positioning, monitoring or removal failures where no acute behavioural disturbance or restraint-related risk-recognition or communication deficiency is identified.
Excludes generic call-handler, police or paramedic training and communication deficiencies unrelated to acute behavioural disturbance or restraint-related risk.
Excludes ambulance dispatch, attendance and treatment failures after restraint-related risks have been reliably recognised and communicated.
Excludes the broader existing concern concerning unsafe police restraint practices when the assertion is solely about the physical application, monitoring or removal of police restraint rather than recognition and communication of restraint-related risk.

Reports: 4
Individual concerns: 6
Date range: 2017–2026
Stated actions: 9

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Association of Ambulance Chief Executives2

College of Policing2

East of England Ambulance Service NHS Trust1

Essex Police1

Joint Royal Colleges Ambulance Liaison Committee1

Metropolitan Police Service1

Mitie1

NHS England1

South Central Ambulance Service NHS Foundation Trust1

South East Coast Ambulance Service NHS Foundation Trust1

South London and Maudsley NHS Foundation Trust1

Surrey Police1

Teesside University1

Thames Valley Police1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

2 Feb2026
Essex
Concerns raised2
1. Inconsistent ambulance response categorisation for Acute Behavioural Disturbance with active restraint
2. Failure to clearly link Acute Behavioural Disturbance and active restraint to Category 1 ambulance triage
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Implement a standalone procedure for suspected or confirmed Acute Behavioural Disturbance, removing “excited delirium” terminology and requiring Category 1 escalation with clinical review for possible downgrade.
  Stated by East of England Ambulance Service NHS TrustStated completed
2. Action
  Update, approve and disseminate the detained-patient procedure and Emergency Operations Centre escalation guidance to reflect the Acute Behavioural Disturbance procedure.
  Stated by East of England Ambulance Service NHS TrustStated completed
Respondent positions 1
1. Position
  National ambulance response categories are determined by NHS England’s ECPAG, not by AACE.
  Stated by Association of Ambulance Chief ExecutivesRedirects responsibility
AI-generated summary

Scott Darren TAYLOR · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Scott Darren Taylor died at Basildon Hospital on 13 August 2022 following multiorgan failure and rhabdomyolysis associated with cocaine use, physical exertion, prone restraint and Neuroleptic Malignant Syndrome. The report raised concerns about inconsistent ambulance response categorisation for acute behavioural disturbance with active restraint, terminology and training, police training, and the removal of restraints during conveyance.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Inconsistent ambulance response categorisation for Acute Behavioural Disturbance with active restraint
Wider context from the report
“b. The East of England Ambulance NHS Trust provide ambulance services across 6 counties and that also includes police/healthcare professionals reporting Acute Behavioural Disturbance and active police restraint. There is concern that there is a different response applied and that this discrepancy between Category 1 and Category 2 responses is significant and could affect the survival of patients. Evidence heard from police trainers and expert witnesses is that Acute Behavioural Disturbance has a high rate of fatality and requires an urgent response, particularly where police officers with training in this condition are reporting to ambulance service and with active restraint. ”
Source location
Scott Darren TAYLOR · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to clearly link Acute Behavioural Disturbance and active restraint to Category 1 ambulance triage
Wider context from the report
“a. Members of the public were restraining Scott Taylor on arrival of the police who quickly became concerned that Mr Taylor was exhibiting signs of Acute Behavioural Disturbance and made an emergency call to the ambulance service. The police, during the 999 call, were put on hold on three occasions by the ambulance service and became increasingly concerned about Mr Taylor’s deteriorating condition over an 18 minute period and confirmation that this remained a Category 2 call despite active police restraint with suspected Acute Behavioural Disturbance. Police decided to ‘scoop and run’ and urgently convey Mr Taylor to hospital due to the severity of their concerns. The EEAST Standard Operating Procedure requires escalation to Category 1 where there is active restraint, but this is not linked to Acute Behavioural Disturbance and remains unclear and may continue to cause confusion during triage by contact call handlers. ”
Source location
Scott Darren TAYLOR · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Implement a standalone procedure for suspected or confirmed Acute Behavioural Disturbance, removing “excited delirium” terminology and requiring Category 1 escalation with clinical review for possible downgrade.

Verbatim wording from the response
“Following the inquest a working group was set up with the intention of revising the guidance for patients exhibiting signs of Acute Behavioural Disturbance and establishing the most appropriate way to respond to those patients within the Emergency Operations Centre.”

Source location
Response from East of England Ambulance Service
Page 2 · response
Published 16 February 2026
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Update, approve and disseminate the detained-patient procedure and Emergency Operations Centre escalation guidance to reflect the Acute Behavioural Disturbance procedure.

Verbatim wording from the response
“The procedure has also been updated to reflect that a Category 1 coding is now applied to all calls where the police are actively restraining a patient; or reporting agitation/behaviour changes; or the police use the term Acute Behavioural Disturbance. The call handler will immediately escalate this to a Call Handler Team Leader who will upgrade the call to a Category 1 and the response will be dispatched on this basis. If, at this point, the Call Handler Team Leader or Dispatcher believe this may not be a Category 1 call, the call will be highlighted to a Clinical Navigator who will complete a clinical review and triage to establish if a downgrade is required.”

Source location
Response from East of England Ambulance Service
Page 3 · response
Published 16 February 2026
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
National ambulance response categories are determined by NHS England’s ECPAG, not by AACE.

Verbatim wording from the response
“With regard to the required classification for ambulance response to emergencies, AACE do not set the categories nationally of ambulance response. Ambulance call codes are determined by NHS England by the Emergency Call Prioritisation Advisory Group (ECPAG). We are aware that cases of suspected ABD should be assigned a Category 2 response, which is the immediate dispatch of an emergency ambulance. However, ambulance services are advised that a senior clinician within the”

Source location
Response from Association of Ambulance Chief Executives
Page 1 · response
Published 16 February 2026
Open published response
15 Dec2022
Berkshire
Concerns raised2
1. Lack of paramedic guidance on the danger of prolonged restraint
2. Lack of guidance defining prolonged restraint
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Meet and liaise with TVP, the College of Policing and AACE to review ambulance guidance and police training materials.
  Stated by South Central Ambulance Service NHS Foundation TrustStated completed
2. Action
  Explore options for an ambulance physical-restraint training package while liaising with AACE on the emerging national training standard.
  Stated by South Central Ambulance Service NHS Foundation TrustStated in progress
3. Action
  Strengthen staff guidance on clinical responsibility, continuous restraint review, obtaining prior restraint duration, and avoiding prone positioning.
  Stated by South Central Ambulance Service NHS Foundation TrustStated planned
1. Action
  Discuss defining prolonged restraint and explore using clinical expertise to inform work with PPST leads.
  Stated by College of PolicingStated planned
Respondent positions 4
1. Position
  Existing mobile access to current JRCALC guidelines is considered sufficient because no Trust staff difficulties accessing the guidance have been identified.
  Stated by South Central Ambulance Service NHS Foundation TrustExisting arrangements considered sufficient
1. Position
  Joint face-to-face training with Thames Valley Police is not currently feasible because of operational demands, although this will be kept under review.
  Stated by South Central Ambulance Service NHS Foundation TrustUnable to act
2. Position
  Joint police and ambulance training is difficult to achieve because of current recruitment pressures and operational demand volumes.
  Stated by Thames Valley PoliceUnable to act
3. Position
  There is no fixed definition of prolonged restraint because physiological changes vary between individuals and situations.
  Stated by Thames Valley PoliceDisputes the concern
AI-generated summary

Neal Terence Saunders · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Neal Terence Saunders was restrained by police for 58 minutes, including 14 minutes in a prone position, after police attended his address following an assault report and concerns about recent cocaine use and paranoid behaviour. He suffered a cardiac arrest while being transported to hospital and died there on 4 September 2020. Concerns included inadequate guidance and training about prolonged restraint, ambulance response expectations, prone transportation, and coordination and training between police and ambulance services.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of paramedic guidance on the danger of prolonged restraint
Wider context from the report
“Brief summary of matters of concern Police training There was extensive BWV footage in this case, which both I and the jury were able to see multiple times. It appeared to me, and (presumably) to the jury, (given their conclusion), that the officers at the scene were trying to take Neal’s welfare into account. The real issue was around their training. Whilst there may not have been any realistic or practicable alternative to restraining Neal, at least initially, it was clear from the evidence that none of the officers recalled their training which had told them that “prolonged” restraint should be avoided. The training gives no guidance as to what constitutes “prolonged” restraint, and this an issue which the jury highlighted. There are also a number of concerns regarding College of Policing training in this respect. The key concerns around training can be summarised as follows:- 1. How long is “prolonged” restraint? 2. One of the witnesses questioned whether the guidelines applied at all if somebody is under arrest, particularly regarding “contain rather than restraint”. Given that these are police guidelines, it seems to me likely that they would apply, whether a person is arrested for public order offences or other matters (but that should be clarified). 3. The College of Policing slides regarding ABD state that a “Cat 1 call” should be made to the ambulance service. The slides go on to say that the ambulance service should respond to ABD as a “category 1” [response]. It is clear that categorisation would be a matter for the ambulance service rather than the police, and this training may result in inappropriate expectations on behalf of officers at scene, who are expecting an ambulance to arrive more quickly that it in fact does. This in turn could affect their decision making. 4. The guidelines also refer to providing “chemical sedation”. This appears to me to indicate an incorrect understanding of what is likely to be done medically by a first responding paramedic or emergency care assistant. 5. It was interesting to note that the parts of the training the officers did seem to remember were around when the training was provided in a very physical way (around positions for restraint etc.) and the final slide “ABD = A&B”. It appears that the more “classroom based” training is less well received. I understand that the College of Policing is changing its methods, and it may be that an educational consultant with policing background could assist with this in trying to achieve training which will stick with those being trained more effectively. 6. Is there a better way for the College of Policing to ensure that the training has worked and is embedded? Training generally I raise 2 points here: 1. Checking of guidance which is infrequently used 2. Joint training with ambulance services Thames Valley Police and the College of Policing will be aware of my Regulation 28 report dated 9th July 2019, following the death of Leroy Medford in 2017. I raised a number of concerns about police training, and received responses from Thames Valley Police and the College of Policing. These are publicly accessible documents on the Chief Coroner’s website. I am concerned that the issues raised around training in that report have been insufficiently addressed. The only substantive change appears to relate to better remote access to guidance. In both inquests, the guidance was in relation to a matter which is not commonly faced by police officers. Whilst I consider ABD training could and should be improved, I accept that there has to be proportionality, given that officers will require training in a number of areas, some of which are far more frequently relevant than this. In addition to achieving better training, I consider that Thames Valley Police (and police nationally), should consider a change of approach. I consider that police officers should be mandated to review guidance (whether APP guidance or otherwise) in any scenario that they have not (or not recently) dealt with. I fully appreciate that this will need to have a “where practicable” caveat, since that will not always be operationally possible. In this case, however, there was ample time for an officer to check. One of the officers is heard saying words to the effect of “there is nothing more we can do here”, whilst waiting for the ambulance to arrive. I consider that Thames Valley Police (and police forces nationally) should consider not only requiring officers to do this wherever possible, but also for control to remind teams to do this or assist them with that. It would be best practice for this to be recorded on the log as having been completed. This could be achieved by a phone call to a senior officer, or by checking guidance directly. It was suggested by the Medical Director of South Central Ambulance Service that police and ambulance services should work together in reviewing their policies and perhaps train together as well. This is something I would endorse completely. Ambulance issues One of the reasons that I consider that joint training would be more effective is that it would appear (based on the evidence I heard at least), that police are potentially given more training on ABD than paramedics. We heard, for instance, that police training includes reference to prolonged restraint being dangerous. The paramedic evidence we heard indicated that this was not known by them, and not referred to in JRCALC guidance. I consider that the JRCALC guidelines should be reviewed to account for this, and potentially to recommend that paramedic staff be encouraged to ask how long somebody has been restrained for when they arrive, as this may affect their management. There should also be care taken regarding terminology, to ensure that all services refer to this umbrella term using the same terminology. ”
Source location
Neal Terence Saunders · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of guidance defining prolonged restraint
Wider context from the report
“Brief summary of matters of concern Police training There was extensive BWV footage in this case, which both I and the jury were able to see multiple times. It appeared to me, and (presumably) to the jury, (given their conclusion), that the officers at the scene were trying to take Neal’s welfare into account. The real issue was around their training. Whilst there may not have been any realistic or practicable alternative to restraining Neal, at least initially, it was clear from the evidence that none of the officers recalled their training which had told them that “prolonged” restraint should be avoided. The training gives no guidance as to what constitutes “prolonged” restraint, and this an issue which the jury highlighted. There are also a number of concerns regarding College of Policing training in this respect. The key concerns around training can be summarised as follows:- 1. How long is “prolonged” restraint? 2. One of the witnesses questioned whether the guidelines applied at all if somebody is under arrest, particularly regarding “contain rather than restraint”. Given that these are police guidelines, it seems to me likely that they would apply, whether a person is arrested for public order offences or other matters (but that should be clarified). 3. The College of Policing slides regarding ABD state that a “Cat 1 call” should be made to the ambulance service. The slides go on to say that the ambulance service should respond to ABD as a “category 1” [response]. It is clear that categorisation would be a matter for the ambulance service rather than the police, and this training may result in inappropriate expectations on behalf of officers at scene, who are expecting an ambulance to arrive more quickly that it in fact does. This in turn could affect their decision making. 4. The guidelines also refer to providing “chemical sedation”. This appears to me to indicate an incorrect understanding of what is likely to be done medically by a first responding paramedic or emergency care assistant. 5. It was interesting to note that the parts of the training the officers did seem to remember were around when the training was provided in a very physical way (around positions for restraint etc.) and the final slide “ABD = A&B”. It appears that the more “classroom based” training is less well received. I understand that the College of Policing is changing its methods, and it may be that an educational consultant with policing background could assist with this in trying to achieve training which will stick with those being trained more effectively. 6. Is there a better way for the College of Policing to ensure that the training has worked and is embedded? Training generally I raise 2 points here: 1. Checking of guidance which is infrequently used 2. Joint training with ambulance services Thames Valley Police and the College of Policing will be aware of my Regulation 28 report dated 9th July 2019, following the death of Leroy Medford in 2017. I raised a number of concerns about police training, and received responses from Thames Valley Police and the College of Policing. These are publicly accessible documents on the Chief Coroner’s website. I am concerned that the issues raised around training in that report have been insufficiently addressed. The only substantive change appears to relate to better remote access to guidance. In both inquests, the guidance was in relation to a matter which is not commonly faced by police officers. Whilst I consider ABD training could and should be improved, I accept that there has to be proportionality, given that officers will require training in a number of areas, some of which are far more frequently relevant than this. In addition to achieving better training, I consider that Thames Valley Police (and police nationally), should consider a change of approach. I consider that police officers should be mandated to review guidance (whether APP guidance or otherwise) in any scenario that they have not (or not recently) dealt with. I fully appreciate that this will need to have a “where practicable” caveat, since that will not always be operationally possible. In this case, however, there was ample time for an officer to check. One of the officers is heard saying words to the effect of “there is nothing more we can do here”, whilst waiting for the ambulance to arrive. I consider that Thames Valley Police (and police forces nationally) should consider not only requiring officers to do this wherever possible, but also for control to remind teams to do this or assist them with that. It would be best practice for this to be recorded on the log as having been completed. This could be achieved by a phone call to a senior officer, or by checking guidance directly. It was suggested by the Medical Director of South Central Ambulance Service that police and ambulance services should work together in reviewing their policies and perhaps train together as well. This is something I would endorse completely. Ambulance issues One of the reasons that I consider that joint training would be more effective is that it would appear (based on the evidence I heard at least), that police are potentially given more training on ABD than paramedics. We heard, for instance, that police training includes reference to prolonged restraint being dangerous. The paramedic evidence we heard indicated that this was not known by them, and not referred to in JRCALC guidance. I consider that the JRCALC guidelines should be reviewed to account for this, and potentially to recommend that paramedic staff be encouraged to ask how long somebody has been restrained for when they arrive, as this may affect their management. There should also be care taken regarding terminology, to ensure that all services refer to this umbrella term using the same terminology. ”
Source location
Neal Terence Saunders · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Meet and liaise with TVP, the College of Policing and AACE to review ambulance guidance and police training materials.

Verbatim wording from the response
“To confirm, your Regulation 28 report was predominantly aimed at the national bodies responsible for providing training and guidance to police and ambulance service emergency personnel. Within that report, you asked the South Central Ambulance Service to consider working jointly with Thames Valley Police (TVP) to review our policies and training as suggested by our Medical Director during the evidence he provided to you.”

Source location
Response from South Central Ambulance Service
Page 1 · response
Published 19 December 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Explore options for an ambulance physical-restraint training package while liaising with AACE on the emerging national training standard.

Verbatim wording from the response
“We are aware that nationally, there is not a definition of what would constitute prolonged restraint. Evidence was provided to you regarding this during the inquest hearing. The guidance currently provided to ambulance staff confirms that any form of patient restraint should be kept to a minimum and the form of restraint must be justifiable based on the circumstances. Currently ambulance personnel do not receive any specific training regarding physical restraint. We are aware that The Association of Ambulance Chief”

Source location
Response from South Central Ambulance Service
Page 1 · response
Published 19 December 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Strengthen staff guidance on clinical responsibility, continuous restraint review, obtaining prior restraint duration, and avoiding prone positioning.

Verbatim wording from the response
“In the interim, it is our intention to strengthen the direction we provide to our staff to ensure there is a clear understanding of the role they must play when attending to a patient who is subject to restraint by police officers or has been restrained prior to our attendance. The guidance will confirm that once in attendance ambulance personnel are clinically responsible for the wellbeing of the patient and they must work with police officers to ensure that any restraint is subject to continuous review and adjusted where appropriate to ensure the wellbeing of the patient whilst they are conveyed to a definitive point of care. This will include making enquiries regarding the length of time the patient has been subject to restraint prior to the arrival of the ambulance crew.”

Source location
Response from South Central Ambulance Service
Page 2 · response
Published 19 December 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Discuss defining prolonged restraint and explore using clinical expertise to inform work with PPST leads.

Verbatim wording from the response
“1. ‘Prolonged restraint’ is not currently defined. This issue has been tabled for discussion at the national Clinical Governance Panel and we will look at ways to use clinical expertise to inform work in conjunction with College PPST leads.”

Source location
Response from College of Policing
Page 1 · response
Published 19 December 2022
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Existing mobile access to current JRCALC guidelines is considered sufficient because no Trust staff difficulties accessing the guidance have been identified.

Verbatim wording from the response
“As you will be aware from previous correspondence and engagement with the Trust, we provide our staff access to the JRCALC guidelines via the mobile APP. This ensures that they are able to access the most up to date version of the guidance for any condition or set of circumstances they may be presented with when they are with the patient they are treating. Whilst it was apparent during the evidence you heard that the paramedic involved in this specific case, who worked for a private provider rather than the Trust, was not aware of some of the specific wording of the guidelines, he was aware that placing someone in a prone position should be avoided generally. From our review, there is no evidence that staff employed by the Trust have experienced any difficulties in accessing the guidance whether due to them being unaware of how to or because of technical difficulties in doing so.”

Source location
Response from South Central Ambulance Service
Page 1 · response
Published 19 December 2022
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Joint face-to-face training with Thames Valley Police is not currently feasible because of operational demands, although this will be kept under review.

Verbatim wording from the response
“2. Operational staff”

Source location
Response from South Central Ambulance Service
Page 2 · response
Published 19 December 2022
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Joint police and ambulance training is difficult to achieve because of current recruitment pressures and operational demand volumes.

Verbatim wording from the response
“8. Joint training with ambulance services”

Source location
Response from Thames Valley Police
Page 7 · response
Published 19 December 2022
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
There is no fixed definition of prolonged restraint because physiological changes vary between individuals and situations.

Verbatim wording from the response
“1. How long is “prolonged” restraint?”

Source location
Response from Thames Valley Police
Page 2 · response
Published 19 December 2022
Open published response
21 Feb2019
Surrey
Concerns raised1
1. Failure of call-handling guidance to capture patient restraint status
This report raised 16 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Terrence Arthur Albert Smith · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Terrence Smith died in hospital on 13 November 2013 after developing amphetamine-induced Excited Delirium/Acute Behavioural Disturbance, being subjected to prolonged restraint, and stopping breathing while being transported to hospital. The principal concerns included failures to recognise the condition as a medical emergency, inadequate assessment and training, excessive restraint, delayed conveyance to hospital, and deficiencies in relevant emergency response, clinical, police and custody policies and training.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of call-handling guidance to capture patient restraint status
Wider context from the report
“I was told that, whilst waiting for version 17 of NHS Pathways, SECAMB has provided its call handlers with guidance (by way of a “Hot Topic”) that a call from the Police or a Health Care Professional stating that a patient is suffering ED/ABD should be given a category 2 response. I was also told, however, that SECAMB’s call handlers have no discretion when using NHS Pathways which must be followed precisely. I have three concerns about the current situation. First, there appears to be a contradiction between the call handlers being told they have no discretion when using NHS Pathways and their being given additional guidance for certain calls. This contradiction could cause confusion. Secondly, the guidance given in the “Hot Topic” is concerned only with calls from the Police or an HCP in which ED/ABD is identified. Currently, therefore, there is no provision for identifying the condition in calls from the Police or an HCP which do not expressly mention ED/ABD or in calls from the public (meaning the call from Terry’s family would still not be recognised as a call relating to ED/ABD, even today). Thirdly, the “Hot Topic” does not guide the call handlers to ask whether the patient is under restraint. If a patient suffering ED/ABD is under restraint this could add to his risk of sudden death and this information could affect the proper categorisation of the response to the call. ”
Source location
Terrence Arthur Albert Smith · Prevention of Future Deaths report
Page 7 · concerns
Open source report
28 Jun2017
South London
Concerns raised1
1. Inadequate definition of prolonged restraint and restraint danger in ABD training
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Embed recognition and emergency treatment of suspected ABD in mandatory, assessed restraint training.
  Stated by Metropolitan Police ServiceStated completed
2. Action
  Produce safer-restraint training material jointly with South London and Maudsley NHS Trust.
  Stated by Metropolitan Police ServiceStated completed
3. Action
  Maintain an ongoing partnership with independent healthcare experts to inform restraint and officer-safety training.
  Stated by Metropolitan Police ServiceStated in progress
Respondent positions 1
1. Position
  A specified restraint time limit will not be introduced because it lacks clinical basis and presents practical timekeeping difficulties.
  Stated by Metropolitan Police ServiceUnable to act
AI-generated summary

Olaseni Lewis · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Olaseni Lewis developed an acute psychotic illness, was admitted to hospital, and was later restrained by police and healthcare staff after becoming agitated. He became unconscious and suffered a cardiac arrest. The concerns included prolonged and disproportionate restraint, inadequate police and healthcare training and communication, unclear responsibilities, and failures to respond appropriately to the medical emergency.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Inadequate definition of prolonged restraint and restraint danger in ABD training
Wider context from the report
“(3) Police were taught that prolonged restraint was dangerous, but had no idea what “prolonged” meant, and were left to use their own judgement. They also seemed to think that prolonged restraint referred to time spent in a prone position and that as long as the detainee was held on his/her side the danger was ameliorated or removed. The pathological and psychiatric expert evidence clearly indicated that restraint in any position can lead to sudden death in patients who are highly agitated. The jury found that the police training was inadequate in its definition of “prolonged restraint” for people exhibiting signs of ABD. ”
Source location
Olaseni Lewis · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Embed recognition and emergency treatment of suspected ABD in mandatory, assessed restraint training.

Verbatim wording from the response
“In addition, the Officer Safety Training Programme (OST), which is pass/fail and mandatory for all officers below the rank of superintendent, reinforces each of the significant areas of information during the instructor-led modules. For example, the complex issues surrounding the condition that has come to be known as Acute Behavioural Disorder (ABD) forms a golden thread through regularly taught, refreshed and assessed modules within restraint training. In this way, officers become”

Source location
2017-0205-Response-by-Metropolitan-Police
Page 2 · response
Published 28 July 2017
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Produce safer-restraint training material jointly with South London and Maudsley NHS Trust.

Verbatim wording from the response
“The potential confusion this term may cause when working with other mental health service providers highlighted in your report is however acknowledged. This barrier can be reduced through improved working relations with the police and health care professionals. Work in this area includes the production of the ‘Safer Restraint’ DVD by the MPS in partnership with South London and Maudsley NHS Trust (SLaM) and the ongoing work of the MPS Mental Health Team in support of the national Memorandum of Understanding (MOU) announced by the College of Policing in January 2017 (College of Policing, 2017). The MOU was provided to you as an appendix to ████████ statement dated 26/01/2017.”

Source location
2017-0205-Response-by-Metropolitan-Police
Page 3 · response
Published 28 July 2017
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Maintain an ongoing partnership with independent healthcare experts to inform restraint and officer-safety training.

Verbatim wording from the response
“The Independent Medical Science Advisory Panel (IMSAP) is an ad hoc panel of leading independent healthcare professionals who advise the National Policing Lead for Personal Safety Training on medical matters relating to physical restraint and self-defence techniques and equipment. The MPS believes that this on-going partnership helps to ensure that its officers receive the best informed training on what remains a complex condition that can present in very challenging and often violent situations. The benefits of changing this approach, which is firmly embedded in national and MPS training, appear to be unclear and could undo much good work already achieved by the police service with medical partners.”

Source location
2017-0205-Response-by-Metropolitan-Police
Page 3 · response
Published 28 July 2017
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
A specified restraint time limit will not be introduced because it lacks clinical basis and presents practical timekeeping difficulties.

Verbatim wording from the response
“3. The introduction of time limits for prolonged restraint has been subject to much discussion in the police service. Advice from the Independent Medical Science Advisory Panel (IMSAP) was that there is no clinical basis for this due to the ‘many and various physiological factors that would preclude a firm medical basis for such an approach’ (Independent Medical Science Advisory Panel, 2014). The advice further cautioned that the introduction of a time limit could give rise to a misconception that restraint within this time period was safe. Doubts were also raised over the practicalities of accurate time keeping such events.”

Source location
2017-0205-Response-by-Metropolitan-Police
Page 4 · response
Published 28 July 2017
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Inconsistent ambulance response categorisation for Acute Behavioural Disturbance with active restraint

Failure to clearly link Acute Behavioural Disturbance and active restraint to Category 1 ambulance triage

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised2

Lack of paramedic guidance on the danger of prolonged restraint

Lack of guidance defining prolonged restraint

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4

Concerns raised1

Failure of call-handling guidance to capture patient restraint status

Concerns raised1

Inadequate definition of prolonged restraint and restraint danger in ABD training

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Actions described in response 2

Respondent positions 1

Actions described in response 4

Respondent positions 4

Actions described in response 3

Respondent positions 1