Oladeji Adeyemi Omishore · Prevention of Future Deaths report

From 3rd March to 24th March 2025, evidence was heard before a jury touching the death of Mr Oladeji Adeyemi Omishore. He had died on the 4th June 2022, aged 41 years, in ITU at St Thomas’s Hospital. He had died following an incident involving police officers on Chelsea Bridge during which he was tasered a number of times and then jumped into the River Thames.

Medical Cause of Death

1 a. Complications arising from drowning

How, when, where and in what circumstances the deceased came by his death; and conclusions as recorded by the jury [in this case by combining boxes 3 and 4 of the Record of Inquest] :

on 4th June 2022, Mr Omishore was suffering with a relapse of schizoaffective disorder/psychosis. In October 2019 he had suffered his first episode of schizoaffective disorder/psychosis based on medical evidence we have heard and accepted. He continued to receive care and deemed stable by the health care team in March 2022. Recent cannabis use likely caused or contributed to this relapse of his illness. We have considered and noted his previous behaviour when psychiatrically unwell.
Mr Omishore left his home on the morning of 4th June 2022 shouting in the middle of the road and waving what is now known to be a firefighter. This prompted a number of 999 calls from members of the public. Amongst other things, the public raised shouting religious remarks, a perceived weapon, aggressive behaviour and that he seemed mentally unwell.

The call handlers determined critical information and passed to dispatchers which included location, weapon and description, with all calls being graded I grade (immediate response). Responding police officers were told by dispatchers the location, suspicious circumstances, weapons and a brief description via the airwaves. Mental health (MH) was not passed over the airwaves. We note from witnesses this should and could have been passed over the airwaves.
The call was accepted by the responding officers at 09:03:54. It was accepted 20 seconds after it was put over the airwaves.
The response officers understood they were responding to an I grade call on Chelsea Bridge Road, which they were aware had at least 3 I grades.
When the response officers arrived, Mr Omishore was in the middle of the road on the North side of Chelsea Bridge when the officers first saw him. The officers perceived him to be holding a screwdriver.
The taser trained officer gave evidence to say he did not initially consider possible MH issues. The non-taser trained officer gave evidence he did consider MH issues during the incident. The response officers gave evidence that they believed this was a genuine threat and took a risk assessment in line with NDM.
The response officers arrived at 09:05:43 and the taser officer got out the car with taser drawn and shouted commands to identify himself as a police officer and to draw attention to the taser. Following lack of compliance to drop the object, the taser officer fired the first taser at 09:06:15, in response to non-compliance and movement in the direction of the non-taser officer. Mr Omishore dropped the ground and dropped the object. Following the first taser, Mr Omishore was rolling around on the ground and was not under control. The non-taser officer kicked the object away from reach. Mr Omishore attempted to get up and swiped towards the non taser officer and there was a second discharge. The second taser did not allow control of Mr Omishore. Following the third taser discharge, Mr Omishore got up and jumped over the pedestrian barrier. The non-taser officer followed.
Mr Omishore swung his hand towards the non-taser officer and knocked the handcuffs out of his hand.
The taser officer deployed the second and final cartridge to stop Mr Omishore. Mr Omishore jumped off Chelsea Bridge and into the River Thames at 09:06:53-55. He was rescued at 09:18 and was given CPR and taken to St Thomas’s Hospital.
He was recognised as life extinct on ITU at St Thomas’s Hospital at 20:29 on 4th June 2022.

Matters that we find possibly caused or contributed to the death.

Despite the response officers having all required training, the use of the taser did not achieve full NMI. Had the officers been able to achieve full NMI, there is a possibility they could have gained control of Mr Omishore and therefore the inability to achieve full NMI and gain control of Mr Omishore possibly contributed to his death.

Information from members of the public (that in their opinion Mr Omishore was suffering from a mental health crisis) was not passed to responding officers before they arrived at the scene. We have heard evidence that such information should and could have been passed on. We have also heard evidence from the responding officers that such information would not have changed their approach.

The majority of the jury find that, had mental health concerns been passed over the airwaves, it is possible this may have had an impact on the sequence of events that may have contributed to Mr Omishore’s death.

Probable Causes

Mr Omishore had suffered a relapse of schizoaffective disorder/psychosis and was severely unwell. This illness affected his understanding and was the likely cause of his actions on Chelsea Bridge Road and Chelsea Bridge prior to and after the arrival of the police. It is likely that he was frightened by what he was seeing and what he thought he was seeing and lacked insight.

Whilst the body worn and phone footage show him running away from police after he had been tasered for the third time, it cannot be concluded that the actions of the police probably caused his death.

1. That there is an inconsistency of approach between call handlers/first responders in the recording of information passed to them by members of the public that may represent a training issue; in this case the mental health matters reported to them.

2. That the call handlers/ first responders may have a training issue in relation to the importance of recording this information in a manner which is likely to be passed on to responding officers by dispatchers, for example in the NICL codes and/ or “golden line”.

3. That the above concern of potential training need is highlighted by the increased use of taser in black men and those suffering mental health issues and so the real need for this information to be recorded and passed on in the most effective form. Whilst training for first responders appears to include advice as to how to communicate with persons suffering with mental health issues, it does not appear to contain any advice in relation to the importance of such information to be recorded especially in relation to black men.

4. That the limitation of 3 NICL codes makes it difficult to record mental health as a qualifier in incidents such as this where the main risk factor is the weapon.

5. That call handlers/first responders may need training as to where to record such information i.e. in the “golden line” or NICL code, as long as of course it is reported to them before the “golden line” and NICL code has gone out.

6. That use of THRIVE usually requires time that is not available in I grade calls and does not mitigate the need to circulate promptly information as to mental health issues, in the format most likely to be digested and passed on by dispatchers that is “golden line” or NICL codes.

7. That the lack of NICL code “mental health believed” compounds this.

8. That dispatchers may require training in relation to the importance of passing on possible mental health concerns for the subject over the airwaves given the increased use of taser in black men and those suffering with mental ill health.

9. That dispatchers may require training in relation to what to pass out more generally given the confusion in the evidence about other units being assigned by CAD, which dispatchers themselves did not seem to appreciate and understand let alone pass such information out to responding officers.

10. That there are apparent system failure issues in dispatcher pods if due to pressure of work, important issues such as mental health concerns for the subject are being missed and the number of units on the way are not being passed over the airwaves, given the potential importance of these matters to responding officers when applying their NDMs, and the reliance of responding officers on the information that they receive over the radio on their way to an I grade call.

11. That training for response officers may require review in relation to tactical options used to de-escalate prior to taser deployment, in appropriate circumstances, given the increased use of taser in black men with mental health issues; and in particular, training in relation to deploying with taser drawn and pointed with accompanying commanding language where the subject may be suffering with mental ill-health.