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Investigation and inquest
On 12th April 2011 commenced an investigation into the death of Kingsley Burrell, aged 29. The investigation concluded at the end of the inquest on 15th May 2015. The conclusion of the inquest was a narrative as per the attached record of inquest.
Circumstances of the death
On 27th March 2011 Kingsley Burrell was detained under S136 of the Mental Health Act following an incident at the Hayer Supermarket in Birmingham. Mr Burrell had claimed he and his son were threatened by men with a fire arm. CCTV from the shop did not confirm such an event. Mr Burrell had to be restrained for the S136 detention. He was taken to a place of safety at Oleaster hospital where he remained for over 4 hours. During this time he was restrained by officers. Mr Burrell was spitting at officers. After a mental health assessment Mr Burrell was detained under S2 of the MHA and taken to Meadowcroft psychiatric intensive care unit based at the Mary Seacole hospital in Birmingham.
On 30th March 2011 at around 5.15pm, Mr Burrell became aggressive and threatened staff. As a result 4 police officers attended and Mr Burrell was restrained with handcuffs to the rear and leg restraints. During the restraint he had been hitting his head on the floor which caused a cut to his left eye. He was also spitting at officers. Mr Burrell was sedated with an intramuscular injection. Arrangements were made to take Mr Burrell to a seclusion room at another hospital. An ambulance was called which had an emergency medical technician and a trainee emergency medical technician as crew. The ambulance staff decided to take Mr Burrell to A&E for his eye to be treated. He was then to be taken to the seclusion room at the Oleaster hospital. During the journey to A&E, Mr Burrell remained in restraints and was strapped to an ambulance trolley. 2 police officers travelled with him in the back of the ambulance with the trainee emergency technician. No mental health nurse travelled with Mr Burrell.
On arrival at the A&E department, he came out of sedation and became aggressive and was spitting. His eye was sutured whilst he remained under restraint with police officers, one of whom was straddling his legs on the A&E trolley to keep him still. Mr Burrell continued to spit. As a result the trainee emergency medical technician placed a blanket over Mr Burrell’s head. Mr Burrell was still restrained and on a trolley with straps applied. This was seen on CCTV.
Mr Burrell was taken to the seclusion room by ambulance staff and the 4 police officers. Once in the seclusion room the restraints were removed but the head covering remained in place. The police and ambulance staff left the seclusion room and mental health staff were observing Mr Burrell through a viewing window. No physical checks had been undertaken on Mr Burrell. At the start of seclusion at 19.50, Mr Burrell’s respiration rate was noted to be 7. At 20.05 it was noted to be 4. CPR was started at 20.18. The first defibrillator had no pads so a second was requested. Staff incorrectly attempted to use a nebuliser mask to provide oxygen. The ambulance service records the 999 call at 20.21 and were at the patient’s side at 20.28. Mr Burrell was then taken to Queen Elizabeth Hospital where he died on 31st March 2011. The total period of restraint and struggle against restraint was 2 ½ hrs.
The jury at the inquest found that:
• Mr Burrell was suffering from an acute behaviour disturbance on the 30th March 2011.
• The covering applied to Mr Burrell’s head remained in place from A&E to the time when he suffered cardiac arrest in the seclusion room and that this contributed to his death.
• Periods of restraint were unreasonable and contributed to his death.
• Delay in instigating resuscitation contributed to his death.
• Neglect contributed to Mr Burrell’s death.
Coroner’s concerns
(1) Medical evidence at the inquest confirmed that Mr Burrell was suffering from acute behaviour disturbance. As a result he continued to struggle against restraint. Patients with this condition are at risk of death through prolonged restraint and struggle against restraint. Most training in relation to restraint deaths focuses on positional asphyxia. Position in this case was not a major consideration. It was clear from the inquest that there was a lack of understanding of how to treat someone with an acute behavioural disturbance. Minimising the period of restraint is key. West Midlands Police have undertaken considerable work and training of staff concerning this condition. My concern is that this has not been rolled out nationally and therefore many other forces will not understand the implications of this condition and how best to treat it. I suggest contact is made with Chief Inspector Russell at WMP for full information on the changes made in the West Midlands area.
(2) The West Midlands area now have a crisis team that works with people who are in a mental health crisis. This involves a mental health worker and ambulance crew working together with the Police to try to help patients with acute mental health disorders. My concern is that this is not a national system. Chief Inspector ███████ at West Midlands Police can provide full details of the scheme.
(3) This case has resulted in a multi-agency review of how patients are managed between the services when crisis occurs. A new conveying of patients policy has been devised. Critically police now only attend a mental health ward if there was a patient who is threatening staff or there is disorder on the ward. My concern is that this is not reflected nationally. Chief Inspector ███████ at West Midlands Police can provide full details of the policy.
Information checked against the published report and official responses