Meirion James · Prevention of Future Deaths report

On 5th February 2015 I commenced an investigation into the death of Meirion James aged 53 years. The investigation concluded at the end of the inquest on 24th January 2019. The conclusion of the inquest was a narrative conclusion in accordance with the completed jury questionnaire which is appended to this report.

The medical cause of death was 1a. Positional Asphyxia; 1b. due to restraint following acute behavioural disturbance; 2. Obesity.

The deceased had been arrested for an assault on his mother and taken to Haverfordwest Police station.

In the immediately preceding period, he had been detained under Section 136 of the Mental Health Act 1983, following a roadside incident, but that fact had not been adequately communicated to the Custody Staff at Aberystwyth Police Station nor the medical staff at Glangwili hospital where he was taken as a (place(s) of safety.

He was subsequently discharged without a mandatory mental health assessment when he proceeded to commit the assault on his mother. While he was at Haverfordwest Police station he became agitated and attempted to leave his cell. He was restrained by police officers during the course of which he became located in the prone position on the floor.

He subsequently stopped breathing and despite attempts to resuscitate him, he died from positional asphyxia.

(1) Whether the content of police training in dealing with restraint should be addressed
(2) Whether the criteria for identifying the most appropriate place of safety and the responsibilities for transporting someone who is detained under Section 136 MHA 1983 should be reviewed
(3) Whether the content and frequency of police training on the status and responsibilities of an Appropriate Adult under the Police & Criminal Evidence Act should be reviewed.