Michael Sweeney

Executive Office 
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Dr ME Hassell 
Senior Coroner Inner London 
St Pancras Coroner‟s Court 
Camley Street  
London N1C 4PP 

Our ref: 
Your ref  

Dear Dr Hassell 

14 November 2013 

Michael James Sweeney – Prevention of Future Deaths report 

Thank you for your letter dated 23 September 2013 enclosing a Prevention of Future Deaths 
report  made  under  the  Coroners  and  Justice  Act  2009,  paragraph  7,  Schedule  5,  and  the 
Coroners (Investigations) Regulations 2013, Regulations 28 and 29. The report brings to my 
attention  the  issues  and  recommendation  for  consideration  by  the  London  Ambulance 
Service  NHS  Trust  (LAS)  from  the  inquest  touching  the  death  of  Michael  James  Sweeney 
under the Preventing Future Death Powers of Her Majesty‟s Coroners: 

From  the  evidence  I  have  heard,  the  safest  and  most  effective  way  to  deal  with  a  person 
exhibiting  such  an  acute  behavioural  disturbance  seems  to  be  simply  to  use  the  term 
“extreme  agitation”.  This  would  require  London  Ambulance  Service  to  amend  its 
protocols and training to recognise extreme agitation as a medical emergency and to 
prioritise appropriately. 

We  have  carefully  considered  this  recommendation  and,  in  doing  so,  we  have  discussed 
with colleagues in the Police Services in London and we have reviewed guidance from other 
bodies and sought to engage others in the process. The term „excited delirium‟ is in common 
use  between  the  police  and  the  London  Ambulance  Service,  and  is  commonly  used  by 
specialist clinicians involved in the management of these patients.  

The  London  Ambulance  Service  NHS  Trust  (the  LAS)  remains  of  the  view  that  „acute 
behavioural  disturbance‟  is  the  term  that  most  accurately  reflects  the  presentations  of  this 
group  of  patients  as  well  as  being  recognised  by  the  appropriate  bodies  and  we  do  not 
consider  that  the  recommendation  can  be  agreed  unless  /  until  the  change  in  terminology 
accords with national guidance for UK ambulance services.  

The LAS has worked consistently over the last 10 years to raise the profile of patients with 
markedly deranged behaviour, and the associated risk profile that exists for these patients. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 We recognise that this clinical condition is often associated with catastrophic outcome which 
requires a careful multi-disciplinary strategy to ensure optimum care. 

We  welcome  the  approach  that  you  have  taken  in  recognising  that  there  are  a  number  of 
terms used to describe such patients, and the confusion that may subsequently occur  as a 
result  of  this.  The  terms  used  include  but  are  not  limited  to:  excited  delirium,  extreme 
agitation and acute behavioural disturbance.  

The LAS alongside our colleagues in the Police Services  in London currently use the term 
acute  behavioural  disturbance  (ABD)  to  describe  the  clinical  manifestation  of  disturbed 
behavior,  which  is  often  associated  with  recreational  drug  use  and  /  or  some  aspects  of 
mental health. The term is described by the Faculty of Forensic and Legal  Medicine of the 
Royal  College  of  Physicians  (England)  in  their  helpful  guidelines  paper  dealing  with  the 
recognition and treatment of this clinical presentation1. It is from these guidelines, produced 
by  this  leading  clinical  authority  on  the  subject,  that  the  LAS  have  taken  the  view  that  the 
term “acute behavioural disturbance” (ABD) is appropriate to describe this group of patients 
and have used this term in the education of our staff.  

The term “excited delirium” has also been used historically within the LAS and as such our 
recent communications with staff have included reference to both ABD and excited delirium. 
The LAS takes the view that the term ABD is now in common use between the police and 
the LAS and by specialist clinicians involved in the management of these patients. The LAS 
is also using the term of acute behavioural disturbance within the patient group direction that 
is  currently  going  through  the  clinical  governance  processes  of  the  LAS  to  allow  certain 
paramedics to use midazolam in assisting in the pre-hospital treatment of acute behavioural 
disturbance. 

We recognise that the evidence you heard was that some Emergency Department staff were 
not familiar with the term ABD and as such we will share this response with the Pan-London 
Emergency Department Consultants Group in order to disseminate the use of the term ABD 
to the Emergency Departments in London. 

On  18th  October  2013  at  the  meeting  of  the  Metropolitan  Police  Clinical  Advisory  Group, 
there  was  consensus  that  the  term  ABD  was  already  in  common  use  by  paramedics, 
Emergency Medical Technicians, police officers and the forensic clinicians.  The Group has 
senior  medical  and  clinical  representation  from  the  LAS,  the  Metropolitan  Police  Forensic 
Medical  Services,  and the  Education and Training  Departments  of  both  organisations. The 
group‟s  view  was  that  to  re-educate  our  staff  on  the  use  of  a  different  term  would  be 
challenging, and may well present a greater risk by using terminology that the pre hospital 
multi-disciplinary team may not be familiar with. It was felt that the term “extremely agitated” 
does  not  adequately  describe  this  particular  clinical  presentation,  is  open  to  wide 
interpretation,  and  would  not  prompt  the  appropriate  timely  response.  In  essence,  it  is  the 
use of the word “acute” that is felt to be key. Since April 2013 the LAS has been upgrading 
the triage category (to our highest level of response) of calls from the police where there is 
information which notes the patient is suffering from acute behavioural disturbance, cocaine 
toxicity, or is being physically restrained.          

The subject of acute behavioural disturbance has been a developing area of medicine and 
since the April 2011, and the time of Mr. Sweeney‟s death, there has been a considerable 
increase  in  the  literature  on  this  subject  including  the  above  guidance  from  the  Faculty  of 
Forensic and Legal Medicine. 

The terms acute behavioural disturbance/excited delirium or extreme agitation do not appear 
within  the  Joint  Royal  College  Ambulance  Liaison  Committee  /  Association  of  Ambulance 
Chief Executives National Clinical Guidelines (2013). There is a single reference to the term 

1 Norfolk G, Stark M, Travis M Acute behavioral disturbance: guidelines on management in police custody (2011) Faculty of 
Forensic & Legal Medicine,  

 
 
 
 
 
 
 
                                                           
 excited  delirium,  which  specifically  relates  to  police  incapacitant  devices  (TASERS).  We 
have  raised  this  issue  through  the  national  Ambulance  Service  Mental  Health  Working 
Group,  asking  them  to  look  both  at  the  appropriate  terminology  and  guidance  around  the 
subject  matter  itself.  The  national  Ambulance  Service  Mental  Health  Working  Group  has 
confirmed  that  they  will  issue  a  position  statement  about  the  use  of  an  appropriate  term 
following a response to their proposal from the Royal College of Psychiatrists. 

I hope that you will be assured by the consideration the LAS has given to your report, and by 
the actions taken to explore this with the police services, and to ask the national Ambulance 
Service  Mental  Health  Working  Group  to  review  the  terminology  and  guidance  on  excited 
delirium.  Meanwhile  we  believe  that  by  sharing  this  response  with  the  Pan  London 
Emergency Department Consultants Group and with my Chief Executive colleagues the term 
ABD can be disseminated and better communicated across the emergency departments in 
London. 

Yours sincerely 

Ann Radmore 
Chief Executive

Coroner ME Hassell, 
Senior Coroner, 
Inner North London St Pancras Coroner’s Court, 
Camley Street  
London  
N1C 4PP 

By Email to: 

Director of Professional Standards 
Room 913 
Tower Block, 
New Scotland Yard 
10 Broadway 
London 
SW1H 0BG 

Your ref:  
Our ref:  

13 November 2013 

Dear Ms. Hassell, 

I  write  on  behalf  of  the  Metropolitan  Police  Service  in  response to  your Regulation  28:  Prevention  of  Future 

Deaths  report,  dated  23rd  September  2013,  following  the  inquest  touching  the  death  of  Michael  Sweeney, 

heard before you at the Coroners Court sitting at St Pancras Coroner’s Court on the 2nd day of September 

2013. 

As you will recall, you identified that the police officers’ use of the phrase ‘excited delirium’, based on training 

they had received prior to the incident, indicated that they had correctly recognised  Mr Sweeney’s behaviour 

as evidence of a major medical emergency.   

However, you also noted that the term ‘excited delirium’ had little currency outside the police service in the UK 

at the time of the incident, and in particular, was not at that time recognised by the professionals in the other 

two agencies, the LAS and the NHS, who were also involved in the incident. You recommended that all three 

agencies  agree  on  a  common  terminology  to  describe  the  ‘constellation  of  symptoms’  exhibited  by  Mr 

Sweeney. You noted that this constellation could in other incidents be attributed to a wide range of underlying 

causes, ranging from illegal substance abuse, to legal drug side effects, to various physical and mental health 

conditions, and it was therefore necessary to agree upon a term which did not imply any single presumptive 

diagnosis.  You  also  made  the  compelling  suggestion  that  since  what  was  being  described  was  a  medical 

emergency,  logic  would  dictate  that  a  term  meaningful  to  medical  personnel  should  be  the  one  adopted. 

Accordingly, your suggestion was that all three agencies should adopt the phrase ‘extreme agitation’.  

You suggested that following this logic would:  

1. 

require police to modify internal training to incorporate the new term, ensuring however that:  

2. 

the awareness that the ‘constellation of symptoms’ comprised a medical emergency must be retained 

in any such training;  

3. 

that  police  control  room  staff  must  receive  training  on  the  condition,  and  on  protocols  for  accurately 

communicating this information to the ambulance service; and finally,  

4. 

that the London Ambulance Service should amend its own protocols to recognise the condition.  

  
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 Point 4 above is of course a matter for the London Ambulance Service. I understand they will be replying to you 

separately on this. 'I would anticipate however that they will in that response make reference to the adoption of a 

new  Memorandum  of  Understanding  between  our  respective  services,  on  providing  ‘…guidance  on  joint  working 

including use of CAD Link and Joint Response Units’, which we are now in the final stages of completing. 

Accordingly,  I  will  now  address  the  overarching  proposal  that  ‘extreme  agitation’  be  the  adopted  common 

terminology;  the  three  outstanding  points  above  for  the  Metropolitan  Police  which  follow  from  the  proposal; 

and,  where  appropriate,  the  underpinning  provided  to  our  response  by  the  new  Memorandum  of 

Understanding.  I  have  been  assisted  in  this  by  subject  area  experts  in  Custody,  Policy,  and  Healthcare 

matters within the MPS; and will also make reference where appropriate to elements of joint working with our 

partner agencies.  

Use of a Common Terminology 

Views were first of all sought, within the MPS, and with our partner agencies, regarding the most appropriate 

common  terminology  to  adopt.  The  response  was  co-ordinated  by 

,  Senior  Advisor,  First  Aid, 

Policy  and  Assurance,  through  her  membership  of  the  interagency  Clinical  Panel  on  which  she  sits  with 

colleagues  from  the  London  Ambulance  Service  and  representatives  of  London  NHS  Trusts.  Her  stance  is 

supported  by 

  Medical  Director,  Metropolitan  Police  (with  overall  responsibility  for  the 

Forensic  Medical  Examiner  role  and  himself  a  practising  senior  doctor  of  Emergency  Medicine  and  former 

council  member  of  the  College  of  Emergency  Medicine);  and  Inspector 

  lead  on  Officer 

Safety  Training  related  issues,  who  provides  the  Metropolitan  Police  link  to  the  Association  of  Chief  Police 

Officers’ national policy debates on such matters.  

The  principle  of  adoption  of  a  common  terminology  is  universally  accepted  –  indeed,  the  Medical  Director 

supports broadening the stakeholder base further  to include additionally the College of Emergency Medicine, 

the  Department  of  Health,  and  the  Independent  Advisory  Panel  on  Custody  Deaths,  chaired  by 

The Medical Director is currently working to progress this. 

However,  the  use  of  the  particular  phrase  ‘extreme  agitation’  in  place  of  ‘extreme  delirium’  was  universally 

rejected, by both the local partner agencies approached by 

 through the Clinical Panel, and by the 

setters  of  national  police  policy  through  the  Association  of  Chief  Police  Officers,  as  reported  by  Inspector 

The reasons for this were as follows:  

Firstly,  the  suggested  replacement  phrase,  ‘extreme  agitation’,  as  several  subject  area  experts  pointed  out, 

risked introducing into the policing realm precisely the  same order of uncertainty the earlier phrase, ‘excited 

delirium’ represented in medical contexts.  This is because police are frequently called to deal with individuals 

who are extremely agitated, or described  variously as such in the mundane understanding of the term, who 

nevertheless  are  not  exhibiting  the  particular  ‘constellation  of  behaviours’  which  presages  a  medical 

emergency.  Using  this  category  of  general  descriptive  terminology  to  also  represent  a  highly  specific 

circumstance, it was felt, therefore runs the obvious risk of the unique medical emergency becoming lost in an 

undergrowth of ordinarily ‘extremely agitated’ persons.   

28/03/2016 

Page 2 of 5 

 
 
 
 
 
 
 
 
 
 Secondly, both national and Metropolitan Police training on the correct terminology to use have in fact already 

moved on since the date of this incident. Though the ‘constellation of behaviours’ has at various points in the 

developing  knowledge  about  it’s  causes  and  effects  been  known  (inter  alia)  as  ‘cocaine  psychosis’,  and 

‘excited  delirium’,  since  2010  the  generally  recognised  phrase  within  UK  police  contexts  has  been  ‘Acute 

Behavioural Disorder’ (‘ABD’). This phrase was chosen to provide exactly the “ ‘precision without ‘diagnosis’ “ 

you  indicated  would  be  a  necessary  element  of  any  common  terminology  adopted.    Inspector 

provides the practitioner’s context: 

“The Metropolitan Police Service Safer Restraint Review of 2005 recognised a growing concern that 

Excited Delirium (as the condition was known then) was too restrictive in scope and didn't necessarily 

address conditions with wider substance  abuse  and mental  health  triggers.  Advice was sought  from 

healthcare  professionals  from  the  US  and  UK  -  most  notably  Professor 

  and 

pathologist 

 who is a member of 

 Independent Advisory Panel. 

The generic term Acute Behaviour Disorder was selected as the most appropriate term and ABD was 

subsequently  fast-tracked  into  the  National  Personal  Safety  Manual.  The  Faculty  of  Forensic  and 

Legal  Medicine  also  adopted  the  terminology  of  ABD,  and  have  produced  guidance  on  the 

management  of  this  condition.  The  medical  implications  of  the  manual's  techniques  and  guidance 

(including  ABD)  were  reviewed  by  Professor 

  in  2010.  Furthermore,  additional 

improvements  were  most  recently  made  to  the  ABD  advice  by  Professor 

  in  2012, 

following Rule 43 advice in another case.  

The  proposed  new  term  in  the  current  case  [extreme  agitation]  was  discussed  at  the  National  Safe 
Detention And Restraint  (SDAR) Practitioners' meeting in Durham on the 1st October 2013. SDAR is 

the policing lead for Officer Safety Training nationally and represents the police services of England 

and  Wales,  in  addition  to  partner  agencies  including  the  Home  Office,  College  of  Policing,  the 

Independent  Police  Complaints  Commission,  the  Health  &  Safety  Executive,  the  National  Offender 

Management Service and IMSAP, an independent medical advisory panel. 

As expected, the suggestion to rename Acute Behavioural Disorder (ABD) was unanimously rejected 

by  the  committee  owing  to  the  significant  consultation,  research  and  training  investment  during  the 

past  ten  years,  for  police  at  national  and  local  level,  and  for  the  aforementioned  partner  agencies, 

which has led to ABD being firmly embedded in national police training - both Officer Safety Training 

and  Emergency  Life  Support.  For  these  reasons,  SDAR  is  confident  that  national  police  training 

remains at the forefront of ABD issues. Whilst the committee wholeheartedly agrees with the necessity 

of  a  joined-up  approach  throughout  the  emergency  services,  it  respectfully  requests  that  partners 

recognise the comprehensive antecedents of ABD, and consider the adoption of this established term 

rather than introduce a new one.” 

At present,  therefore, the ‘constellation of behaviours’ now and for some years past described by the MPS as  

Acute Behavioural Disorder remains an active part of every officer’s regular Officer Safety and Emergency Life 

Support Training.  

The logic of this position, and use of the phrase ‘Acute Behavioural Disorder’ has also been adopted by the 

London Ambulance Service in the still ongoing joint agency work represented in the MPS/LAS ‘Memorandum 

28/03/2016 

Page 3 of 5 

 
 
 
 
 
 
 
 of Understanding’, the final draft of which we anticipate signing off imminently. In a practice note issued to all 

LAS staff by their Deputy Medical Director Fenella Wrigley on 30th August 2013, she stated: 

“All [LAS] staff must ensure they review all MPS CAD link calls, for the following terms: 

  Acute Behavioural Disturbance or the initials ABD 

  Excited Delirium 

  Cocaine Toxicity 

  And ANY call where the patient is described as BEING PHYSICALLY RESTRAINED.” 

Following identification of any such call, her note directs, LAS staff must refer the call to an on-call clinician 

who  in  turn  must  upgrade  the  response  category  of  the  call  to  their  most  urgent  category  ‘RESP  1’,  and 

establish contact with responding medical staff to offer additional clinical support.  

In a separate development, a cadre of paramedics with the means to sedate violent patients - a tactic which 

has  shown  some  success  in  reducing  the  risk  of  fatality  in  American  incidents  of  ABD  -  is  currently  being 

considered  as  a  preferred  choice  of  medical  deployment,  where  available,  to  situations  where  ABD  is 

suspected.  

Meanwhile, in a response to coroner in another recent unrelated case, on the  6th of September 2013, senior 

London Ambulance Service managers 

 LAS Medical Director, and 

 LAS Director 

of  Service  Delivery  underlined  their  commitment  to  the  terminology  preferred  by  police,  and  to  working 

practices in support of an improved response where it is noted, by quoting from a further practice note they 

had sent  to all  staff.  In  a  passage  of  the  note  dealing  with  responses  to  four high risk  categories  of  patient, 

they inform their staff that: 

"…Acute  Behavioural  Disturbance  /  Excited  Delirium...are  conditions  where  a  patient's  behaviour  is 

significantly  altered  and  often  displaying  one  or  more  of  the  following:  Acutely  bizarre  or  aggressive 

behaviour;  impaired  thinking;  disorientation;  paranoia  or  hallucinations.  These  patients  may  have  a 

history of illicit drug use (such as cocaine) and/or psychiatric illness. Acute behavioural disturbance / 

excited  delirium  carries  a  significant  mortality  risk  and  during  restraint  these  patients  require  careful 

monitoring to ensure their safety." 

The note concludes by asking staff to reacquaint themselves with the joint MPS/LAS-produced training DVD 

Death in Police Custody & LAS Medical Advice, which contains content on Acute Behavioural Disorder. 

These  moves  to  enhance  staff  awareness  of  the  condition  and  the  terminology  of  ABD  to  describe  it, 

undertaken by our partners in the LAS, have been mirrored in steps undertaken within our own call-handling 

centre,  the  Central  Communications  Command  (CCC).  On  the  20th  September  2013,  Chief  Inspector 

Horwood issued the following practice direction to all Central Communications Command Staff: 

With immediate effect any call, where the LAS have been, or are being requested where the patient is: 

A)  Believed  to  be  suffering  from  Acute  Behavioural  Disorder  (commonly  referred  to  as  ABD)  or 

described as having Excited Delirium 

28/03/2016 

Page 4 of 5 

 
 
 
 
 
 
 
 
 
 
 B) Suffering from Cocaine Toxicity 

C) Currently being PHYSICALLY RESTRAINED 

Then  this  must  be  placed  in  the  free  text  of  the  [message]  and  sent  to  the  LAS.  The  LAS  will  then 

classify this as a RESP 1 (8 minute intended response). 

Operators  are  reminded  that  where  there  is  a  significant  change  to  a  current  demand,  then  a  new  CAD 

message with a new [message to LAS] must be completed.” This message was reinforced with a copy of the 

parallel LAS practice note to their own establishment, and further, specific training for CCC civilian staff (who 

do not receive the ABD message through officer safety and emergency life support training that police officers 

working at CCC routinely receive).Conclusion 

Your recommendation regarding a common terminology has been accepted by all partners. It is respectfully 

submitted  however  that  the  adoption  by  the  London  Ambulance  Service  of  the  term  ‘Acute  Behavioural 

Disorder’ as the term of choice effectively negates  the additional training changes recommended in points 1 

and 2 of your report, as active training on ABD and responses to it remain an ongoing element in all regular 

refresher  training  sessions  for  police  officers,  and  this,  we  are  given  to  understand,  is  now  being  paralleled 

within the LAS via their own training and practice direction regimes.  

The  potential  information  gap  for  MPS  civil  staff  working  at  Central  Communications  Command  who  do  not 

receive this training routinely has been addressed by the issuing of direct practice notes, and supported by a 

programme of in-house training on awareness of the issues and correct procedures to adopt. Meanwhile, the 

development  of  a  detailed  and  documented  joint  agency  call-handling  protocol  with  our  partners  at  London 

Ambulance  Service,  contained  within  the  new  Memorandum  of  Understanding,  gives  both  ‘First  Responder’ 

agencies a common wellspring of guidance to draw upon, a robust channel of communication where ABD is 

suspected,  and  clarity  regarding  the  expectations  each  agency  can  have  of  the  other’s  response  in  these 

circumstances. It is now important that staff in emergency departments are also made aware of this condition 

and its management. The Medical Director, in his capacity as a senior emergency medicine practitioner, will 

therefore  seek  to  encourage  the  adoption  of  the  terminology  in  this  domain,  and  to  increase  the  supporting 

awareness by our partners in the NHS. 

I  hope  therefore  that  you  will  agree  with  me  that  the  above  package  of  measures  demonstrates  that  the 

Metropolitan  Police  Service  is  responding  effectively  to  the  concerns  highlighted  by  the  inquest  into  Mr 

Sweeney’s death.  

Yours sincerely 

Allan Gibson 

Commander 

Director of Professional Standards 

28/03/2016 

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