Leon Briggs

Association of Ambulance Chief Executives 
25 Farringdon Street 
London 
EC4A 4AB 

W:  www.aace.org.uk 

29 November 2021 

Senior Coroner – Emma Whitting 
Bedfordshire & Luton 

Dear Ms Whitting 

REGULATION 28:  LEON BRIGGS 

I am writing in response to the Regulation 28 report to prevent future deaths concerning the death 
of Leon Briggs which you issued on 4th  October 2021 to 
 chair of the Association of 
Ambulance Chief Executives (AACE). Please note that as Managing Director of AACE, I am 
responding on his behalf. 

AACE is a private company owned by the English Ambulance NHS Trusts. It exists to provide 
ambulance services with a central organisation that supports, co-ordinates and implements 
nationally agreed policy. Our primary focus is the ongoing development of the English ambulance 
services and the improvement of patient care. It is a company owned by NHS organisations and 
possess the intellectual property rights of the Joint Royal Colleges Ambulance Liaison Committee 
UK ambulance service clinical practice guidelines (the “JRCALC guidelines”). AACE is not 
constituted to mandate or instruct ambulance services however it has national influence via the 
regular meetings of ambulance Chief Executives and Trust Chairs along with a network of 
national specialist sub-groups. One of its specialist sub-groups is the National Ambulance Service 
Medical Directors (NASMeD); this response is from AACE having been informed by NASMeD. 

With regard to your matter of concern about the adequacy of the local S136 Multi-Agency Policy. 
We are unable to comment on local S136 policy, but we can confirm that the national S136 
guidance has recently been revised, updated, and issued nationally. The revised guidance 
includes wording to highlight that the police officer on scene should call the local ambulance 
service and include in the information passed whether the patient is being actively restrained and 
if so how, and if acute behavioural disturbance (ABD) is suspected. Ambulance trusts will assign a 
Category 2 response to patients detained under S136 and suspected of having ABD unless there 
are other immediately life-threatening clinical features that would warrant a Category 1 response. 

The national S136 guidance highlights that ambulance services must involve a clinician in any call 
where a patient is being actively restrained so that clinical support can be provided and the 
patients vital signs monitored. The revision also includes wording to highlight the fact that if a 
patient is restrained incorrectly there may be an increased risk of positional asphyxia, so it is vital 
that the patient’s airway and breathing is carefully monitored at all times during restraint. 

AACE works closely with the police via the National Police Chiefs Council (NPCC) and liaises with 
them on a regular basis. We have emphasised the importance of direct contact from the officer on 
scene to the ambulance control and suggested that police forces explore with their ambulance 
trusts how this can be established if not already in place. 

 
 
 
 
 With regard to your matter of concern around lack of sufficient training for police officers, 
ambulance crew and other front-line responders and the critical issues of recognising and 
responding to a medical emergency and the effects of restraint. We are unable to mandate the 
training that is required, nor the depth and degree of training. This is for local ambulance trust 
determination. However, we are very aware of the need for emphasis on and relevant training in 
this important area. 

In the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) UK ambulance service 
clinical practice guidelines we developed and published a new guideline around acute behavioural 
disturbance in December 2019. The guideline highlights the importance of trying to minimise 
physical restraint for fewer than ten minutes and avoid airway or respiratory compromise. We are 
aware that factors have been proposed as contributory to sudden death in ABD and other types of 
intoxication such as amphetamines, positional asphyxia secondary to restraint, drug toxicity itself 
or underlying cardiac disease resulting in cardiac arrhythmias. We suggest that provided there is 
not an immediate risk to life, verbal de-escalation should be attempted before restraint or 
pharmacological agents are used. We emphasise that clinicians on-scene are responsible for the 
clinical safety of the patient at all times and should immediately inform any other personnel on-
scene if they believe the patient’s clinical condition is at risk of deteriorating, particularly if there is 
any restriction to the patient’s airway or breathing. The first healthcare professional on scene 
should be specifically responsible for monitoring and treating the patient. Any other healthcare 
professionals or ambulance staff in attendance should be closely liaising with the designated 
police safety officer. During restraint, clinicians should be prepared for a rapid deterioration in the 
patient’s condition, including cardiovascular collapse. On 1st  February 21 we updated the acute 
behavioural disturbance guidance with wording to emphasise the need for close monitoring of a 
patient when restraint is used and that the clinician is clinically responsible for the patient. 

We have also developed national JRCALC guidance around Mental Health Presentations 
including Crisis, Distress and Disordered Behaviour.  In this guideline, we also have a section 
highlighting the risks of physical interventions including restraint. 

I trust that this response addresses your concerns.  If I may be of further assistance, please do 
not hesitate to make contact. 

On behalf of AACE, I would like to extend our sincere condolences to the family of Leon Briggs. 

Yours sincerely 

Managing Director

Deputy Chief Constable 

Force Headquarters, Woburn Road 
Kempston, Bedford, MK43 9AX 

26th November 2021 

Ms Emma Whitting 
Senior Coroner for Bedfordshire 

Dear Ms Whitting, 

Regulation 28 Report – Leon Briggs 

I write in response to your regulation 28 report to prevent future deaths dated 4 October 2021 (‘the 
report’) addressed to the Chief Constable of Bedfordshire. This is the formal response of Bedfordshire 
Police. 

I start by repeating the apology which I made on 12 March 2021, acknowledging that the Inquest Jury 
had identified a number of significant failings by police which contributed to the death of Mr Briggs in 
2013  and  for  which  we  are  truly  sorry.  The  Jury  recorded  their  specific  findings  in  the  Record  of 
Inquest, including that Mr Briggs’ death was contributed to by neglect. 

The matters of concern identified in the report relate to the adequacy of the local section 136 multi-
agency  policy;  lack  of  sufficient  training  for  police  officers,  ambulance  crew  and  other  front-line 
responders; and the adequacy of monitoring of detainees, subject to restraint. 

Bedfordshire Police has considered the terms of your report carefully and consulted relevant local and 
national stakeholders before giving the following response. 

Adequacy of the local section 136 multi-agency policy 

As  you  are  aware  from  the  evidence  at  the  inquest,  the  policy  which  applied  in  2013  had  been 
superseded.  The  current  policy  is  under  a  task  and  finish  group.  It  was  reviewed  by  the  current 
National  Lead  for  Mental  Health,  Deputy  Chief  Constable 
,  whose  team  stated  they 
thought it was comprehensive. Additionally, officers met with partners on 13 October 2021 to review, 
update  and  confirm  understanding,  which  took  place  with  the  benefit  of  the  concerns  you  have 
identified. A revised policy is due to be signed-off this year. I will ask my legal services department to 
provide you with a final copy as soon as it has been signed off. 

 
 
 
 
 Significant  learning  came  out  of  the  Briggs  Inquest  and  resulted  in  the  local  multi-agency  Mental 
Health Hub being even more determined to form better working practices with our partner agencies. 
Despite good working relationships already, there are still challenges for front-line officers including 
medically-supervised transport; resourcing;  making  sure ambulance  colleagues are leading medical 
assessments, monitoring and taking responsibility for medical situations brought to their attention; 
and ensuring there are routes into emergency departments. 

Chief Constable 
, CEO for the College of Policing, confirmed in his meeting with the Chief 
Constable of Bedfordshire on 29 October 2021, the current College of Policing and National Police 
Chiefs’ Council (NPCC) Mental Health Leads are the most appropriate sources of guidance and support, 
and referrals to experts, and will continue to act as consultees in these respects. 

Lack of sufficient training for police officers, ambulance crew and other front-line responders 

The  Chief  Constable  met  with  the  National  Lead  for  restraint’s  team,  headed  by  Deputy  Assistant 
Commissioner 
,  on  29  October  2021.  The  national  position  is  that  officers  are  not 
mental health practitioners and that the skills officers have are not the same as those of clinicians and 
practitioners in mental health units. It is important to keep in mind that police officers should defer to 
ambulance staff and clinicians on medical matters because of their specialist training and focus. 

However, Bedfordshire Police officers do receive training on section 136, mental health awareness 
and First Aid (see below) and the regular training provided to all officers and meets the standards set 
out by the College of Policing. If you would like more detail regarding the current training provision, I 
will ask my legal services department to provide you with all the relevant units and guidance. 

The circumstances of Mr Briggs’ death, which again I acknowledge the Jury found was contributed to 
by neglect in the particular circumstances of his case, is well known to those responsible for training 
and refresher training, and will have a lasting impact on their provision of training to individual officers. 

Adequacy of monitoring of detainees, subject to restraint. 

The  College  of  Policing  has  issued  updated  Authorised  Professional  Practice  (APP),  and  provides 
‘College  Learn’  (formerly  NCALT)  with  regards  Officer  Safety  Training,  First  Aid  and  Mental  Health 
Awareness. These packages have been updated significantly since 2013 to reflect learning with regards 
to awareness of Acute Behavioural Disturbance (ABD) and principles of detainee monitoring. 

Our policies around ‘observation and risk assessment’ of a detainee in custody, also provided in Use 
of Force training, reflect national guidance from the College of Policing, which in turn is reinforced by 
respective NPCC Leads. 

Bedfordshire Police highlighted, in light of your report, the ‘NHS Patient Safety Alert’ to the National 
Mental Health Lead. Their view was that this document reinforced the requirement for monitoring of 
‘vital signs’ for patients post restraint. Monitoring of vital signs, as referred to in a clinical context, is 
not  something  officers  are  trained  or  equipped  to  do.  However,  officers  do  receive  the  modern 
training referred to above (including First Aid) and it was felt that a separate document adapting the 

 
 
 
 
 
 
 
 
 
 NHS  Patient  Safety  Alert  may  lead  to  duplication,  or  create  confusion.  On  reflection  it  would  be 
preferable to incorporate any additional guidance into existing guidance for the relevant policing areas 
such as Use of Force and Custody. 

I make clear that all officers involved in the provision of restraint and care to a detainee are required 
to  monitor  the  detainee.  That  did  not  happen  appropriately  in  Mr  Briggs’  case.  While  we  cannot 
guarantee a particular specialist level of additional monitoring in every case, due to the significant 
variety of circumstances and resourcing challenges, there is in the current training the concept of a 
‘Safety  Officer’,  where  possible  a  supervisor,  who  will  not  have  a  hands-on  role  in  restraint  of  a 
detainee but will be observing them and looking for any signs of problems and can give advice to the 
officers performing restraint. 

The National Lead for Mental Health informed Bedfordshire Police that at the NPCC National Forum 
in July 2021, an update was provided by Chief Superintendent 
 of South Yorkshire Police, who 
 (Medical Director for West Yorkshire Metropolitan Ambulance Service, 
is working alongside Dr 
and Consultant in Emergency Medicine and pre-hospital care at Mid Yorkshire Trust) on a national 
ABD policy. I understand that it is likely that, once completed, a request will be made to the NPCC and 
College  of  Policing  to  incorporate  any  recommendations  from  this  review  into  APP,  including 
recommendations  being  made  for  officers  to  formally  declare  suspected  ABD  cases  as  ‘critical 
incidents’ therefore ensuring they receive immediate management oversight. 

Bedfordshire Police are grateful to the Coroner for the opportunity to address the steps which have 
been, and are being, taken in respect of the matters of concern outlined in the report. And, again, I 
will ask that you be forwarded the most up to date multi-agency policy as soon as it has been signed 
off. 

Yours sincerely 

Deputy Chief Constable

Ms Emma Whitting 

     Senior Coroner for Bedfordshire 

East of England Ambulance Service NHS Trust 
Whiting Way 
Melbourn 
Cambridgeshire 

SG8 6NA 

22 November 2021 

Dear Ms Whitting 

Thank you for your communication regarding the Regulation 28 (Report to Prevent Future Deaths) in 
respect of the death of Leon Briggs. I would like to offer my condolences to Leon’s family and those 
affected by this tragic event. 

I have responded to the points raised in the Regulation 28 report separately below: 

1.  Adequacy of the local S136 Multi-Agency Policy  

Whilst the local S136 guidance has changed considerably since the death of Leon, in my 
view, it is still not fit for purpose for the following reasons: (i) It requires streamlining and 
re-formatting (including the use of a larger font) to make it easier for all agencies to follow 
–  it  may  assist  to  focus  on  multi-agency  activities  ONLY  (leaving  individual  agencies  to 
provide their own specific policies to support the multi-agency interaction) (ii) Reference 
to other  regulations  might  best  be  avoided (see  for  example 3.3)  so  that it  can  stand  as 
freestanding  guidance  for  those  attending  fast  moving  incidents  to  apply  without  delay; 
(iii) The guidance should closely follow the chronology of a relevant incident i.e. it should 
start  with  the  decision  to  detain,  followed  by  the  relevant  risk  assessment,  appropriate 
conveyance, place of safety etc. Information regarding permitted periods of detention and 
roles and responsibilities could be dealt with at the end.  

You  also  suggested  that  agencies  work  with  an  expert  in  this  field  to  facilitate  these   
improvements.   

The National Ambulance s.136 Guidance was recently approved (November 2021) by the National 
Ambulance Service Medical Directors group (NASMED), which is a working group that reports to 
the Association of Ambulance Chief Executives (AACE). These changes will now be implemented 
locally  and  this  work  is  being  led  by  the  Bedfordshire  AMHPs  (on  behalf  of  the  Crisis  Care 
Concordat) and the forum includes representation from both EEAST and Bedfordshire Police.  

The updated national guidance highlights that the police officer on scene should indicate if ABD is 
suspected and if the patient is being restrained. Nationally, the agreement is that these patients 
will warrant a Category 2 response as a minimum. Within EEAST, the decision has been made that 
patients  who  are  detained  under  s.136  and  being  restrained  by  the  police  will  be  treated  as 
Category  1  calls  in  line  with  the  attached  EOC  Standard  Operating  Procedure.  The  national 

www.eastamb.nhs.uk 

 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 guidance also directs ambulance services to ensure a clinician is involved in the call and highlights 
the risk of positional asphyxia if the patient is being restrained incorrectly. 

EEAST’s Mental Health team have also been working on updating the guidance documents for our 
partners  in  relation  to  managing  s.136  patients  within  the  community  setting.  This  document 
‘Requesting Conveyance for Patients Detained under the MHA’ will be sent to you once the review 
and update has been completed in December 2021. This will also be shared with the regional police 
forces and mental health partners through the regional Approved Mental Health Practitioner.  

2.  Lack  of  Sufficient  Training  for  Police  Officers,  Ambulance  Crew  and  other  Front-Line 

Responders.  

Although, the MHCCC Strategic Group are progressing joint training for all first responders 
including  hospital  staff  who  might  need  to  assess  medical  fitness  and/or  treat  S136 
detainees, it was clear from the evidence heard at the Inquest that there remains insufficient 
or inadequate instruction of both police and ambulance crew about the critical issues of 
recognising and responding to a medical emergency and the effects of restraint including 
positional  asphyxia.  Consideration,  therefore,  needs  to  be  given  by  National  and  Local 
Police  and  Ambulance  services  as  to  whether  the  current  individual  service  training 
(including  refresher  training)  is  adequate  (and  of  similar  level  to  that  provided  to  those 
working in Mental Health Units pursuant to the Mental Health Units (Use of Force) Act 2018) 
to ensure the welfare and safety of S136 detainees. 

Since this inquest, EEAST’s Mental Health Team have worked collaboratively with the NHS partner 
organisations across  the  East  of  England   to develop  and implement  a new  mental  health care 
service model. The manager’s briefing relating to this new model has been attached with this letter 
and  outlines  the  changes  that  have  been  made.  Our  chosen  service  model  is  to  establish  an 
EEAST  Mental  Health  team  that  is  based  within  the  operational  setting,  working  alongside  our 
clinicians and linking with system partners. Through this model we hope to deliver relevant training, 
identify and improve access to appropriate care pathways and increase the confidence of our staff 
in the assessment and management of presenting mental health need across the organisation.  

EEAST has also developed a specific training session in relation to Acute Behavioural Disorder, 
including  positional  asphyxia.  The  commencement  of  this  training  session  is  planned  for  
2021/2022 for all frontline staff across EEAST as part of the Essential Care Skills, which is EEAST’s 
annual clinical update.  

In addition to this, in July 2021, the Mental Health Team reviewed and re-published the following 
pocket guides to all frontline staff: What is s.135/136; Mental state examination; Mental Health Act 
v Mental Capacity Act. The dissemination of these guides was supplemented by a video for staff 
to view. Further pocket guides relating to ABD and conveyance of mental health patients are in 
progress and will be published and shared with all patient-facing staff over the coming months. 

I  hope  this  letter  demonstrates  the  steps  the  Trust  is  taking  to  improve  our  response  and  care 
delivery to patients who may be detained and the associated risks that may arise when attending 
to these patients. Please do not hesitate to contact me should you require a further update. 

Yours sincerely 

Chief Executive 

www.eastamb.nhs.uk