Prevention of Future Deaths reports · 2022

Lee Brown

Regulation 28 report to prevent future deaths, reference 2022-0360, written 13 Nov 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report13 Nov 2022
Reference2022-0360
DeceasedLee Brown
CoronerNadia Persaud
Coroner areaEast London
CategoryPolice related deaths · State Custody related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

MISS N PERSAUD 
HER MAJESTY’S AREA CORONER 

EAST LONDON 

East London Coroners, Queens Road Walthamstow, E17 8QP 

REGULATION 28:  REPORT TO PREVENT FUTURE DEATHS (1) 

Ref: 100016 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

THIS REPORT IS BEING SENT TO: 

• 

 Secretary of State for Foreign, 

Commonwealth and Development Affairs 

1 

CORONER 

I am Nadia Persaud, Area Coroner for the coroner area of East London 

2 

CORONER’S LEGAL POWERS 

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 
and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 

3 

INVESTIGATION and INQUEST 

On 25th July 2015, I commenced an investigation into the death of Lee Bradley Brown, 
age 39 years. The investigation concluded at the end of the jury inquest on 4th 
November 2022. The conclusion of the jury was a narrative conclusion with neglect.  
The findings of the jury are as follows: 

Lee Bradley Brown’s death took place on the 12th April 2011 at 8pm in Bur Dubai Police 
Station in Dubai, UAE. 

The factors that probably contributed to Lee’s death were as follows: 

•  The beatings Lee Bradley Brown received from other detainees and police 

officers/guards 

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 •  The lack of adequate food and water 
•  The lack of habitable living conditions 
•  Lack of access to the necessary medical care whilst in Bur Dubai Police Station 

The factors that possibly contributed to Lee’s death were: 

•  The lack of access to consular services 
• 

Inadequate clothing provided for the conditions that he was staying in 

To confirm, neglect was by Dubai Police authorities [in Bur Dubai Police Station]. 

4 

CIRCUMSTANCES OF THE DEATH 

Lee Brown arrived in Dubai on the 7 April 2011.  He was arrested at the Burj Al Arab 
Hotel during the afternoon on the 7 April 2011.  He was taken to the Bur Dubai Police 
Station and placed into the custody of Dubai police authorities.  On the 8 or 9 April 2011, 
Mr Brown was placed into a solitary cell.  Telephone calls were made to the FCDO and 
to Mr Brown’s family on the 11 and 12 April 2011, by detainees of the Bur Dubai Police 
Station, reporting that Mr Brown was covered in bruises, was lying on the floor of his 
solitary cell and was in need of urgent assistance.  The family of Mr Brown made calls to 
the FCDO on the very late evening of the 11 April and during the 12 April to raise their 
concerns about Mr Brown and to request urgent consular assistance.  At around 22.00 
on the 12 April 2011 a guard observed Mr Brown in an unnatural position within his cell.  
A paramedic was called who pronounced his life extinct.  The medical examiner who 
attended at around 0100 on the 13 April 2011 considered that it is likely that Mr Brown 
had passed away around 8-9pm on the 12 April 2011.   

5 

CORONER’S CONCERNS 

During the course of the inquest the evidence revealed matters giving rise to concern. In 
my opinion there is a risk that future deaths could occur unless action is taken. In the 
circumstances it is my statutory duty to report to you. 

The MATTERS OF CONCERN are as follows.  –  

1.  The inquest heard evidence that there is no emergency access protocol to 

ensure that consular officers can reach detained British nationals in the event of 
a reported emergency.   

2.  The inquest heard concerns in relation to the current FCDO travel advice.  
There was considered to be insufficient information relating to the possible 
consequences of detention in Dubai (and the possible circumstances of such 
detention).  The inquest heard that the number of new cases of British Nationals 
reporting allegations of torture or mistreatment in Dubai to the FCDO has risen 
from 3% of the global total in 2016 to 13% of the global total in 2020.   

3.  A concern was raised at the inquest in relation to the procedures in place to gain 

consular access to detained British nationals who may be suffering from a 
mental health crisis.  Such British nationals may not be able to provide the 
necessary consent for consular services.  

6 

ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I believe you have the 
power to take such action.  

7 

YOUR RESPONSE 

2 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 You are under a duty to respond to this report within 56 days of the date of this report, 
namely by 9 January 2023. I, the coroner, may extend the period. 

Your response must contain details of action taken or proposed to be taken, setting out 
the timetable for action. Otherwise, you must explain why no action is proposed. 

8 

COPIES and PUBLICATION 

I have sent a copy of my report to the Chief Coroner and to the Interested Persons to the 
Inquest. I have also sent it to the local Director of Public Health who may find it useful or 
of interest. 

I am also under a duty to send a copy of your response to the Chief Coroner and all 
interested persons who in my opinion should receive it.   

I may also send a copy of your response to any other person who I believe may find it 
useful or of interest.  

The Chief Coroner may publish either or both in a complete or redacted or summary 
form. He may send a copy of this report to any person who he believes may find it useful 
or of interest.  

You may make representations to me, the coroner, at the time of your response, about 
the release or the publication of your response. 

9 

   13 November 2022                                       

3

Responses

1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.

Response from Foreign Commonwealth Development Office (PDF)
David Rutley MP 
Parliamentary Under Secretary of 
State (Americas & Caribbean)   

King Charles Street 
London 
SW1A 2AH 

            6 January 2023 

Dear Coroner, 

I am writing in response to your report dated 13 November 2022, following the inquest 
into the death of Lee Bradley Brown on 12 April 2011 in Dubai, United Arab Emirates. I 
am replying as the Minister for Americas and Caribbean. We welcome the opportunity to 
update you on changes the FCDO has made to improve our consular services since 
2011, and to inform you of other actions we have taken, or propose to take, in response 
to your report.  In doing so we again reiterate our sincere condolences to the family and 
friends of Mr Brown. 

In your report, you note three areas of concern. These are stated and addressed below.  

1.  The inquest heard evidence that there is no emergency access protocol to ensure 
that consular officers can reach detained British nationals in the event of a re-
ported emergency. 

It is important to begin by noting that the safety and security of individuals in a foreign 
jurisdiction is the responsibility of the host state and the relevant local authorities.   

The Vienna Convention on Consular Relations (VCCR) provides a mutual right of 
communication between consuls and nationals of a sending state.  If a national is 
arrested, committed to prison or to custody or is detained in any other manner, then, if 
the national so requests, the host state is obliged to inform us without delay.  Consular 
officers have the right to visit a British national who is in prison, custody, or detention.  
Standing instructions for British consular officers overseas are that British nationals 
should be contacted as soon as possible after their arrest or detention where possible.  

The local police or prison authorities have the responsibility for the welfare of all 
detainees and usually deal with arrangements for visiting or speaking to a detainee. We 
are reliant on the local authorities for the facilitation of visits and we cannot guarantee 
access will be given to any specific prison or detainee on an urgent basis or on a specific 
date.  

Since 2011, post Mr Brown’s death, we have developed further our overall consular 
services and our operating methods so that our 24/7 response is as effective as 
possible.  We continue to refine and improve our services for the benefit of British 
nationals abroad who seek our support and help.  Since 2017, a Consular Contact 
Centre (CCC) has triaged all consular calls no matter which country in the world they 
relate to or originate from every day of the year.  They respond to the majority of queries 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 directly and direct those needing specific assistance to the relevant Embassy1 or UK 
team to provide support.  Only 10% of all calls need specific assistance.  The remaining 
90% are handled directly at source by the CCC.  When an Embassy is closed, or the 
calls come in out of hours, the FCDO Global Response Centre (GRC) is available to 
assist 24/7.  This triaging by the CCC allows the GRC to focus on assisting the most 
urgent callers, such as the call made by Mr Brown’s family.  The GRC are able to act 
directly, as they have details for most key operations and personnel around the globe, 
but they can also ask the Embassy staff to assist them where in-person support is 
needed.  They also have access to a senior point of contact to whom they can escalate 
issues when necessary. 

GRC colleagues are specifically trained and use their professional judgement to decide 
when to escalate a call out of hours or contact a colleague for assistance in country.  
Nevertheless, as a result of the inquest, we have codified a protocol for the GRC to 
follow in the event of an emergency call where there is a risk to life.  We have also 
reminded GRC staff of our guidance on cases of torture and mistreatment (T&M).  By 31 
January 2023 all those working GRC shifts will have attended refresher training by 
FCDO’s Human Rights Advisers on our consular guidance on T&M cases.  Training on 
best practice in T&M cases has also been delivered to consular officers across the 
consular network over recent years.   

2.  The inquest heard concerns in relation to the current FCDO travel advice. There 
was considered to be insufficient information relating to the possible conse-
quences of detention in Dubai (and the possible circumstances of such deten-
tion). The inquest heard that the number of new cases of British nationals report-
ing allegations of torture or mistreatment in Dubai to the FCDO has risen; from 
3% of the global total in 2016 to 13% of the global total in 2020.  

The safety of British nationals abroad is always our main concern in providing our travel 
advice.  We keep our travel advice under regular review to ensure it reflects our current 
assessment of the risks in each country and that it contains information relevant to 
British nationals.  

Our consular team responsible for foreign travel advice is considering how we could 
reflect the risks associated with detention across the globe – including the UAE – in a 
way that enables British nationals to make better-informed decisions when they travel.  
We will consider how to represent this alongside other risks to British nationals so that 
we set out all the relevant risks, including those of torture or mistreatment, 
proportionately.  A broader internal review of FCDO Travel Advice is underway.  We will 
ensure the findings of the report are included in that work.  The review is expected to be 
completed in mid-2023. 

3.  A concern was raised at the inquest in relation to the procedures in place to gain 
consular access to detained British nationals who may be suffering from a mental 
health crisis. Such British nationals may not be able to provide the necessary con-
sent for consular services. 

FCDO staff are trained to help identify cases where an individual may have poor mental 
health and where they may require further assistance or may need their case to be 
prioritised.  However, consular officers are not trained or expected to take a view on 
whether someone has capacity to make decisions on their own behalf or to comment on 

1 While we have used the term Embassy as a short-hand, this could be an Embassy, High Commission or 
Consulate/Consulate-General 

 
 
 
 
 
 
  
 
                                         
 whether the local treatment is appropriate.  Where more specialist expertise and advice 
is required, consular staff have access to mental health experts in the FCDO who are 
able to guide and, where necessary, provide contact and liaison assistance with social 
services and other relevant providers. 

Improved training packages and enhanced support from our mental health specialists 
have been developed and implemented over the past several years as part of a wider 
scheme to improve consular staff’s understanding of potential mental health issues.  

The potential complications around obtaining consent to inform others, or informing 
others without consent, in relation to an individual with perceived or possible poor mental 
health is also an area that has been considered more broadly, particularly in light of our 
General Data Protection Regulation (GDPR) and Data Protection Act (DPA) 2018 
obligations. 

The threshold for potentially sharing information without consent is very high. 
Nevertheless, we recognise that, on some occasions, it may not be possible to obtain 
the consent of the individual requiring assistance prior to sharing their personal data with 
third parties (such as relatives, or with the local authorities). There may be situations 
where an individual lacks the mental capacity to give consent, or is physically or legally 
unable to do so.  In these cases, an assessment is made, with specialist advice, on 
whether the individual’s vital interests may be at risk.  This would most commonly be 
applied to situations where there is a risk to life, but could encompass other legal bases 
for sharing data where there is a clear, legitimate interest for either the FCDO or relevant 
third-party.  In such circumstances, staff are required to identify the clear legal basis 
prior to taking any action.  Out of hours our Global Response Centre would liaise with 
the Consular Assistance Senior Point of Contact (SPOC) and on duty Legal Advisers to 
ensure decisions align with this policy. 

The FCDO will continue to review our consular services to improve the help we give 
British nationals, including drawing on user research and all forms of feedback from 
those who have used our services.  We will continue to strive to do more for those who 
need more help.  

Yours sincerely, 

David Rutley MP 
Parliamentary Under Secretary of State (Americas & Caribbean)

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