Kaine Fletcher

The report

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PS02/22

‘Acute behavioural 
disturbance’ and 
‘excited delirium’

September 2022

POSITION STATEMENT  Contents

Executive summary 

Key messages for professional bodies  
Key messages for future guidance 
Key messages for patients and carers  

The working group  
1. Background  
2. The role of psychiatrists  
3. Terminology  

Excited delirium  
‘Acute behavioural disturbance’ in emergency services  
Identifying cases of ‘ABD’/’ExD’ 

4. Societal context 

Structural racism in the UK  
‘ABD’/’ExD’ and racism 
Securing appropriate mental health input  

5. A way forward 

Finding a way forward  
Terminology  
Guidance on the management of acute disturbance  
Responding to the societal context  

6. Conclusion  
Annex 
References 

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How to cite this publication: Royal College of Psychiatrists (2022) College Position Statement PS02/22: ‘Acute behavioural disturbance’ and ‘excited delirium’  © 2022 The Royal College of PsychiatristsCollege reports and position statements constitute College policy and have been sanctioned by the College via the Policy and Public Affairs Committee (PPAC).The Royal College of Psychiatrists is a charity registered in England and Wales (228636) and in Scotland (SC038369). Executive summary

The terms ‘acute behavioural disturbance’ (‘ABD’) and ‘excited delirium’ (‘ExD’) have 
been used to describe a situation in which a person is extremely agitated and distressed, 
usually in a public place, and in such a state of agitation that they may be at risk of a 
potentially fatal physical health emergency. While physical restraint must always be seen 
as the last resort, it is thought to significantly increase the likelihood of poor outcomes in 
this group of people. It has been argued that ‘ExD’ should be understood as a distinct 
syndrome with a high likelihood of a fatal outcome without medical intervention. However, 
there has been a clear move in the UK towards ‘ABD’ as a broader umbrella term for a 
patient presentation of severe agitation, distress and signs of physiological deterioration 
of unknown cause. Neither term is recognised as a diagnosis in the Diagnostic and 
Statistical Manual of Mental Disorders (DSM-5) or the International Classification of 
Diseases (ICD-11).

Current guidance on the management of ‘ABD’ across emergency services emphasises 
the importance of recognising this presentation as a physical health emergency. 
However, the lack of validated criteria to assess whether someone is experiencing 
‘ABD’ means that some current management guidelines may apply to a significant 
number of people who are agitated and in distress, including people experiencing a 
mental health crisis without a physical health emergency. 

The terminology, particularly ‘ExD’, has also been controversial when used in a way that 
minimises the role of restraint in understanding why someone has died following the use 
of force by police or health services, particularly those from ethnic minority backgrounds. 
The disproportionate use of force against people of colour is well documented across 
health and criminal justice in the UK. This makes the need for a robust consensus about 
how to understand, define and respond to this patient presentation particularly urgent, 
to make sure frontline services are supported in providing the best possible standard 
of care while ensuring appropriate scrutiny and accountability in the event of a death. 

The Expert Reference Group reviewed best practice across mental health services as 
well as the broader literature on ‘ABD’ and ‘ExD’. During the development of this position 
statement, we, the Royal College of Psychiatrists, conducted extensive consultation 
with stakeholders across police, ambulance, forensic and emergency medicine, as well 
as with patients and carers and voluntary sector organisations working with affected 
communities. 

This document is aimed at experts and professional bodies working across services 
caring for patients who are severely agitated and distressed. Noting the need for 
consensus and the development of comprehensive and aligned guidance for frontline 
staff, it does not provide clinical guidance but seeks to contribute to the development 
of a more robust consensus by setting out the psychiatric perspective on this important 
and controversial subject.   

•  Chapter 1 provides a brief history of the terms ‘ABD’ and ‘ExD’ and our motivation 

for producing a position statement on this subject. 

•  Chapter 2 sets out why a psychiatric perspective is critical to discussions around ‘ABD’. 

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 •  Chapter 3 explores the way in which ‘ABD’ (and ‘ExD’) are used across different 
services,  considering  the  evidence  base  for  current  understandings  of  the 
terminology. 

•  Chapter 4 puts these discussions within the broader societal context, discussing 

how this influences how the terminology is understood and used today. 

•  Finally, Chapter 5 sets out a potential way forward. 

In this position statement, we start by setting out our concern that the way ‘ABD’ is 
currently defined may lead to people who are agitated and distressed but not suffering 
from a physical health emergency being subjected to avoidable and potentially harmful 
interventions. We draw on mental health best-practice guidelines, including ongoing 
efforts to reduce restrictive practice and tackle mental health stigma, to consider how 
care for agitated and distressed persons outside of mental health settings could be 
strengthened, regardless of whether a person is suffering from a medical emergency 
or not.  Finally, we make specific recommendations for how to address concerns about 
current definitions, including to support appropriate lesson-learning and accountability 
following deaths.

The position statement acknowledges the need for practical guidance for frontline 
staff who are being asked to respond to incredibly challenging situations. It speaks 
to how management approaches are necessarily determined by the capacity and 
capability of individual services, the settings in which they respond to patients, and the 
evidence and expertise that has been gathered across disciplines.  On the basis of this 
position statement, we hope that we can work with partner organisations in a cross-
disciplinary effort to develop strengthened and more aligned guidance and training for 
all professionals involved in the care of this vulnerable patient population.

Key messages for professional bodies 

•  Staff working in mental health services, including psychiatrists, manage extremely 
agitated and distressed patients on a daily basis across crisis, liaison, addictions, 
forensic and psychiatric intensive care services. Joint protocols and more robust 
training should be in place across services to ensure the care received by patients 
who are severely agitated and distressed is truly multi-disciplinary.  

•  There is significant variation in how ‘ABD’ is defined and understood across professions. 
This causes unhelpful confusion for frontline staff, those delivering training and those 
working in the coronial system. A consensus is urgently needed across stakeholders. 

•  Current guidance on ‘ABD’: 

 º

could potentially be applied to persons whose needs would be better met 
through de-escalation and a specialist mental health response. A lack of 
specificity regarding signs and symptoms that should prompt rapid transfer 
to an emergency department could put patients at risk of avoidable and 
potentially harmful interventions, including restraint.   

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  º would be strengthened by drawing on the mental health evidence base on 
de-escalation, reducing restrictive practice, safe restraint, and compassionate 
communication and follow-up with patients. 

 º

should acknowledge and reflect on the societal context in which these 
terms are defined and applied, including unconscious bias, discrimination, 
and mental health stigma. 

• 

It is important that if someone is harmed by the inappropriate use of physical 
restraint or medication, services can learn from these mistakes. Those responsible 
must also be held to account. To ensure that this happens, the terminology used to 
describe someone who is distressed and agitated should not suggest that death 
is a very likely outcome.

•  A “red-flag” approach to identifying physical health emergencies in an agitated person 
would help move away from diagnostic criteria based on controversial literature on 
ExD. Such “red-flags” could be applied to all persons subjected to restraint without 
resorting to a binary concept of ‘ABD’.

•  Current definitions of ‘ABD’ are too entangled with contested definitions of ‘ExD’ to 
effectively respond to criticisms of the latter. ‘ExD’ should never be used. Subjective 
and potentially racialised diagnostic criteria should be removed. Where this is not 
already the case, all guidance must acknowledge the scientific uncertainty surrounding 
these terms, emphasising that ‘ABD’ is not a diagnosis or cause of death. 

•  While a shorthand such as ‘ABD’ can facilitate effective triaging and rapid-health-
based responses, alternative terminology which does not infer a diagnostic category, 
and which is more humanising, should be sought. 

Key messages for future guidance

•  Staff working in mental health services, including psychiatrists, manage extremely 
agitated and distressed patients on a daily basis, across crisis, liaison, addictions, 
forensic and psychiatric intensive care services. Specialist mental health input 
should be sought and made available at the earliest opportunity when responding 
to patients presenting in this way to support effective de-escalation, reduce 
unnecessary restrictive interventions and support safe restraint and appropriate 
follow-up. 

•  Acutely disturbed behaviour refers to a wide range of behaviours, with a wide 
range of underlying aetiologies and outcomes. It is characterised by agitation, 
distress, and potential violence. It is not a distinct diagnosis or cause of death.

•  Verbal and environmental de-escalation are critical tools in supporting patients who 
are agitated and distressed. This is a critical step in providing care to people who 
are agitated and distressed, with a trauma-informed approach and the reduction 
of environmental and communication-related triggers at its core.

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 •  Clinicians are encouraged to consider differential diagnoses when determining how 
to keep patients and other people safe. Some people who are severely agitated 
and distressed may be at risk of a sudden physical health emergency, particularly 
where the level of agitation is intense and sustained or where the patient has been 
restrained.

• 

It is important that clinicians are able to identify signs of a physical health emergency so 
that patients receive the right medical care quickly. These include a high temperature, 
rapid breathing, rapid pulse rate and extreme and sustained agitation. 

•  Restraint can both cause and exacerbate physical symptoms, increasing the likelihood 
of a sudden physical health emergency. Patients who have been restrained for their 
own or others’ safety should be monitored closely. 

•  Transport to an emergency care setting and rapid tranquilisation or sedation should 
be considered for patients who do not respond to sustained attempts at de-escalation 
and for whom there is a serious concern of physiological collapse. Compassionate 
communication and follow-up with patients are critical throughout this process. 

•  A patient’s ethnic background can have an enormous impact on their experience of 
interacting with emergency services. Previous negative experiences with police and 
health services will shape a patient’s behaviour, while ingrained racial biases can 
affect the behaviour of staff.  This must be considered when responding to patients’ 
needs, particularly those from ethnic minority backgrounds.  

• 

‘Acute behavioural disturbance’ (‘ABD’) is a shorthand used across emergency 
services to describe patients who are agitated, distressed, and reasonably believed 
to be experiencing a medical emergency to expedite a health-based response. 

•  The evidence-base for these presentations is generally poor and the terminology 
remains controversial. ‘Excited delirium’ or ‘ExD’ should never be used and changes 
to terminology may occur as research advances and consensus is sought across 
stakeholders. 

• 

It is important that if someone is harmed by the inappropriate or excessive use of 
physical restraint or medication, services can learn from these mistakes. Those 
responsible must also be held to account.  To ensure that this happens, the terminol-
ogy used to describe someone who is distressed and agitated should not suggest 
that death is a very likely outcome. 

Key messages for patients and carers 

•  People can become very agitated and distressed for a range of reasons. Sometimes, 

this can be caused by or lead to a physical health emergency. 

•  When someone has to be restrained to protect themselves or others from harm, this 
can worsen an underlying physical health problem. When someone is restrained too 
forcefully, this can also lead to a physical health emergency. 

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 • 

It is important that police officers, paramedics and pre-hospital clinicians, and 
healthcare professionals are trained to respond to people who are agitated and 
distressed in a health-focused and culturally sensitive way. This includes effective 
methods for de-escalation, safe restraint, recognising and responding to a medical 
emergency, and compassionate communication and follow-up with each patient. 
Current guidance and training should be strengthened to ensure this, and should 
include greater input from mental health experts.

•  The terminology used to describe a situation where someone is agitated, distressed, 
and experiencing a medical emergency is controversial. Different professional 
groups use these terms in different ways, and the Royal College of Psychiatrists 
is concerned that this causes confusion and puts some patients at risk.

•  The Royal College of Pyschiatrists advises against using ‘ExD’. While we recognises 
the benefits of ‘ABD’ as a shorthand for frontline services, we recommend a search 
for a more humanising term.

• 

It is important that if someone is harmed by the inappropriate or excessive use of 
physical restraint or medication, services can learn from these mistakes. Those 
responsible must also be held to account. To ensure that this happens, the 
terminology used to describe someone who is distressed and agitated should 
not suggest that death is a very likely outcome.  

•  People from ethnic minority backgrounds are subjected to disproportionately 
greater use of force across health and criminal justice settings. The Royal College 
of Psychiatrists recommends that guidance on managing extreme agitation and 
distress should recognise and respond to this context and ensure that such 
guidance does not inadvertently perpetuate racial discrimination. 

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 The working group 

This position statement was developed by the Expert Reference Group (ERG) on ‘acute 
behavioural disturbance’ (‘ABD’) and ‘excited delirium’ (‘ExD’), with representatives from 
across a number of RCPsych faculties. The ERG’s members were:  

•  Dr Trudi Seneviratne (Chair) 
•  Dr Adrian James (President)
•  Dr Subodh Dave (Registrar)
•  Dr Lade Smith (Presidential Lead for 

Race and Equality)

•  Dr Rajesh Mohan (Presidential Lead 

for Race and Equality) 

•  Dr Mayur Bodani 
•  Dr Michael Dilley 
•  Dr Matt Hartley
•  Dr Josanne Holloway 
•  Dr Kate Jefferies

•  Dr Josie Jenkinson 
•  Dr Nicola Kalk 
•  Dr Mani Krishnan 
•  Dr Mona-Lisa Kwentoh 
•  Dr Maurice Lipsedge 
•  Dr Aileen O’Brien 
•  Dr Annabel Price
•  Professor Keith Rix 
•  Dr Prakash Shankar 
•  Dr Alex Thomson
•  Dr Derek Tracy

The working group was supported by Janika Hauser, Policy Analyst and Commentary 
Manager at the Royal College of Psychiatrists. 

The group is grateful for the valuable input received from colleagues across numerous 
faculties, including the Intellectual Disabilities Faculty in particular.

The  working  group  engaged  with  a  wide  range  of  stakeholders  throughout  the 
development of this position statement and wishes to express its appreciation to 
colleagues from across police, ambulance, emergency and forensic medicine, and the 
voluntary sector for their input. While the consultation underlined the lack of consensus 
on this topic, there is a universal desire to improve patient outcomes and widespread 
recognition that greater consistency and collaboration is needed to secure this. 

Patient and carer engagement took place through a series of workshops convened 
in partnership with the South London and Maudsley (SLaM) NHS Foundation Trust. 
Given the vulnerabilities of people thought to be most affected by ‘ABD’, this mode of 
engagement was selected to reduce barriers for participation and ensure maximum 
input from patients and carers into the ERG process. 

SLaM provides services to patients in South-East London and was particularly well placed 
to support this rapid piece of work given its well-established system for commissioned 
patient and carer engagement. We would encourage those conducting further work 
on ‘ABD’ to partner with organisations across the UK to ensure greater geographic 
representation.

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 1. Background 

The terms ‘acute behavioural disturbance’ (‘ABD’) and ‘excited delirium’ (‘ExD’) have been 
used to describe situations in which a person is extremely agitated and distressed. In  
emergency services, the terms are applied when someone is in such a state of agitation 
that they may be at risk of a physical health emergency. In some cases, first responders 
such as police and/or ambulance services may determine that there is a need to 
restrain the person to stop them from causing harm to themselves or others and to 
transport them to an emergency department for treatment of their physical symptoms. 
It is thought, however, that the application of restraint can lead to a worsening of their 
physical symptoms and mental state and therefore present a threat to life.

As has been noted by experts involved in the development of this position statement 
and in the guidance produced by UK professional bodies, this is an incredibly distressing 
situation for patients and their families. 

For emergency service staff, ensuring the safety and welfare of the patient, members of 
the public, and staff themselves can be incredibly challenging, underlining the importance 
of robust guidance, protocols and training. In the UK, coroners have repeatedly 
criticised mental health crisis care services’ failure to recognise and respond to medical 
emergencies in people who are distressed and agitated, as well as the excessive use 
of force against people who are in distress. 

Considerable controversy has surrounded the terms ‘ExD’ and ‘ABD’ because of the 
frequency with which they are referred to in cases where someone has died following 
the use of restraint and/or force, particularly men from ethnic minority backgrounds 
(Rimmer A, 2021; American Medical Association, 2021). Hypotheses about potential 
hormone and electrolyte imbalances prompting agitation and physiological collapse have 
not been scientifically validated, and agitation and distress are generally not thought to 
be life threatening in and of themselves.  There is, however, significant evidence that 
prolonged restraint can lead to physiological collapse.

While neither ‘ABD’ nor ‘ExD’ is a formal diagnosis, they have often been used as 
such, including as primary causes of death in inquests. Critics point to unvalidated 
diagnostic criteria, and to how many reported deaths are among people restrained for 
prolonged periods of time and where the restraint itself is likely to have been the principal 
cause of death. They note the increased use of force against people of colour across 
healthcare and law enforcement and argue that the terms prevent effective scrutiny 
and accountability by minimising the role of restraint in determining a cause of death. 

Experiencing this kind of agitation and distress is terrifying – 
it feels like you are dying, and the response from emergency 
services often makes that worse. I remember not being able 
to speak to explain what was happening to me, and I was just 
treated as a threat.

 — Quote from patient and carer workshop

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”“ How commonly ‘ExD’ and ‘ABD’ are used varies between countries and there is little 
reliable data. ‘ExD’ is more frequently used in the USA and in recent years, a number 
of organisations have issued statements rejecting ‘ExD’ as a diagnosis, noting their 
concern about racial bias and discrimination. In the UK, there has been a shift to using 
‘ABD’ as a less controversial, broader umbrella term. However, concerns have been 
raised about how the term is defined and about how it is used, with criticisms similar 
to those made about the use of ‘ExD’.  

In 2021, the Royal College of Psychiatrists issued a public statement rejecting ‘ABD’ 
and ‘ExD’ as diagnoses and noting their potential for perpetuating racial bias and 
discrimination. Though well received by many, some stakeholders raised concerns 
about the statement. One of the core criticisms was that emergency services rely on 
this terminology to train staff and develop protocols that support the recognition of 
people at risk of, or suffering from, a physical health emergency, emphasising minimal 
restraint and ensuring rapid transfer to emergency departments for physical stabilisation.  

At the time of writing, several UK professional bodies have published guidance on 
the appropriate management of ‘ABD’. This includes the Royal College of Emergency 
Medicine, the Joint Royal Colleges Ambulance Liaison Committee, the Faculty of Forensic 
& Legal Medicine of the Royal College of Physicians, and the College of Policing. 

The Royal College of Psychiatrists chose to withdraw its initial public statement pending 
the development of this position statement. This position statement has been developed 
by an Expert Reference Group (ERG) with members from across a number of the 
College’s faculties and following consultation with stakeholders as well as patients 
and carers. It is hoped that this statement presents a more detailed exploration of the 
issues at hand and contributes to the development of a professional consensus which 
ensures improved patient outcomes.

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 2. The role of psychiatrists 

The terms ‘ABD’ and ‘ExD’ have primarily been used by the police, ambulance services, 
custodial services, those working in emergency departments, and forensic pathologists 
and coroners who are conducting investigations following a death. In this context, many 
psychiatrists working in liaison or forensic services are familiar with these terms, though 
they are not generally used in psychiatric practice. Nonetheless, the discussion about 
‘ABD’ benefits from a psychiatrist’s perspective for a number of reasons. 

First, psychiatrists regularly engage with patients who are distressed, agitated and 
potentially violent. Some research has suggested that individuals with mental illnesses 
are at higher risk of experiencing potential episodes of ‘ABD’, particularly following an 
abrupt cessation of psychotropic medications (Stevenson R and Tracy D, 2021). More 
broadly, however, psychiatrists manage patients suffering from severe mental illnesses 
that can lead to unusual and erratic behaviour, similar to that described in cases of 
‘ABD’, and which can at times be complicated by physical illness or substance use. 
Psychiatrists also support patients experiencing symptoms where the boundary between 
physical and mental health is blurred, such as in cases of delirium where there is an 
underlying physical cause for the altered mental state.  

Regardless of the precise aetiology of the acutely disturbed behaviour, psychiatrists, 
and their colleagues within multidisciplinary mental health teams have considerable 
expertise in verbal de-escalation techniques, restraint and pharmacological interventions 
that are critical to the safe management of patients whose behaviour presents a risk 
of harm to themselves and/or others, and who may be at risk of a physical health 
emergency (National Institute for Health and Care Excellence, 2015; Patel, Sethi et 
al., 2018; Taylor D, Barnes T et al., 2021). Acknowledging the history of the use of 
excessive force and coercion, considerable work has been done in recent years 
across mental health services to improve patient care by reducing restrictive practice. 
This work continues. 

Secondly, psychiatrists are also well versed in the application of mental health legislation, 
including the Mental Health Act 1983, the Mental Capacity Act 2005, and Use of Force 
Act 2018 in England and Wales, the Mental Health (Care and Treatment) (Scotland) Act 
2003 and Adults with Incapacity (Scotland) Act 2000, and the Mental Health (Northern 
Ireland) Order 1986 and Mental Capacity Act (Northern Ireland) 2016. Some of these 
laws provide the frameworks under which police can detain someone who they think 
has a mental illness and needs immediate help. It is also the framework under which 
medical professionals can administer rapid tranquilisation and other treatments to 
individuals who lack capacity to consent to this.

A full understanding of these legal provisions and their application across different 
settings is critical in supporting people who are extremely agitated, distressed and 
who may be at risk of a physical health emergency while upholding their rights as 
an individual. The Royal College of Psychiatrists has also been actively involved in 
discussions regarding the reform of the Mental Health Act 1983 and is therefore well 
positioned moving forward to consider the implication of any legislative changes that 
may affect the management of patients. 

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 Finally, as a specialty, psychiatry is continuing its efforts to unpick, understand and 
challenge racism in society, its impact on the mental health of patients and how racism 
has shaped the health system. The Royal College of Psychiatrists knows that profound 
inequalities exist for people from ethnic minority backgrounds in their ability to access 
treatment, their experiences of care, and their outcomes across the health system. 

The Royal College of Psychiatrists has made an institutional commitment to address 
inequalities arising from a number of issues with diversity and inclusion, specifically in 
relation to racism (Royal College of Psychiatrists, 2021). A number of work areas are now 
being pursued as part of the College’s Equality Action Plan, seeking to tackle racism 
and discrimination through its work as a membership organisation and a training body, 
in quality improvement initiatives alongside mental health trusts, and in its engagement 
with policymakers. This is ongoing work, relying on continued reflection and challenge, 
but the College hopes that the insights gained thus far will make a valuable contribution 
to the discussion on ‘ABD’ and thus help to improve patient outcomes.

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 3. Terminology 

Excited delirium 

While several links have been drawn to historical descriptions of mania (Bell LV, 1840; 
Maudsley H, 1897), the term ‘ExD’ was coined by Charles Wetli and David Fishbain in 
1985. Based on a study of a small number of recreational drug users who died following 
police attendance, Welti and Fishbain described the following clinical progression: 

“Symptoms began with the acute onset of an intense paranoia, followed by 
bizarre and violent behaviour necessitating forcible restraint. The symptoms 
were frequently accompanied by unexpected strength and hyperthermia. 
Fatal respiratory collapse occurred suddenly and without warning, generally 
within a few minutes to an hour after the victim was restrained. Five of the 
seven died while in police custody. Blood concentration of cocaine averaged 
0.6mg/L, about ten times lower than that seen in fatal cocaine overdoses. 
Police, rescue personnel, and emergency room physicians should be aware 
that excited delirium may result of a potentially fatal cocaine intoxication; its 
appearance should prompt immediate transport of the victim to a medical 
facility. Continuous monitoring, administration of appropriate cocaine antag-
onists and respiratory support will hopefully avert a fatal outcome.” 

 —  Wetli CV and Fishbain DA, 1985

Over the following years, the term ‘ExD’ was increasingly used by first responders 
and pathologists in the United States. In 2009, the American College of Emergency 
Physicians (ACEP) formally recognised ‘ExD’ as a ‘unique syndrome’ (‘ExDS’ – excited 
delirium syndrome), characterised by the “hallmark triad of conditions that are delirium, 
psychomotor agitation and physiological excitation” (Hoffman L, 2009). ACEP went 
on to say that while the term had “long been the sole purview of medical examiners, 
largely because the syndrome is only diagnosed on autopsy”, the formal recognition 
of ‘ExD’ marked “an initial step towards identifying its causes and preventing deaths 
that can occur in these patients”. First responders were encouraged to recognise the 
condition as a physical health emergency, and to seek medical support as a matter 
of urgency.

ACEP’s formal recognition of ‘ExD’ as a unique syndrome contributed to the term’s 
further popularisation, used to delineate a distinct syndrome with a high fatality rate if left 
untreated and often being used as a primary cause of death in restraint-related fatalities 
across the US and UK (McGuinness T and Lipsedge M, 2022). Debate continued, 
however, over the precise diagnostic criteria, pathophysiology of fatal cases, and the 
prevalence of fatal outcomes outside of the use of restraint (Rimmer A, 2021). This, 
combined with its frequent use in relation to the deaths of Black men in custody 
and allegations of potential conflicts of interest among proponents of ‘ExD’, meant 
considerable controversy surrounds the term (Parquette M, 2003; Lipsedge M, 2016; 
McGuinness T and Lipsedge M, 2022).  

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 While this debate prompted a move away from ‘ExD’ and towards ‘ABD’ in the UK (see 
below), the term continued to be widely used in the USA. More recently, however, renewed 
criticism was sparked by reference to ‘ExD’ in the defence of Derek Chauvin during his 
trial for the murder of George Floyd. In addition to its potential to prevent appropriate 
scrutiny of police violence through minimising the role of restraint in determining a cause 
of death, concerns have also been raised about the increased use of ketamine to sedate 
people declared to be potential ‘ExD’ cases, sometimes purely on the basis of their 
non-compliance with police orders (De Yoanna and Solomon R, 2020).1

In 2020, the American Psychiatric Association issued a statement concluding that ‘ExD’ 
should not be used until a clear set of diagnostic criteria could be validated, and calling 
for a comprehensive, nationwide investigation into the term’s use (American Psychiatric 
Association, 2020). The American Medical Association followed suit in 2021, issuing a 
statement which opposed the use of ‘ExD’ as an official diagnosis, and warning against 
its use to justify excessive police force and pharmacological interventions such as the 
administration of ketamine (American Medical Association, 2021). Without updating or 
refuting its 2009 white paper, ACEP issued a document in 2021 suggesting alternative 
terminology be used to refer to these patient presentations, namely ‘hyperactive delirium 
with severe agitation’ (Hatten B, Bonney C et al., 2021). 

This terminology is so dehumanising – it suggests there 
is a diagnosis where there isn’t one and can be used to 
justify harmful restraint and sedation.

 — Quote from patient and carer workshop

Acutely disturbed behaviour in psychiatric settings

Acutely disturbed behaviour is a well-recognised descriptor in psychiatry. It is important to 
emphasise, however, that it does not represent a distinct clinical syndrome or diagnosis. 
The following definition has been proposed:  

“It usually manifests with mood, thought or behavioural signs and symptoms 
and can either be transient, episodic or long-lasting. It can have either a 
medical or psychological aetiology and may reflect a person’s limited capac-
ity to cope with social, domestic or environmental stressors. Use of illicit 
substances or alcohol can accompany an episode of acute disturbance or 
can be causative. The acute disturbance can involve threatening or actual 
violence towards others, the destruction of property, emotional upset, phys-
iological distress, active self-harming behaviour, verbal abuse, hallucinatory 
behaviour, disinhibition, disoriented or confused behaviour and extreme phys-
ical over-activity.” 

 — Beer MD, Pereira SM et al., 2001

1 

It should be noted that this concern has not been raised explicitly in the UK, where the policing system and guid-
ance around ketamine use in pre-hospital settings is different from the US. 

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”“ The British Association of Psychopharmacology (BAP) and the National Association of 
Psychiatric Intensive Care and Low Secure Units (NAPICU) note the lack of unified definitions 
on this subject, but go on to define ‘acute disturbance’ as: 

“an acute mental state associated with an underlying mental and/or physical 
disorder in the form of: (i) agitation and distress, which is excessive verbal or 
motor activity that may or may not lead to aggression or violence; or (ii) actual 
aggression or violence entailing harm, hurt or injury to another person, or damage 
to property regardless of whether it is verbally or behaviourally expressed, phys-
ical harm is sustained, or the intention is clear”

 — Patel, Sethi et al., 2018 

In mental health settings, these terms are used to describe a wide range of behaviours, 
ranging from distress and agitation that can be managed by de-escalation through to 
those that may require physical restraint and chemical intervention in order to keep the 
patient and staff safe. As such, psychiatrists would very rarely describe someone as 
“having ‘ABD’ ”, and never in a way that suggests that it is a distinct diagnosis. 

Crucially, psychiatrists emphasise that behavioural disturbance is a non-specific term 
applied to a presentation which has one, or sometimes more than one, underlying 
specific cause. While some underlying physical causes of acute disturbances may 
themselves represent a threat to life (e.g. brain injury, drug toxicity, etc.), most do not 
unless there is prolonged or excessive restraint or rapid tranquilisation. Where restraint 
is used, there is recognition of a clear risk of physiological dysregulation and/or collapse 
(Patel, Sethi et al., 2018). Patients and carers consulted for this position statement 
emphasised that while the distress they have experienced has not threatened their 
physical health, the interventions taken by public services in response to this behaviour 
have caused both psychological and physical harm. As such, a psychiatrist would never 
regard acutely disturbed behaviour on its own as a medical emergency.

The only physical harm I experienced following a 
mental health crisis came from being restrained 
inappropriately. Distress doesn’t kill, but the 
response to it can.

 — Quote from patient and carer workshop

Instead, specific indicators are used to identify where a patient may be deteriorating while 
they are extremely agitated and distressed, including when restrained. These are in line 
with those monitored by the National Early Warning Score (NEWS), namely temperature, 
pulse, systolic blood pressure, respiratory rate, oxygen saturation, level of consciousness 
or new confusion (Patel, Sethi et al., 2018). When restraint is applied, guidance insists on 
a designated and appropriately trained person being solely responsible for monitoring 
the patient’s physical condition. Nonetheless, the acutely disturbed behaviour is not, 
in and of itself, considered a potential cause of a physical health emergency or death. 

Guidance about the appropriate management of patients presenting in this way, based 
on the psychiatric evidence base, is discussed further in section 5. 

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15

”“ ‘Acute behavioural disturbance’ in emergency 
services 

Over the last ten years, ongoing controversy surrounding ‘ExD’ has prompted a move 
away from the terminology among UK stakeholders. In 2014, a Metropolitan Police 
Review concluded that the term ‘ExD’ “encourages failure to recognise the multi-factorial 
pathophysiology” of deaths following restraint, and that its inclusion in documentation 
“has the tendency to prevent lessons from being learned following adverse incidents” 
(Metropolitan Police Service, 2004). The same conclusion was reached by The Rt Hon 
Dame Elish Angiolini DBE QC in her 2017 Independent Review of Deaths in Police 
Custody. She recommended that: 

“ ‘Excited Delirium’ should never be used as a term that, by itself, can be 
identified as the cause of death. The use of Excited Delirium as a term in 
guidance to police officers should also be avoided” 

 — Angiolini E, 2017 

The Angiolini Review argued that, regardless of a debate on the terminology and 
diagnostic classification, there was “a constellation of signs and symptoms” indicative 
of a person requiring urgent medical attention, and that these persons should not be 
restrained except in the most extreme, life-threatening circumstances (Angiolini E, 2017). 

Emergency service staff continued to face immense challenges in providing urgent 
medical care to patients who were distressed, agitated and potentially violent. While 
the usefulness of the term ‘ExD’ had been questioned, repeated criticism by coroners 
of police and ambulance services for failing to recognise the physiological deterioration 
of patients underlined the importance of guidance and training to secure better patient 
outcomes.  

In this context, UK stakeholders were drawn to using ‘acute behavioural disturbance’ 
(‘ABD’) as a less controversial alternative. This is particularly because the possibility 
of multiple underlying physical and psychological aetiologies is more explicit within 
established definitions of acutely disturbed behaviour in the psychiatric literature. The 
London Ambulance Service, for example, has noted that the move to ‘ABD’ is to 
recognise that it is not a definite condition but a spectrum of behaviours, with multiple 
potential causes (Helppi A, 2021). The Royal College of Psychiatrists has itself contributed 
to the development of guidance for managing this kind of presentation, emphasising 
the importance of a health-based response and focusing on de-escalation. The College 
is also aware of a number of welcome ongoing efforts across the UK to improve the 
recognition and response to this patient presentation. 

While most stakeholders now principally use ‘ABD’, the link with the heavily criticised 
term ‘ExD’ has been difficult to sever on a practical level. Because guidance on ‘ABD’ for 
emergency services focuses on patients who may be at risk of physiological deterioration, 
descriptions of the signs and symptoms continue to be drawn from ‘ExD’-specific 
literature as opposed to broader categories used in psychiatric practice. While the 
stronger focus on de-escalation in UK guidance must be welcomed, descriptions of 
potential clinical progression emphasise the risk of sudden physiological collapse among 

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 all patients presenting in this way, often regardless of restraint or rapid tranquilisation. 
While reference to verbal and environmental de-escalation is often made more explicitly 
than in historical guidance on ‘ExD’, the focus remains on rapid transfer to an emergency 
department, where drugs may be administered following clinical assessment, including 
high-dose antipsychotic drugs or general anaesthesia. 

There has also been a need to communicate the shift in terminology to professionals 
with pre-existing awareness of ‘ExD’ as a medical emergency. As a result, much of the 
current guidance offered to UK professionals still makes explicit reference to ‘ExD’. In 
some cases, the terms are used almost synonymously as “ABD/ExD”. Some guidance 
also suggests that ‘ExD’ is still used to describe the most severe forms of ‘ABD’. ‘ABD’ 
has often been described as “the new name for ExD”, and while some texts recognise 
the latter has been surrounded by controversy, very little detail is offered as to the 
reasoning behind this shift. While most guidance emphasises that ‘ABD’ should not be 
used as a distinct diagnosis but as an umbrella term, further confusion may be sown 
by phrases like “diagnosing ‘ABD’ ”, “people suffering from ‘ABD’ ” or descriptions of 
‘ABD’ as “a condition”. 

Thus, while most psychiatrists would refer to “acutely disturbed behaviour” when 
describing a very broad range of presentations, ‘acute behavioural disturbance’ often 
appears to be a much more distinct category which is necessarily associated with a 
significant risk of a physical health emergency. As such, definitions of ‘acute behavioural 
disturbance’ [noun] in emergency service contexts are sometimes far more similar to 
established definitions of ‘ExD’ than psychiatric understandings of ‘acutely disturbed 
behaviour’ [adjective]. For this purpose, this position statement will use ‘ABD’ where this 
refers to a condition of imminent physiological collapse, and an adjectival description 
when referring to the broader patient presentation described in psychiatric services 
(e.g. severely agitated and distressed). 

Identifying cases of ‘ABD’/’ExD’

Neither ‘ABD’ nor ‘ExD’ are recognised diagnoses in the Diagnostic and Statistical 
Manual of Mental Disorders (DSM-5) or the International Classification of Diseases 
(ICD-11). Rather than being conceived as a distinct entity, some have argued that 
‘ABD’ should instead be seen as a “final common pathway” where different causes 
of agitation and distress can lead to potentially fatal physical symptoms (Stevenson R 
and Tracy D, 2021). The pathophysiologic mechanism to ‘ABD’ has not been elucidated 
fully. However, existing literature proposes that for some people in a disturbed mental 
state, a fight-or-flight response can result in a severe state of catecholamine excess 
and metabolic acidosis (a severe hormone and electrolyte imbalance), which may be 
accompanied by hyperthermia (high body temperature). These symptoms may be so 
severe that they represent a threat to life, especially where combined with prolonged 
struggle against restraint (American Medical Association, 2021; Stevenson R and Tracy 
D, 2021). Notably, excessive restraint and prolonged struggle against restraint can lead 
to similar symptoms, regardless of any underlying physical or mental condition. 

In the absence of a validated pathophysiology or diagnostic criteria, a series of signs 
and symptoms based on case reports are generally used to determine if someone is 

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 likely experiencing an episode of ‘ABD’. The original ACEP paper on ‘ExD’ proposed 
a total of 10 “pre-hospital potential features”, drawing on a Canadian study of 1 million 
police/public encounters (Hall C, Kader AS et al., 2009). Of the 698 encounters involving 
force, 24 probable cases were identified based on perceived abnormal behaviour and 
the following criteria:

•  Pain tolerance 
•  Tachypnoea (unusually rapid breathing)
•  Sweating 
•  Agitation 
•  Tactile hyperthermia (hot to touch)
•  Police non-compliance 
•  Lack of tiring 
•  Unusual strength 
• 
•  Mirror/glass attraction 

Inappropriately clothed 

These signs and symptoms have been rephrased and supplemented by further 
publications across the academic literature and professional guidance, including 
guidance referring to ‘ABD’ only (Gonin P, Beysard N et al., 2018). Reference has 
been made to repetitive requests for help and expressions such as “I’m dying”, a lack 
of fear, extreme violence, and an insensitivity to irritant sprays and tasers (College of 
Paramedics, 2018; the Faculty of Forensic & Legal Medicine of the Royal College of 
Physicians, 2019; Forensic Science Regulator & Royal College of Pathologists, 2020; 
Joint Royal Colleges Ambulance Liaison Committee, 2021; College of Policing, 2021; 
Royal College of Emergency Medicine, 2022). These are all based on retrospective 
analyses of case reports or case series. Given ongoing debates around the precipitative 
role of restraint in physiological deterioration of extremely agitated patients, it should be 
noted that most of these studies rely on use-of-force case reports, where the precise 
interaction of restraint and an underlying pathophysiology is difficult to untangle (Hall 
C, Butler C et al., 2009; Baldwin S, Hall C et al., 2016; Baldwin S, Hall C et al., 2018).

Furthermore, although the ACEP white paper referred to the “hallmark triad of conditions 
that are delirium, psychomotor agitation and physiological excitation”, features of delirium 
have not been assessed in many of the case reports and case series. This includes the 
Canadian study of police/public encounters, which calls into question the designation 
of the 24 cases as being ones of probable ‘excited delirium’ (Hall C, Kader AS et al., 
2009). In some cases, the terms ‘ExD’ and ‘ABD’ have been applied to patients who 
have clearly not been delirious.

While the ACEP white paper suggests that 6 out of 10 clinical features are used as 
a threshold for identifying a ‘case’ of ‘ExD’, reports suggest that many patients are 
“diagnosed” despite presenting with far fewer of these features (Kutcher S et al., 2009; 
Gonin P, Beysard N et al., 2018). The most recent guidance issued by the Royal College 
of Emergency Medicine on ‘ABD’, for example, offers a similar list of signs and symptoms 
as literature on ‘ExD’ but notes that “one or more features may be present in ‘ABD’ ” 
[emphasis added] (Royal College of Emergency Medicine, 2022). 

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 Discussion

Current UK definitions of a suspected case of ‘ABD’ are thus both exceptionally broad and 
based on highly subjective signs. Beyond potentially applying to patients whose relatively 
mild behavioural disturbance could be managed through de-escalation, many of the listed 
signs and symptoms are experienced in day-to-day life with no underlying pathology. For 
example, fear and panic are often a natural response to threatening or otherwise unpleasant 
stimuli. Sustained non-compliance with police or ambulance staff can be an intentional and 
even rational choice. Understandings of what precisely constitutes hypervigilance, unusual 
strength or an appropriate response to pain vary from person to person. Patients and carers 
consulted during the development of this position statement have emphasised that most 
of the signs and symptoms used to identify ‘ABD’ are reflective of their experience of intense 
distress, as opposed to any diagnosable health condition.

I have experienced all these symptoms while being 
in a mental health crisis, and there was absolutely 
no physical health emergency. The way that ‘ABD’ is 
defined is way too broad.

 — Quote from patient and carer workshop

Section 4 discusses these criteria in the context of racial discrimination and bias, but it is 
clear that the way in which signs and symptoms of ‘ABD’ are currently described is not 
sufficiently specific to those patients at risk of a sudden physical health emergency. The 
Royal College of Psychiatrists is therefore concerned that current clinical guidelines may 
be applied to patients, including people with severe mental illnesses, for whom alternative 
interventions would be far more appropriate. The preference for a health-based response in 
situations of uncertainty is no doubt positive, but by creating a potentially skewed perception 
of an extreme risk of sudden physiological collapse, the quality of de-escalation efforts may 
be significantly impacted. 

Beyond the impact this has on the care received by individual patients, this approach to 
defining ‘ABD’ remains problematic in relation to retrospective investigations of patients’ 
deaths. There are few confirmatory tests to determine whether a person was experiencing 
a condition that would result in a sudden physical health emergency if left untreated. While 
a minority of the signs may be tested directly or indirectly by measuring body temperature, 
heart rate, blood pressure and by specific blood tests, many of these can often only be 
done after the suspected episode of ‘ABD’, usually following physical or chemical restraint. 
Furthermore, the results provided are by no means specific to ‘ABD’ and can be indicative of 
a whole host of differential diagnoses, including having been subject to excessive restraint. 
As the 2009 ACEP paper itself recognises: 

“The difficulty surrounding the clinical identification of ExDS is that the spectrum 
of behaviours and signs overlap with many clinical disease processes. ExDS is not 
intended to include these diseases, except insofar as they might meet the definition 
of ExDS. Treatment interventions targeted at one of these alternate diagnoses may 
potentially alleviate or exacerbate ExDS, thus further confounding the diagnosis.” 
 — American College of Emergency Physicians, 2009

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”“ The lack of validated diagnostic criteria also presents a real challenge for those wishing 
to conduct further research on ‘ABD’, particularly efforts to prove current hypotheses 
about any potential underlying pathophysiology or to conduct epidemiological studies. 
More than a decade after ACEP’s initial statement, the American Medical Association 
summarised its review of the literature on ‘ExD’ in 2021: 

“Despite a lack of scientific evidence, a universally recognised definition, a 
clear understanding of pathophysiologic mechanisms, or a specific diagnostic 
test, law enforcement and EMS personnel are taught that ‘ExD’ is a potentially 
deadly medical condition – including at times, by physicians. Even deaths 
attributed to ‘ExD’ have no consistent anatomical findings, resulting in ‘ExD’ 
diagnosis being one of exclusion, defined by epidemiology and the subjective 
description of a clinical presentation.” 

 — American Medical Association, 2021

In this context, the Royal College of Psychiatrists welcomes the move away from ‘ExD’ 
and the attempts to use terminology that accounts for the multiple aetiologies that may 
lead people to become distressed and behave in erratic and potentially dangerous ways. 
However, it is concerning that the way in which ‘ABD’ is being used today is difficult 
to distinguish from ‘ExD’, potentially creating the impression of a distinct diagnostic 
entity and suggesting that a series of broad and non-specific signs and symptoms 
indicate that someone is, or was, at high risk of sudden death. While other alternative 
terminologies have been proposed, including “autonomic hyperarousal state” (AHS), 
agitated delirium, and hyperactive delirium with severe agitation, the same challenges 
persist (Kutcher S et al., 2009; Strommer E, Leith W et al., 2020; American College of 
Emergency Physicians, 2021). As such, the change in terminology has failed, in the 
College’s view, to adequately respond to criticisms of ‘ExD’ and risks being used in 
much the same way, while applying to a far broader group of patients – for many of 
whom the proposed management approaches would be entirely disproportionate.  

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 4. Societal context

Structural racism in the UK 

I have seen the disproportionate use of force against 
young Black men repeatedly. This is a systemic problem, 
and it has a massive impact on my community.

 — Quote from patient and carer workshop

Ethnic disparities in healthcare are complex and can be difficult to unpick. Broader 
societal inequities increase the risk of people from different ethnic groups becoming ill, 
while direct and indirect racial discrimination have an enormous impact on their access 
to, experience of and outcomes from healthcare (Raleigh V and Holmes J, 2021). 

The Independent Review of the Mental Health Act 1983, chaired by former Royal College 
of Psychiatrists President Professor Sir Simon Wessely, found a consistent over-rep-
resentation of Black African and Caribbean people among those patients subject to 
restraint and/or detention in the mental health system (Department of Health and Social 
Care, 2018). The review heard that people of Black African and Caribbean heritage: 

•  are 40% more likely than white British people to come into contact with mental 

health services through the criminal justice system. 

•  are disproportionately subjected to the use of section 136. 
•  have longer average lengths of stay in hospital. 
•  have higher rates of repeat admissions. 
•  have higher rates of seclusion. 
•  are up to eight times more likely to be placed on Community Treatment Orders. 
•  are less likely to be offered psychological therapies.
•  have higher drop-out rates from cognitive behavioural therapy for psychosis. 

Evidence of racism and ethnic disparities in medicine is by no means restricted to 
mental health services. In the UK, maternal mortality rates are five times higher among 
Black women than among white women, and Black patients have lower than expected 
rates of access and use of a wide range of services, including cardiovascular and 
cancer services (MBRRACE-UK, 2020; Raleigh V and Holmes J, 2021). Studies have 
also demonstrated racial bias in admission rates in emergency departments, and in 
pain assessment and treatment recommendations, with Black patients systematically 
undertreated relative to white patients (Hoffmann K, Trawalter S et al., 2016; Zhan X, 
Carabello M et al., 2020). The experiences of staff from ethnic minority backgrounds 
across the NHS offers further evidence of the institutional racism that continues to 
plague our health services (Tonkin T, 2022).

The impact of racism and discrimination is also well-established in policing. At a 
global level, the 2021 annual report of the United Nations High Commissioner for 
Human  Rights  focused  on  the  “excessive  use  of  force  and  other  human  rights 
violations by law enforcement officers” against Africans and people of African descent 

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”“ (United Nations High Commissioner for Human Rights, 2021). The UK Government 
has acknowledged that there is ‘significant overrepresentation of Black, Asian and 
minority ethnic (BAME) individuals in the criminal justice system’ (Gov.uk, 2016).2 
Almost two decades after the Macpherson Report into the death of Stephen Lawrence 
(where it was found that the Metropolitan Police were institutionally racist), the Independent 
Review of Deaths and Serious Incidents in Police Custody chaired by Dame Elish Angiolini 
highlighted the disproportionate number of people from BAME communities who have 
died following the use of police force. A report by the IOPC found a pattern of more 
extensive or prolonged use of conducted electrical devises (e.g. TaserTM) against Black 
people and also against people in distress (Dodd V, 2021).

It is important to emphasise that these findings do not in any way indicate that every single 
person working within these services is racist. That would be to disregard the immense 
effort of staff to deliver high quality care and challenge racism every day. Instead, these 
findings reflect the insidious nature of bias and its effect on our perceptions of other people, 
as well as the progress which still needs to be made across institutions to ensure proper 
accountability for those whose behaviour is overtly racist. In this context, the Royal College 
of Psychiatrists welcomes ongoing efforts to better understand disproportionality across 
public services, including the Race and Health Observatory, the Independent Review into 
Disproportionate Effects of Use of Taser, and the Independent Advisory Panel on Deaths in Custody. 

‘ABD’/’ExD’ and racism

There is evidence that some proponents of the term ‘ExD’ were intentionally seeking to min-
imise the role of restraint and conducted electrical devices (e.g. TaserTM) in explaining deaths 
in custody (American College of Emergency Physicians, 2021; McGuinness T and Lipsedge 
M, 2022). It is unsurprising, then, that organisations advocating for racial justice have been 
especially critical of ‘ExD’. In the US, both the American Civil Liberties Union (ACLU) and the 
National Association for the Advancement of Colored People (NAACP) have long argued 
that ‘ExD’ is being used as a ‘medical scapegoat’ for police abuse (Parquette M, 2003). 

Despite emphasis on ‘ABD’ being an umbrella term and prompting a health-based response, 
a number of UK stakeholders have raised concerns about the insufficient distinction between 
‘ABD’ and ‘ExD’. Black Thrive has argued that ‘ABD’ has “been used as a justification for 
deaths in custody and within the health and care system” (Black Thrive, 2021). The charity, 
INQUEST, has echoed these concerns:

“There is a longstanding pattern of dangerous and disproportionate use of fatal 
restraint and neglect against people from racialised groups, particularly Black 
men and those in mental health crisis. We share concerns that Acute Behavioural 
Disturbance is often framed as a diagnosis to explain away the role of restraint 
and deny the responsibility of those involved, be they police, prison or health 
workers. Many deaths have raised serious concerns about the demonization and 
dehumanisation of those who have died, pointing to the reality of institutionalised 
racism in our public services.” 

 — Black Thrive, 2021  

2  The term ‘BAME’ has rightly been criticised as an unhelpful acronym which aggregates a group of people from diverse 

backgrounds with huge disparities in experience and outcomes across the health system. In recognition of this, this posi-
tion only uses this term in direct quotes or when referring to reports in which this grouping was used to conduct analyses.

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 There is clearly a link between how the terms ‘ExD’ – and to a lesser extent ‘ABD’ – have 
been used and racial discrimination. The ‘typical case’ of ‘ABD’ is often described as being 
a Black man in his thirties, but the reasons for a person’s race or gender predisposing 
them to the condition are unclear. ‘ExD’ has been found to be more likely to be applied 
posthumously following deaths in custody, while alternative terminology is used to describe 
the presentation of patients and detainees who survive an encounter with emergency 
services (Strommer E, Leith W et al., 2020). The UK inquests of which we are aware that 
reference ‘ExD’, and more recently ‘ABD’, are disproportionately related to the deaths of 
men with ethnic minority backgrounds (see annex). Many of them died following periods 
of prolonged and intense restraint, with concerns frequently raised about insufficient 
recognition of the role of restraint in contributing to these deaths directly.  

While guidance against the use of ‘ExD’ as a primary cause of death is now in place, ‘ABD’ 
has been invoked as the cause of death in a number of recent inquests, including that of 
Andrew Hall and Jason Lennon. Police have questioned the Scottish government’s decision 
to include consideration of the role of race within the inquiry into the circumstances of Sheku 
Bayoh’s death, while arguing that he died as a result of ‘ABD’ (Scottish Government, 2020). 

It is in this context that the current set of signs and symptoms ascribed to ‘ABD’ are 
particularly concerning. Dame Elish Angiolini writes in her review that “the stereotyping 
of young Black Men as ‘dangerous, violent and volatile’ is a longstanding trope that is 
ingrained in the minds of many in our society”. She goes on to say:

“It is not uncommon to hear comments from police officers about a young 
Black man having ‘superhuman strength’ and being ‘impervious to pain’; and 
often, wholly inaccurately, as ‘the biggest man I have ever encountered’. Such 
perceptions increase the likelihood of force and restraint being used against 
an individual who may be unwell. The detainee is effectively dehumanised. 
In such circumstances the police officers may also use force and restraint in 
order to gain compliance to the exclusion of any focus on the wellbeing of 
the detainee which can ultimately lead to a medical crisis or death.”

 — Angioloni E, 2017

The physiological conditions thought to precipitate death in cases of ‘ABD’ are difficult to 
distinguish from the conditions that can also arise following excessive restraint and prolonged 
struggle (Lipsedge M, 2016). Retrospective descriptions of people of colour experiencing 
the signs and symptoms associated with ‘ABD’ are thus deeply problematic, especially 
where used to minimise the role of restraint as a cause of death. Aside from playing into 
well-known racist stereotypes, the current set of signs and symptoms pathologises fear, 
resistance to restraint and statements such as “I’m dying” by suggesting these are indicative 
of some underlying and potentially fatal medical condition, as opposed to a potentially 
understandable reaction to police force. 

There’s no such thing as superhuman strength. I am a human in distress. I 
may feel like I am fighting for my life, but that doesn’t stop be from being a 
person with human strength. That label is so prone to bias and stigma.

 — Quote from patient and carer workshop

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”“ 
 
 Stigma and mental health 

Mental illness has a long history of being stigmatised, and there is significant evidence 
that this stigma presents a barrier to seeking and obtaining appropriate treatment for 
people with mental illnesses (Sickel A, Seacat J et al., 2014). There is also significant 
evidence of mental health stigma within emergency services, which harms both patients 
and staff, who are often exposed to traumatising experiences (Bell S, Palmer-Conn S 
et al., 2021; Auth N M, Booker M J et al., 2022).

De-escalation delivered by the emergency services can be highly effective when 
responding to the needs of people in mental health crisis. However, where a patient’s 
response to attempts at de-escalation is not as hoped, this can be more reflective of 
the quality of this de-escalation than any underlying medical emergency.

While current guidance often refers to the importance of de-escalation, the patients and 
carers consulted as part of this position statement emphasised that their experience of 
attempted verbal and environmental de-escalation by emergency and health service 
staff was often poor. Participants recounted repeated incidents in which attempts at 
de-escalation were restricted to being talked or shouted at. Staff often didn’t introduce 
themselves by name, did not offer reassurance or support, and relied heavily on jargon.

There remains a lack of knowledge about the impact of sensory overload. This includes the 
particular needs of people with intellectual disabilities. People with intellectual disabilities 
have higher rates of mental disorders than the general population, but emergency and 
health service staff often struggle to distinguish between behaviours and symptoms 
indicative of a mental health crisis, responses to changes in their environment, and a 
physical emergency. This is particularly the case where a person may be non-verbal, 
with insufficient attempts at reasonable adjustments and alternative communication 
methods potentially undermining the quality of care.

Patients and carers also reflected on their experience of physical restraint being employed 
for behaviour that did not pose any risk but was deemed to be odd or inconvenient by 
police, ambulance, and health service staff.

The threshold for restraining someone is often really low – I have been 
slammed against the pavement or a wall because my behaviour was 
deemed odd or eccentric.

 — Quote from patient and carer workshop

While participants emphasised that they had often come to experience the very best 
of police and NHS during physical health emergencies, they described some of their 
interactions with the same institutions during mental health crises as “being treated as 
sub-human”. In this context, it is alarming to hear of anecdotal evidence that people 
presenting with ‘ABD’ are described as universally lacking capacity to consent. Given 
the non-specificity of current case definitions, this is likely incompatible with current 
mental health legislation and risks undermining the quality of care for a significant 
number of patients. Similarly, the continued criminalisation of distress and use of 

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”“ 
 mechanical restraints like handcuffs on patients with acute mental health needs is 
entirely unacceptable and a reflection of how much more must be done to root out 
mental health stigma across public services and wider society.

Securing appropriate mental health input 

The capacity and capability of emergency service staff to respond to acutely distressed 
and agitated persons will always be different to that of inpatient mental health services, 
and the discussion above highlights the value of direct input from mental health specialists 
when responding to patients who are agitated and distressed. 

The Royal College of Psychiatrists recognises and shares concerns about the consistent 
challenges faced by police, ambulance and emergency medicine services in securing 
this specialist mental health input at the speed required when responding to the most 
acute patient presentations. While the ‘Side by Side’ consensus on working together to 
help patients with mental health needs in acute hospitals has started to address some of 
these barriers, there is still significant work to be done (Royal Colleges of Pyschiatrists, 
Nursing, Emergency Medicine and Phycisians, 2020). Similarly, the expansion of mental 
health crisis services has prompted the development of innovative new services like 
street triage teams and joint response cars. While encouraging, provision remains very 
patchy and efforts to strengthen the evidence-base are likely required before widespread 
roll-out is possible.

While these efforts continue, there remains a pressing need to improve the mental 
health training offered to staff working within emergency services. While incidents with 
a primary or secondary mental health component represent an ever-increasing proportion 
of call-outs, mental health remains a relatively small component of training for police 
officers and paramedics – both pre-qualification and during regular continuing professional 
development. For example, while ‘ABD’ as a medical emergency is refreshed annually 
as part of a police officer’s first aid training, mental health training remains patchy across 
the country despite continuing efforts to improve this.

Staff need more training, particularly on how to put 
themselves in the shoes of someone in this state. Role 
plays and involvement from experts by experience could 
be life-saving.

 — Quote from patient and carer workshop

Discussion

The Royal College of Psychiatrists recognises the existence and impacts of racism, 
discrimination and mental health stigma across all sections of society, including in 
healthcare and policing. The definition and application of terminology such as ‘ABD’ 
has to be understood in this context. 

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”“ 
 The way in which ‘ABD’ is currently defined is deeply problematic because of the way 
in which some signs and symptoms play into racist stereotypes. In the context of the 
increased and often disproportionate force used against Black men in both healthcare 
and policing, the College is concerned about the way in which ‘ABD’ can be used to 
minimise the role of restraint in explaining why someone has died. As a result, current 
definitions may undermine effective accountability, particularly in relation to deaths where 
there was no underlying physiological dysregulation prior to the application of restraint. 
While the intention of current professional guidance is to improve patient outcomes, the 
College is not satisfied that it takes sufficient steps to mitigate against the risks posed by 
current definitions of ‘ABD’ for people of ethnic minority backgrounds. In order to offer 
appropriate care to people who are agitated and distressed, it is vital that guidance and 
training takes into account unconscious bias and mental health stigma more broadly. 

The Royal College of Psychiatrists is concerned that currently frontline staff are not 
sufficiently supported to offer the best possible standard of care. While current guidance 
on ‘ABD’ emphasises the importance of proper de-escalation, training on how to do 
this in a way that is responsive to the individual needs of patients, and how to maintain 
de-escalation throughout any medical interventions, remains insufficient. Meanwhile, 
the rationing of specialist mental health input vis-à-vis emergency services is the inevitable 
product of the historic underfunding of mental health services and persistent staff 
shortages. It is nonetheless unacceptable – particularly in situations in which there is 
a potentially acute threat to life. This status quo does a disservice to both patients and 
staff.

This is a traumatising experience for emergency 
service staff too – they need proper training and 
support.

 — Quote from patient and carer workshop

In the long term, the ideal scenario would likely be that specialist mental health services 
act as first responders in these situations, seeking additional medical or law enforcement 
support only where required. However, the current staff and resourcing landscape 
means that closer integration and collaboration between services is likely the most 
practical way forward. This means expanding integrated services wherever possible 
and strengthening joint protocols, clinical leadership and training across services is 
essential. This patient population has complex needs which transcend boundaries 
between professions and specialties, and securing positive outcomes will rely on a 
proactive breaking down of siloes.

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”“ 5. A way forward

Finding a way forward 

This position statement is not intended to resolve ongoing debates around ‘ABD’. The 
scientific uncertainty means that a coherent resolution to these controversial discussions 
will likely be dependent on significant additional research and in-depth discussions 
between professionals working across different services and specialties. Research 
is needed to understand the patient presentation and pathophysiology as well as to 
consider the most appropriate treatment approaches. The latter should include, for 
example, research into the incidence of ‘emergence phenomena’ of psychotic symptoms 
following ketamine use and toxicological research to establish associations with particular 
forms of intoxication or withdrawal states.  Progress could be made through improved 
data collection across services, including a national registry of cases and outcomes, 
but greater public funding for research in this field is urgently needed.

Until such a time, however, there is clearly a need to establish an interim consensus 
which ensures that patients who are extremely agitated and distressed receive the right 
care, regardless of whether they are at risk of an imminent physical health emergency 
and without undermining appropriate accountability for deaths caused by an excessive 
use of force. The lack of consensus on this topic creates unhelpful confusion for staff 
working across frontline services, which undermines patient outcomes and makes 
collaboration and learning across professions more difficult. To ensure that patients 
receive the best possible standard of care, while minimising the risks that have been 
identified in relation to existing terminologies and practices, this interim consensus will 
need to be reached across specialties and professions. 

We need proper accountability to learn lessons. It’s already 
really difficult to get information from services after things 
go wrong. This terminology can be used to stand in the 
way of proper investigations and challenging questions by 
suggesting a person was going to die anyway.

 — Quote from patient and carer workshop

Below, we set out a potential way forward, drawing on psychiatric expertise and evidence 
to respond to the questions and concerns raised in prior chapters. Some of these may 
find quick support from across different stakeholders, while others may require more 
detailed discussions and deliberation to find a workable agreement.   

In this context, the Royal College of Psychiatrists therefore recommends: 

•  A cross-sector working group should be convened to develop an interim consensus 
on ‘ABD’, with active involvement of patients and carers, to agree terminology, key 
principles for professional guidance, and priorities for further research.

PS02/22: ‘Acute behavioural disturbance’ and ‘excited delirium’

27

”“ •  This group should include representatives from police, custodial, ambulance, 
emergency medicine, mental health, and the judicial and coronial system. Support 
from relevant government departments would help ensure consistency across 
services. 

•  Further research should be urgently commissioned, including detailed investigation 

into how racial bias plays into the application of terminology such as ‘ABD’.

•  Members of the cross-sector working group should collaborate on the development 

and delivery of training materials for staff working across public services 

•  All services should seek to improve standardised collection of disaggregated data 
on presentations and outcomes, and to conduct regular multi-disciplinary reviews 
to support high-quality research on this topic.

Terminology 

The terminology currently used to describe a presentation of extreme agitation 
with signs and symptoms indicative of physiological deterioration is flawed. While 
describing a vast range of presentations, it can still be misconstrued as a distinct 
diagnosis. While the evidence-base about the likelihood of fatal outcomes in the 
absence of physical or chemical restraint remains highly contested, some current 
definitions suggest that this is almost inevitable. RCPsych welcomes the move 
away from ‘ExD’ and towards a label which seeks to recognise multiple underlying 
aetiologies and potential outcomes. However, current definitions of ‘ABD’ are still too 
closely bound to contested definitions of ‘ExD’ to sufficiently respond to criticisms 
of the latter. 

Nonetheless, it is vital that progress made in the UK to improve recognition and prompt 
health-based responses is not lost in an effort to resolve this problem. Despite the 
relative dearth of evidence on ‘ABD’, there is of course a need to offer guidance to 
emergency services about the appropriate management of people who are extremely 
agitated and who may be at risk of a physical health emergency. Patients presenting 
in this way can pose a very real danger to themselves, staff and other people around 
them, and require quick decision making on the part of emergency call handlers, police 
officers, paramedics and pre-hospital clinicians, and emergency department staff. 
Given the literature which suggests a high risk of sudden death and the potential for 
interventions such as prone restraint to worsen prognoses, emergency services staff 
are understandably anxious to ensure their policies and practices are based on the 
best scientific evidence available. 

There may also be a practical value to a short hand term which enables different services 
to quickly communicate that a person who is behaving in a troubling and agitated way may 
be at risk of physiological deterioration. In this vein, it is encouraging to see the efforts of 
police and ambulance services to use the label ‘ABD’ to prompt a health-based approach 
and ensure faster response times so that those patients experiencing a physical health 
emergency receive the best possible standard of care. Similar efforts are also underway 
for improving cardiac care through shared terminology and training across services.

PS02/22: ‘Acute behavioural disturbance’ and ‘excited delirium’

28

 However, it is vital that this terminology does not undermine effective clinical management 
by creating the impression of a distinct diagnostic entity or the false impression of 
However, it is vital that this terminology does not undermine effective clinical management 
by creating the impression of a distinct diagnostic entity or the false impression of 
an imminent physical health emergency where this is not the case. While the Royal 
College of Psychiatrists fully recognises that the acuity of the situation means that 
emergency services may have to contain someone until investigations can take place, 
it is concerned about any terminology which might prevent appropriate consideration of 
the cause of a patient’s behaviour, any differential diagnoses (e.g. sedative withdrawal 
states, delirium tremens, organic psychosis, infection, brain trauma etc.) and the impact 
of characteristics such as young or advanced age on the patient’s presentation and 
management approach. 

Patients and carers consulted during the development of this position statement 
welcomed terminology which prompted a health-based response to people who are 
in distress and may be at risk of a physical health emergency. However, they expressed 
their concern that current guidance and literature is often dehumanising in that it fails to 
recognise how distressing the experience will be from the patient’s perspective. They 
therefore recommended a focus on ‘distress’ rather than ‘behavioural disturbance’ as 
a clinical diagnosis. The fact that broad and subjective signs and symptoms are being 
used to define ‘ABD’ also raised fears that the terminology could be used to justify 
inappro

Text truncated at 80,000 characters — see the source PDF for the remainder.

Responses

3 responses 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.

Ms Alexandra Pountney 
Assistant Coroner 
South Yorkshire (West) 

19 September 2025 

Re: Regulation 28 Report – Kaine Regan Flecther  

Dear Ms Pountney 

Thank you for your report dated 25th July 2025 concerning the tragic death of Kaine Regan Fletcher. We 
extend our sincere condolences to his family and all those affected. 

We have carefully considered the matters of concern raised in your Regulation 28 report. This response 
outlines the College of Policing’s position on Acute Behavioural Disturbance, and police training in respect 
of the Mental Health Act. In relation to the operational elements and local partnership working, we have 
been  in  contact  with  Nottinghamshire  Police  and  understand  that  a  number  of  measures  are  being 
implemented and a full response to the concerns you have raised is being provided. 

1.  Acute Behavioural Disturbance (ABD) 

ABD  is  addressed  in  the  College  of  Policing’s  First  Aid  Learning  Programme  (FALP)  under  learning 
outcome  9  ‘Explain  acute  behavioural  disturbance  –  recognise  the  signs  and  symptoms  of  acute 
behavioural disturbance’ (Module 2 and 4). Police forces are required to train this learning outcome for all 
public facing officers. 

The National Police Chiefs’ Council (NPCC) clinical panel recognises the complexity of ABD and following 
a meeting on 17th July 2025 the panel discussed the need to develop material to support the service’s 
management of incidents of ABD. This has led to the following actions: 

•  The panel is currently reviewing existing guidance developed by the Faculty of Legal and Forensic 
Medicine,  alongside  representatives,  with  the  intention  of  ensuring  first  aid  training  remains 
appropriate 

•  The panel has offered clinical support to the NPCC Self Defence & Restraint (SDAR) Group and 

ongoing work in the Public & Personal Safety Training (PPST) curriculum 

•  The panel chair raised the aim of developing consensus on ABD with the NPCC Health & Safety 

strategic lead 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The College recognises the term ‘Acute Behavioural Disturbance’ (ABD) as an ‘umbrella term for a variety 
of medical conditions that can cause a person to behave in a way that is out of character and potentially 
harmful to themselves of others’ – as set out within the training material the College provides for police 
forces. This is informed by the position set out by the Royal College of Emergency Medicine (RCEM). 

The key  emphasis  of  the College  ABD  training  is  about  recognising the potential  for serious harm  and 
acting accordingly. In particular, the training emphasises the importance of avoiding the use of force, where 
possible. One of the key messages within the ABD training material, is to ‘Avoid physical restraint unless 
absolutely necessary for the safety of the subject, self or public.’ 

The  College  is  aware  of  the  recent  Delphi  study  publication,  titled;  Consensus  on  acute  behavioural 
disturbance in the UK: a multidisciplinary modified Delphi study to determine what it is and how it should 
be managed. Humphries C, et al. Emerg Med J 2023. The study concluded by setting out ‘It is key that 
Acute Behavioural Disturbance should be understood to be a presentation, not a diagnosis.’ 

The College guidance does not focus on diagnosis, instead the focus is on presentation as outlined in the 
College’s ABD training. Since this was published, the Delphi study highlighted the need for consensus on 
shared terminology and offered some ideas in relation to using new terms, including the term ‘Agitation’ – 
The College of Policing sets out to support Health partners in leading and developing the work in this area.  

This is an area that requires further research and an evidence base to inform national policy. The police’s 
role  in  responding  to  ABD,  particularly  as  a  medical  risk,  needs  to  be  informed  and  based  on  agreed 
guidance from our partners in Health – it is imperative that health should lead on areas of national health-
related policy. 

The College recognises that ABD presentation can lead to risks of serious harm, and therefore medical 
intervention by health professionals, who are the most appropriate agency with the skills and expertise, is 
crucial in these cases. This is consistent with the principles set out within the national Right Care Right 
Person (RCRP) toolkit. This does not however absolve the police from being involved where there is an 
immediate risk of serious harm, or where a crime is involved. 

As it currently stands, the term Acute Behavioural Disturbance is a health term that is recognised across 
different agencies, and any changes to the term will have to be carefully mitigated to ensure that patients 
are not put at risk. The use of consistent, recognised terminology helps ensure appropriate response by 
emergency services and correct medical management. The Delphi study sets out, ’Specific terminology 
should  be  used  to  identify  this  group  and  provide  a  common  language  regarding  prioritisation  and 
management strategies’. 

The College is currently undertaking a review of the mental health Approved Professional Practice (APP), 
which  will  ensure  that  any  development  in  the  published  guidelines  in  relation  to  ABD  are  updated  to 
ensure consistency with updated health policy. 

Right Care Right Person (RCRP) is a national initiative that has been adopted by policing and partners 
under the National Partnership Agreement: Right Care, Right Person (RCRP) - GOV.UK with the aim 
to ensure that vulnerable people get the right support from the right services. The RCRP toolkit went live 
in June 2023 and forces have continued to work with partners to ensure effective implementation. 

 
 
 The RCRP toolkit, hosted by the College of Policing, applies to calls for service about: 

•  concern for the welfare of a person 
•  people who have walked out of a healthcare setting 
•  people who are absent without leave (AWOL) from mental health services 
•  medical incidents, including conveyance 

The focus of RCRP is to ensure vulnerable people receive care from the most appropriate agency. This 
will  often  not  be  the  police.  The  Right  Care  Right  Person  toolkit  sets  out  that  forces  should  work  with 
partners, as follows:  

Protocols will need to be developed at a local partnership level to set out the lines of responsibility for 
each agency. Once agreed, these changes to ways of working must be communicated to staff within 
each agency and guidance provided. 

2.  Transporting patients 

Where  the  police  remove  a  patient  under  section  136  of  the  MHA,  the  default  mode  of  transport  is  by 
ambulance  or  other  healthcare-led  transport.  Transportation  using  a  police  vehicle  should  only  be  in 
exceptional  circumstances.  This  should be  subject to risk  assessment. See  Code of  Practice: Mental 
Health Act 1983 (Department of Health, 2015). 

The  RCRP  Toolkit  sets  out  that  ‘Staff  should  be  aware  of  inter-agency  attendance  and  transportation 
arrangements  when  dealing  with  s135  and  s136  MHA  patients,  as  well  as  casualties.’ 
https://www.college.police.uk/guidance/right-care-right-person-toolkit/force-control-room-
implementation-guidance#13cbaa76-afc8-4491-b947-4e78b4b52a2f 

3.  Police training on s.136 MHA 1983 detention and mental health 

The College of Policing’s Mental Health Training Programme provides learners with knowledge and skills 
that are required when responding to individuals with mental health conditions. The programme comprises 
a suite of learning standards for use at all levels of the service, setting out the learning requirements for 
staff  working  within  different  roles,  and  enabling  progression  so  that  learners  can  develop  their 
understanding  of  the  topic  area  as  required  for  their  role.  The  Mental  Health  Learning  Programme  is 
available via College Learn. The purpose of the programme is to ensure that officers and staff are able to 
recognise indicators of potential mental ill health and understand appropriate methods to communicate 
with and respond to people exhibiting those indicators. The programme specification and Trainer Guide 
has been updated as of October 2021. 
The College training on ABD is also available via College Learn, which is accessible for all forces to use 
as part of their organisational training programmes. 

The College of Policing provides the Mental Health Approved Professional Practice (APP) to assist forces 
in developing their policies and responses to incidents relating to people with mental ill health. Within the 
APP there is specific guidance on how officers should explain the detention of a person under Section 136 
of  the  MHA,  which  can  be  found  on  the  following  link.  https://www.college.police.uk/app/mental-
health/mental-health-detention#explanation-of-detention-avoid-the-use-of-arrest-terminology.  

 
 
 
 
 
 
 
 
 
 
 
 The College has liaised directly with Nottinghamshire Police and highlighted the current guidance available 
and following this we are aware that they have now developed specific guidance, based upon the APP 
guidance, for frontline officers to use when exercising this power. 

4.  Commitment to Continuous Improvement 

The  College  remains  committed  to  supporting  forces  in  delivering  lawful,  proportionate,  and  effective 
responses  to  incidents.  The  concerns  raised  will  be  communicated  with  all  forces  within  the  national 
governance structures, where learning can be shared.  The College will: 

•  Review all recommendations for potential learning through the NPCC First Aid Forum 
•  Review and update national guidance based on emerging learning 
•  Support forces in developing local protocols with partner agencies 
•  Promote national consistency through the Mental Health Forum and Tactical Delivery Board 
•  Encourage a culture of continuous improvement and reflective practice 

We  hope this  response provides  assurance  of  our  commitment  to addressing  the  issues raised and to 
preventing future deaths in similar circumstances. Please do not hesitate to contact us should you require 
any further information. 

Yours sincerely, 

Chief Executive Officer 
College of Policing

Parliamentary Under Secretary of State  
for Women’s Health and Mental Health  

39 Victoria Street  
London  
SW1H 0EU  
020 7210 4850  

HM Assistant Coroner Alexandra Pountney  
The Council House 
Old Market Square 
Nottingham 
NG1 2DT 

19 November 2025  

Dear Ms Pountney  

Thank you for your Regulation 28 report to prevent future deaths dated 25 September 
2025  about  the  death  of  Kaine  Regan  Fletcher.  I  am  replying  as  the  Minister  with 
responsibility  for  mental  health  and  I  am  grateful  for  the  additional  time  you  have 
allowed for me to do so.       

Firstly, I would like to say how saddened I was to read of the circumstances of Kaine’s 
death  and  I  offer  my  sincere  condolences  to  his  family  and  loved  ones.  The 
circumstances your report describes are very concerning and I am grateful to you for 
bringing these matters to my attention.   

Your report raises concerns addressed to a number of organisations and I understand 
your concerns. Those for my Department include the lack of joint agency policy/cross 
sector  working  on  Acute  Behavioural  Disorder/Disturbance,  police  use  of  an 
ambulance  as  the  mode  of  conveyance  for  section  136  detainees  and  the  gap  in 
mental  health  services  for  people  who  have  a  dual  diagnosis  of  a  mental  health 
condition, combined with a substance misuse diagnosis. In preparing this response, 
my officials have made enquiries with NHS England to ensure we adequately address 
your concerns.  

I have been advised by NHS England that it recognises the importance of ensuring 
that individuals presenting in extreme distress receive timely, safe, and effective care. 
However, the term “Acute Behavioural Disorder” (ABD) is not a formal diagnosis within 
the International Classification of Diseases (ICD-11), which is the global diagnostic tool 
used in the NHS. ABD is an umbrella term often used across emergency services to 
describe  behaviours  linked  with  extreme  agitation  or distress,  which  may  indicate  a 
potentially life-threatening physical health emergency.  

NHS  England  has  noted  the  Royal  College  of  Psychiatrists’  position  statement  and 
recommendations on ‘Acute behavioural disturbance’ and ‘excited delirium’ and fully 
supports ongoing multi-agency initiatives led by the Royal College of Psychiatrists and 
the Royal College of Emergency Medicine, including new training launched in 2024.  

 
  
  
   
 
 
  
  
  
  
  
  
  
 Your  concern  about  the  lack  of  agreed  joint  agency  policy  between  East  Midlands 
Ambulance  Service  and  the  police  on  section  136  detentions  is  a  matter  for  those 
organisations  

However,  I  note  that  Nottinghamshire  Healthcare  NHS  Foundation  Trust,  in  its 
response to your report, has confirmed it is in discussions with Nottinghamshire Police 
and  East  Midlands  Ambulance  Service  to  establish  a  collaborative  approach  to 
address the concerns relating to patients with a clinical presentation of ABD including 
training, pathways and clinical guidance.   

With  regard  to  your concerns about the  police  use  of  ambulances  to  convey people 
detained  under  section  136  of  the  Mental  Health  Act,  the  National  Partnership 
Agreement on Right Care, Right Person (RCRP) between policing, health and social 
care partners and other relevant partners was published in July 2023, and sets out the 
principles  around  the  RCRP  approach  which  aims  to  ensure  that  those  in  need  of 
mental health support or experiencing a mental health crisis receive the right support 
framework  promotes  coordinated, 
from 
evidenceinformed multi-agency responses (whether it is police, ambulance, or mental 
health services, or a joint agency response).  

right  professional.  The  RCRP 

the 

NHS  England  has  issued  comprehensive  guidance,  including  on  the  conveyance  of 
individuals detained under section 136, which sets out that:  

- 

- 

local  partners  –  including  police  and  ambulance  services  –  should  agree  the 
most appropriate health-based vehicle provision, informed by lived experience, 
to ensure safe and compassionate transport;  
for people detained under section 136, the target ambulance response time is 
an average of 30 minutes, as set out in the NHS England Ambulance Quality 
Indicators.  

-  while police have the legal power to remove individuals under sections 135 and 
136, health-based transport should usually be used. Police should accompany 
the individual to ensure a safe handover.  

I  understand  that  the  College  of  Policing  has  addressed  your  concern  about  police 
training on section 136 detentions in its response to your report and Nottinghamshire 
Healthcare NHS Foundation Trust has done so in respect of your concern about the 
local Street Triage Team.   

Your report lastly raises concerns regarding the care of individuals with co-occurring 
mental health and drug or alcohol use disorders.   

The  Department  recognises  that,  too  often,  people  with  co-occurring  substance  use 
and  mental  health  needs  do  not  receive  the  integrated,  person-centred  care  they 
require  and  deserve. Although  there  are  examples  of  good  practice  and  integrated 
services,  we  recognise  the  need  for  better  integrated  care  between  mental  health 
services and substance use services, to ensure people no longer fall through the gaps 
of treatment.   

Dame Carol Black’s independent review of drugs1 underlined the complex relationship 
between mental health and drug and alcohol use. The review identified that people can 
be excluded from mental health services until they resolve their drug problem, while 

1 Independent review of drugs by Professor Dame Carol Black - GOV.UK  

  
  
  
  
  
  
  
  
 
 also  excluded  from  substance  use  services  until  their  mental  health  problems  have 
been addressed.  

Working  with  subject  matter  experts,  including  people  with  lived  experience, 
academics,  clinicians, and  service  providers,  the  Department  and NHS  England  are 
currently  finalising  the  Co-occurring  Mental  Health  and  Substance  Use  Delivery 
framework. This framework will provide national commitments and calls to the sector 
on  how  the  health  system  can  improve  delivery  of  integrated,  person-centred  care 
across drug and alcohol treatment and mental health services.  

This approach is fully aligned with the National Institute for Health and Care  
Excellence’s  guideline  on  coexisting  severe  mental  illness  and  substance  misuse 
1, which states: “Do not exclude people with severe mental illness because of 
(
their substance misuse.”  

NHS  England  continues  to  promote  joined-up,  holistic  support  for  people  with  dual 
diagnosis  needs,  ensuring  services  work  collaboratively  to  meet  the  full  range  of 
individual needs.  

I hope this response is helpful. Thank you for bringing these concerns to my attention.   

Yours sincerely,  

1Recommendations | Coexisting severe mental illness and substance misuse: community health and 
social care services | Guidance | NICE

Nottinghamshire Healthcare NHS Foundation Trust 
Duncan Macmillan House 
The Resource 
Porchester Road 
Mapperley 
NG3 6AA 

16 September 2025 

Private and Confidential 
HM Assistant Coroner Alexandra Pountney 

Dear Ms Pountney 

Regulation 28 Response: Mr. Kaine Regan Fletcher 

I write in response to the inquest which was concluded on 25 July 2025 into the death of Mr Kaine 
Regan Fletcher. We accept your findings in relation to the received Regulation 28 and offer our 
sincere apologies to the family of Mr Fletcher.  Please find below the Trust response in relation to 
the relevant three of the six matters of concern and actions taken. 

Lack of joint agency policy/cross-sector working on Acute Behavioural 
Disorder/Disturbance (ABD) 

This point was accepted as important key learning prior to, during and at the conclusion of the 
inquest. Although this is clearly both a national and regional issue, the Trust wished to reiterate the 
internal learning and changes being made in response to the learning from M Fletcher’s death. 

There is training for all acute facing mental health staff from a GP medical volunteer from EMICS 
(voluntary emergency paramedic teams) arranged over two sessions. One session in August and 
the other in October 2025, specifically providing training on ABD.  

Signs and symptoms, clinical assessment and escalation processes are now included within the 
Trust Fundamentals of Care training for mental health staff under the medical emergency section. 
This has been peer reviewed by the GP medical volunteer from EMICS to ensure accuracy and 
appropriateness. 

The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 A quick reference guide for staff has been developed alongside both Royal Colleges of Psychiatry 
and Nursing guidance and this has been peer reviewed by emergency services. This has been 
shared with the Street Triage Team and will be distributed broadly once all staff have received the 
training.  

We are conducting a review of ABD related content within PMVA and the provision of this to acute 
facing community mental health staff, including learning from past cases of ABD related deaths. 
The insights and expertise of 
NICE-endorsed Positive and Safe Violence Reduction Training Manual, will be incorporated into 
this process. 

, a leading topic expert and advisor to the previously 

A clinical guidance document is being developed for Trustwide clinical staff and developed in 
conjunction with pathways established within EMAS and Nottinghamshire Police. This will be 
finalised by the end of September 2025. This will be supported by a revised version of the clinical 
algorithm within Joint Royal Colleges Ambulance Liaison Committee (JRCALC) and Royal College 
of Emergency Medicine.  The Trust have in development a clinical decision support tool that will be 
available for front facing acute mental health clinicians in supporting the knowledge and actions 
should ABD be a suspected clinical presentation. This will be finalised following consultation with 
wider agencies (Nottinghamshire Police and EMAS).  

The Trust is in discussions with Nottinghamshire Police and EMAS to establish a collaborative 
approach to address the concerns relating to patients with a clinical presentation of ABD including 
training, pathways and clinical guidance. There is an agreement with EMAS to meet with the Trust 
to explore opportunities for collaboration. This will be continued through to completion and take into 
consideration any wider national guidance from any response to this Regulation 28 Report 
received from Secretary of State for Health and Social Care. 

The availability of the Street Triage Team 

Since the conclusion of the inquest, the Trust has worked with Nottinghamhire Police colleagues in 
order to collate and analyse the data available to consider the current operational hours of the 
Street Triage Team. This review of the mental health incident demand experienced by 
Nottinghamshire police force, has actually highlighted that demand continues to be broadly at its 
highest during the operating hours of the Street Triage Team, meaning that the service model 
continues to be appropriate and offer best value and quality in its current format. However, to 
further strengthen our urgent mental health response to the public from the Trust, we are also 
currently undertaking a number of improvement programmes that will see us strengthen the offer 
made by our crisis services over the full twenty-four hour period, meaning that urgent mental health 
care will be more accessible to the public at all times of the day and night, every day of the week. 

The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA 

 
 
 
 
 
 
 
 Mental Health Services – ‘the gap’ 

Although  this  has  been  identified  as  a  national  issue  by  the  coroner  in  this  case,  we  did  want  to 
provide some information in response to this point from a Trust perspective as we recognise that 
there was a gap in provision of service for people with a dual diagnosis presentation during the time 
that Mr Fletcher accessed services in 2022.  

As part of the wider community mental health transformation programme which commenced in 2022, 
a  key  area  for  improvement  was  improving  access to  services  for  patients  with  a  dual  diagnosis. 
During 2022 this work was in its infancy and there was only one worker who was allocated to liaise 
with  the four  City  Local Mental  Health  Teams  (LMHTS).  As  the  improvement  work  progressed,  it 
became clear that the remote liaison was not working, and additional resource was also required. 
Key changes have since been made which includes co-located substance misuse workers, which 
includes Peer Support workers who have lived experience being located into the LMHTs, working 
as part of the team. The introduction of an additional three staff members and the service having its 
own referral pathway on the patient electronic system means that prior to any discharge, the core 
LMHT  would  be  able  to  see  the  person  is  accessing  the  co-located  practitioners  and  therefore 
consider  any  post  discharge  needs  and  liaison.  As  we  have  now  established  the  workers  within 
teams the staff are also embedded as part of the internal escalation meetings and processes should 
there be a requirement to escalate any concerns around discharge planning or unmet care needs. 

Whilst the structural changes that have been made, such as resource configuration, have made a 
huge  difference  for  people  with  dual  diagnosis  needs,  work  has  also  been  completed  to  support 
wider mental health staff in relation to core training and awareness for people with dual diagnosis 
needs.  We  continue  to  review  and  strategically  plan  access  and  treatment  for  people  with  dual 
diagnosis needs and this is in the form of a strategy group and works across the system including 
wider system partners and organisation, so people’s needs are not just considered in isolation. Public 
Health  England  is  working  alongside  the  services  and  planning  to  complete  an  evaluation  of  the 
pathway  and  wider  system  working  which  will  inform further service  developments  to  ensure  that 
mental health services work with people holistically, in a non-judgemental way to ensure that they 
receive the right care and treatment.  

A key area of concern was also identified in relation to people that have an identified need which 
can be met by another service or organisation, such as third sector or voluntary services, and the 
process of self-referral. Whilst services work collaboratively with people, we recognise that it is not 
always realistic for some people to complete the appropriate self-referral processes and time is often 
dedicated  by  staff  to  do  this  however  we  have  updated  our  team’s  Internal  Working  Instructions 
which outlines the expectation of staff and services to ensure that this is clear. We will also be sharing 
and  discussing  this  learning  within  a  planned  learning  event  to  further  support  awareness  and 
practice change.  

The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA 

 
 
 
 
 I can confirm that any responses from other organisations / individuals involved in this case, including 
the  wider  response  from  Secretary  of  State  for  Health  and  Social  Care,  will  also  be  carefully 
reviewed, including any guidance shared and partnership working opportunities fully accepted. 

I  hope  that  this  response  provide  reassurance  that  the  Trust  has  taken  the  concerns  highlighted 
seriously and have robust plans to address these as far as practicable in order to improve services 
for our large and varied patient population. 

Yours sincerely  

Chief Executive Officer 

The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA

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