Kaine Fletcher died aged 26 on 3 July 2022 after a period of prolonged restraint by officers from Nottinghamshire police who had been called to visit him for the purposes of a welfare check.
Prior to his death the police use of force upon him included using a baton to force him into a police car, and then prolonged restraint, which included the use of handcuffs, a baton strike and the application of three leg restraints and a spit hood, and involving as many as nine police officers.
During this, several officers delivered blows to Kaine: with one officer striking Kaine to the jaw twice, others using knee and leg strikes, and much of this being simultaneous and despite Kaine being in handcuffs and leg restraints. Kaine had been restrained for approximately 30 minutes before police recognised that there was a medical emergency and called an ambulance. Kaine continued to be restrained by police officers in the ambulance and for some time after his arrival at the Emergency Department at Queen’s Medical Centre.
All of this occurred, as the inquest heard, in circumstances where Kaine should not have been conveyed to hospital by police car or police van. The police policy is that the officers should have called for an ambulance when detaining someone for mental health reasons.
Having heard 4 weeks of difficult and distressing evidence the inquest jury concluded that a number of serious failings by the police contributed to Kaine’s death, including that:
- There was ineffective communication between the officers at the scene, between the supervisors in the control room and a lack of clear leadership on the scene. The jury also found management and leadership failures “in all departments”;
- There was a “gross failure” in dissemination in training across all agencies. In particular, the police disregarded vital information, policies and training on section 136 and ABD – including the requirement to convey detained patients to hospital by ambulance;
- The decision by the Street Triage Team not to detain Kaine on 2 July 2022 following an inadequate assessment, a lack of engagement with Kaine and Kaine’s family, EMAS and other police officers at the scene was a “gross failure”; and
Kaine was “lost in the system with no effective or practical treatment available. This was a gross failure in the care of Kaine”.
In the course of the inquest, it became apparent that a state of confusion had existed for some years prior to the death between the police and ambulance services as to response times when a person had been detained and/or restrained by the police under the Mental Health Act. That confusion created such a risk to life that the Coroner in the inquest took the exceptional step of issuing – before the inquest had even concluded – a report to EMAS and to Nottinghamshire Police urgently requesting that they resolve the matter in order to prevent future deaths.
The Coroner issued a further preventing future deaths report following the conclusion of the inquest, highlighting six areas of concern including “a training issue within the police in relation to s.136 detentions and the correct mode of conveyance. Either officers do not know that they should call an ambulance, or they are ignoring their training/the instructions that they are given.”
Erica San of Bhatt Murphy acts for Kaine’s family.
Read the family’s press release here.
Read the Preventing Future Deaths reports here and here.
Read the Record of Inquest here.
