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Six Missed Chances
written by Mental Health Cop on the 21st September 2017 at 10:21

I want to ask you to put all your preconceptions to one side for the five minutes it will take to read this and for a short while afterwards. If you use the links below and read the Six Missed Chances report from the IPCC, which is published today and follows the death of James Herbert in Somerset in 2010, your instinct may be that some of it is not practical. I fully and freely admit, that was my instinct when I read a draft copy of it last year and I’ve had to really think about this because it’s challenging us to think again about whether we can think differently. I suspect and do understand some officers may wonder whether the IPCC actually understand police work at all or live in the real world – social media shows these questions are emerging as people read the media coverage that is coming out. I would suggest they read the report instead, because it’s not the longest thing of this type you’ll ever see.

A man died here – the report merely asks the service to think again about whether we could think or act differently: in how we respond to crisis incidents and consider or undertake restraint as a tactic. I admit I don’t think it’s a big ask and would argue we all owe it to James and all those who have been affected by his death to think again about whether it’s possible for us to think differently about the use of force in handling a mental health crisis.


Tony Herbert, James’s father, spoke earlier this month at the NPCC / College of Policing conference on mental health. I admit to sitting there, watching this man speak for his dead son to an audience of people doing the same job as those who were with him in the hour or so prior to his death. I sat there thinking about Harrison, my “nearly-13” year old son, simply unable to conceive of any situation where he has already lived more than half of his life and not with us in another 13 years – I admit I dream some non-specific dreams about the life he may be able to lead.  And there was Tony, having lived that nightmare, saying out loud that he doesn’t think officers acted maliciously and that he is absolutely confident no officer came to work that day aiming to hurt anyone. But regardless, James died in police custody and it appears there were lots of complicated reasons as to why he did. These issues are not just about frontline police officers: it is about senior police officers and their responsibilities around policies, joint protocols and effective training; it’s also about healthcare partners who must be able to deliver on their side of the deal: the ambulance service, the emergency departments and the mental health system.

The report is about trying to help the police understand how those various factors combine and need to be addressed in their totality – unless I’ve entirely missed the point. It’s about asking whether the police – at all levels – can think differently, given that James’s death is not the most recent death in police custody involving someone in mental health crisis and the lessons it offers are not unique to James’s circumstances. You can look at the death of Thomas Orchard in Devon in 2012, Sean Rigg in London in 2010 and many, many others and see similar issues: this is about frontline police officers, but it’s not JUST about them – it’s about creating a context in which they stand a chance of thinking that the ideas in this report are possible.

  • As long as they believe it’s unlikely an ambulance can turn up at all, the more likely they are to think we should “get on with it” by conveying people in police vans.
  • As long as they are told by joint protocols that people who are resistant, challenging or even violent should be detained in custody, they are more likely to go to custody.
  • As long as they hear that “A&E is not a place of safety”, the more likely they are not to take someone there who needs it for emergency psychiatric reasons to which published medical guidelines relate.

We could go on.  Last night, I did some Google searching of MH trust websites, in an area of England where I know the ambulance service will not agree to comply with the Crisis Care Concordat requirements for ambulance services, where Place of Safety services still insist that anyone who is intoxicated, aggressive or under 18yrs old still cannot access the NHS Place of Safety and where A&E are openly resistant to the idea of anyone going there purely in preference to custody. So the toxic circumstances that existed in Somerset in 2010, still exist in some parts of England in September 2017. Just imagine if there was another death in custody where officers had used a police vehicle to convey someone to custody?!


The report itself says what it says: it doesn’t necessarily say what the media are purporting to have it say. Read it for yourself, if you’re going to get in to the discussion: it’s less than 40 pages so anyone with a specific interest in this won’t have to spend too much of their time – and if do just you want a summary, read the IPCC press release, because it covers the salient points. But what this report does NOT say, contrary to the BBC News headline, is that “the police should not restrain people in custody with mental health problems”.

No, no, no – the report simply did not say that!

It acknowledges in various places that the police have difficult judgements to make and that restraint when it is used, merely needs to be proportionate to the situation. All over social media this morning, officers are putting up hypotheticals about scenarios they’ve dealt with, then reflecting on the (inaccurate) BBC headline that restraint should not be used as if to ask, “So what do they want us to do here, then?!”  This is why it’s important to take time to read this and reflect: the IPCC are not saying officers should never restrain: but to justify inflicting a fatal restraint on someone, you need to be managing a pretty serious level of risk and threat to justify that as proportionate.

We need to remember this: a man died here and a family’s life is still in turmoil as processes connected to this concluded only this month, more than seven years down the line. My own view is we owe it to James’s parents and family to take a small amount of time to think again about whether we can think differently. We absolutely need to accept, if nothing else, that the strategic and partnership context in which the operational decisions were taken, was inadequate. I was formally commissioned by the IPCC a few years ago to review the multi-agency s136 policy in play at that time. It is correct to say, as mentioned in the report, that if any police force had asked my advise about the policy, I would have advised against signing it.

No-one is saying that the ideas in this report will make a difference in every case, because this is complex stuff with fast-moving factors and no-one is saying it is never relevant for officers to use force and we know, when we do, that is sometimes on people who are medically very unwell. But we do need to show we’ve not just defensively rejected the ideas amidst an immediate sense that it’s not practical and then, this may make a difference to just one or two families who will not have to experience the utter trauma of losing a son and perhaps that can afford Tony and Barbara a small measure of peace.

I just think we owe all them at least a small amount of our time to think on it. And what’s to disagree about? –

  • Prioritise safety and wellbeing
  • Try to de-escalate things to prevent or reduce the use of force.
  • Aim to contain, rather than restraint, wherever possible.
  • Ensure robust, effective local protocols across police / NHS.
  • Proactively share and better disseminate information about vulnerable people.

I’m not sure we’re allowed to disagree with this, are we?!  Most of it is the just law of the land in operation and it always has been.

IMG_0053IMG_0052Winner of the President’s Medal from
the Royal College of Psychiatrists.

Winner of the Mind Digital Media Award.


 Originally posted at

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