Inquest finds that neglect and a series of omissions and failures by police and ambulance services contributed to the death of Leon Briggs

An inquest has found that a series of omissions and failures by Bedfordshire Police and East of England Ambulance Service contributed to the death of Leon Briggs on 4 November 2013.
 
The jury found, on the balance of probabilities, that there was a gross failure to provide Leon with basic medical attention and that there was a direct causal connection between this conduct and his death. They recorded a conclusion that his death was ‘contributed to by neglect’.

Leon Briggs, from Luton, was 39 years old when he died on 4 November 2013 following restraint by Bedfordshire police officers. The conclusion marks the latest step in the family's fight for answers.

Leon had a mixed-race heritage. He was a father to two children. His family describe him as “a loving, son, brother and father, caring and genuine”. He had previously worked teaching computer skills to the elderly and as a lorry driver.
 
The jury criticised the restraint by Bedfordshire Police, which they found to be mostly in the prone position with the application of inappropriate use of force. They also criticised a failure to recognise Leon as a medical emergency, inadequate assessments and a failure to monitor him. They pointed to an unsatisfactory conveyance in the police van as well as miscommunication throughout. These failures contributed to his death.
 
The jury also found a number of serious failings by the East of England Ambulance Service. 
 
Leon had been moving erratically around the local area, with numerous witnesses describing that he appeared to have mental ill health and seemed ‘confused’ but not aggressive.  Bedfordshire Police initially arrived on the scene after a member of the public called 999, concerned for Leon's welfare. The caller asked for an ambulance as well as police as Leon “needed calming down”.
 
The police control room, who could see Leon on CCTV, logged this as ‘an aggressive male’. Armed police officers arrived on scene and Leon was detained under section 136 of the Mental Health Act. He was quickly brought to the ground and restrained in the street by three officers. Leon was in prone restraint (face down) for over 13 minutes, and in handcuffs and leg restraints for 25 minutes. Staff from the East of England Ambulance Service arrived on scene, but did not assess or communicate with Leon.
 
Leon was then taken in a police van to Luton Police Station, rather than the local hospital despite it being closer in distance. The custody team had been alerted that a ‘violent male’ was being brought in. Unable to walk, he was carried into a cell where he was restrained again then left unconscious for 6 minutes and 15 seconds, before becoming silent and unresponsive. At this point Leon was taken by an ambulance to hospital, where he was pronounced dead.
  
Throughout the nine-week inquest, held by the Senior Coroner for Bedfordshire, Ms Emma Whitting, jurors heard evidence of a catalogue of failings that culminated in Leon's death. The inquest heard his primary cause of death was "amphetamine intoxication in association with prone restraint and prolonged struggling”, with a secondary cause of coronary heart disease. A medical expert told the inquest Leon would have survived, beyond reasonable doubt, if he had been taken to hospital rather than police custody.

The credibility of the officers’ accounts was called into question after the breach of a non-conferral order, initial statements from the officers were nearly identical when given.

At the conclusion of the inquest the coroner praised the family for the ‘complete understanding and courtesy’ they had shown throughout the process. The coroner said that Leon deserved to get the full services owed to him by the police and ambulance service. She said Leon had been “so very let down”.

The coroner also made the point that, unlike Bedfordshire Police, the EEAST had acknowledged their failures before the end of the inquest. The Coroner indicated that this was to their “credit” and that she hoped the Chief Constable would “reflect” on the implications of the findings. She gave a clear hint that she considered it would be appropriate to make a ‘Prevention of Future Deaths’ report linked to the police conduct.

A full statement was read on behalf of the family outside court, available here.

Margaret Briggs, Leon's mother, said:

“Today marks a milestone in our fight for justice for Leon. After seven long years of waiting, those present during Leon's restraint have finally been made to explain their actions. 
 
“The conclusion of Neglect does not, I believe, reflect the evidence and I am disappointed that the jury did not return a conclusion of Unlawful Killing.  
 
“Over our long fight for the truth there has been no remorse shown by the police – in fact they have tried to disrupt the investigation at every turn, determined to cover their own backs. To this day, those police officers still have their jobs and livelihoods and no one has been punished for Leon’s death. There has been no accountability or justice. The CPS must now reconsider bringing prosecutions.
 
“We think that Leon’s race was a factor in the way he was treated by the police.  He was treated as someone who posed a threat rather than someone in need of help.
 
"Leon was also failed by the East of England Ambulance Service staff who made no attempt to help him or do their job to care for him. They were faced with a man in crisis, who posed a medical emergency, and yet they failed to even check if he was all right.
 
“I wouldn’t wish the pain we have suffered on anyone.” 

Anita Sharma, Head of Casework at INQUEST who has worked closely with the family, said: 

“Officers treated Leon’s obvious distress as aggression and violence. They used brutal and almost immediate force and chose not to seek clinical support, while the Ambulance service made no attempts to intervene. These actions and inactions are part of a pattern of inhumane treatment rooted in systemic racism.
 
“This damning conclusion is an important recognition of the seriousness of the system wide failures. The police will say that seven years on things have changed. Why then are Black men still subject to disproportionate use of force by police? Why are they more likely to die after police contact particularly when in a mental health crisis? And why have the police resisted scrutiny and accountability since his death by neglect.”

Jocelyn Cockburn, Partner at Hodge Jones & Allen solicitors said: 

“Given that Leon was a vulnerable person, detained for his own safety (not arrested) the level of force used against him is incomprehensible.  It should be no surprise that the family now question whether racial stereotyping by the police played a part in his treatment and ultimately his death.  
 
“Shockingly several years after the death, the police officers displayed little or no insight into the consequences of their actions.  Officers said they would do the same today. This shows an unmitigated failure on the part of the Chief Constable to take appropriate actions following the death. The attempts by Bedfordshire Police to obstruct the investigatory process from the very first moments (when officers conferred in preparation of their statements) have meant that there has been a failure to learn lessons. There has been no accountability.  

“The evidence heard during this inquest has been an important step towards learning lessons.  It is the interests of officers of Bedfordshire Police as well as the general public that the rights lessons are learned following this tragedy.

"The coroner made her view clear that the Chief Constable should reflect on the actions of the police – something that for over 7 years has not happened.

"There is every need for a prevention of future deaths report in this case as there are serious concerns that the police simply will not face up to the truth of what happened and the lessons that should be learned from it. This family’s fight for justice continues.”

Gimhani Eriyagolla, Solicitor at Hodge Jones & Allen, said: 

“While we still believe there was enough evidence for unlawful killing, the conclusion of neglect showcases how system wide failures were at fault for Leon’s death. However, it is shameful that it has taken nearly eight years to get to this result. There has been a continuous lack of accountability from the Bedfordshire Police, something which has only gotten worse through this inquest. Officers have fabricated accounts and excuses to cover up this injustice. 
 
“The issues presented in this case, such as the treatment of mixed-race person in custody, the dangerous restraint used on someone suffering from ill mental health, and the lack of medical intervention, shows a myriad of systemic problems from the Bedfordshire Police as well as failings by East of England Ambulance Service that are simply unacceptable.”

A version of this press release was first published on INQUEST's website on 12th March 2021.