'Failings' of police over restrained man's death

Kaine Fletcher, 26, died in hospital after being detained by police under the Mental Health Act

A jury has found "gross failings" contributed to the death of a man who was restrained by police during a mental health crisis.

Kaine Fletcher, 26, died in hospital on 3 July 2022 in Nottingham after a police welfare check escalated into a decision to section him.

A four-week inquest at Nottingham Coroner's Court concluded on Friday, with a jury delivering a narrative verdict outlining multiple failings on the part of Nottinghamshire Police and other organisations involved in Mr Fletcher's care.

HM Assistant Coroner Alexandra Pountney said the evidence she had heard had left her with concerns and issued a six-point prevention of future deaths report on the conclusion of the inquest.

Nottinghamshire Police gave its sincere condolences to Mr Fletcher's family and said it would now reflect on the findings the coroner had made to ensure it continued to take all the necessary steps to keep the public and its workforce safe.

Police were called out to Mr Fletcher, a father-of-two with drug addiction and mental health issues, over concerns he would harm himself.

He was found to be agitated, sweating and "talking nonsense", found the jury, but after initially agreeing to be taken to hospital, he began to suspect the police were not genuine and resisted being inside a police car.

He ended up handcuffed, struck multiple times, placed in leg restraints and, after banging the inside of a police van's cage with his head, on the floor wearing a spit hood.

Eventually an ambulance arrived, and Mr Fletcher was taken to Queen's Medical Centre where he died.

Mr Fletcher grew up in a "large, close-knit" family in Strelley, the inquest heard

Delivering their conclusion, the foreman of the jury - who broke down in tears while delivering the findings - said there had been "ineffective communication" at the scene and a "lack of clear leadership".

The officers did not communicate clearly with Mr Fletcher.

While the level of restraint was "appropriate" and the "tactical strikes" by individual officers had not been excessive, their combined force was "uncontrolled" they found.

Police should too have considered the length of time that Mr Fletcher was kept in restraints, they said.

The jury said there was a "gross failure" in training across all agencies.

The jury also found a nurse from the city's Street Triage Team had made an "inadequate assessment" and decided not to section Mr Fletcher the day before the 999 call which led to his death.

The jury said Mr Fletcher was "lost in the system with no effective or practical treatment available".

'We will reflect'

The coroner issued a Prevention of Future Deaths report, her second during the course of the proceedings.

Recommendations include:

• Developing a joint mental health crisis policy for Nottinghamshire Police and East Midlands Ambulance Service

• Ensuring staff are trained in handling such incidents.

• Reviewing the availability and effectiveness of the Street Triage Team, which was off duty during the crisis.

• Improving support for individuals with co-occurring substance misuse and mental health conditions.

Following the conclusion, Assistant Chief Constable Suk Verma, of Nottinghamshire Police, said officers had been at "a challenging and fast-moving medical incident" and an independent investigation had found no individual officers at fault.

She said: "First and foremost, our sincere condolences to the family of Kaine Fletcher. Our thoughts remain with all those affected by his death.

"Making sure we operate in the safest way possible is of paramount importance to us.

"We will now reflect on the findings the coroner has made to ensure we continue to take all the necessary steps to keep the public and our workforce safe.

"We continue to offer training to our workforce around Acute Behavioural Disturbance (ABD)."

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