7 May 2021

UPDATE 19 May 2021: This inquest has been adjourned for the remainder to be heard from 26 July 2021.

Before HM Assistant Coroner Sonia Hayes
Oxfordshire Coroner’s Court – access on request

Opens 10am, Monday 10 May 2021 - Scheduled for two weeks

Adam Stanmore, a 37 year old man of mixed heritage from Oxford, was found dead on 13 June 2019. He had expressed suicidal intentions and was restrained, Tasered and taken to custody by Thames Valley police, before being put into an ambulance. Adam, who had recently been in touch with mental health services, left the ambulance. He was reported missing and weeks later was found dead. The inquest into Adam’s self-inflicted death opens on Monday (10 May).

Adam’s family describe him as a peace keeper who believed strongly in justice, anti-bullying and felt strongly that all people should be treated equally without prejudice. He had a cheeky, boyish charm with a quick wit which was hard to match. He was of mixed heritage with English and Caribbean family.  He was close to his young daughter and they were often called two peas in a pod. While Adam was deeply intelligent and had the potential do well in life, he lacked confidence and was often reluctant to ask for help. He had a history of self-reported depression and type 1 diabetes.

On 23 April 2019, Adam contacted his GP and reported paranoid thoughts and hearing voices which were telling him to kill himself. Adam used cannabis and the GP suspected that this was drug induced psychosis, so referred him to the Oxford Health NHS Foundation Trust Adult Mental Health Team. They saw him the same day at Warneford Hospital. The doctor found he had experienced drug induced psychosis, but the outcome of the assessment was referral back to the GP and a contact for the charity MIND for support.

A few weeks later, on the morning of 18 May 2019, Adam left his mother’s house and left a note suggesting suicidal intentions. In the early afternoon he got a knife from a neighbour and Thames Valley police were called. Two officers found him with the knife and he told them “I want to kill myself”. Armed Response Officers then arrived and approached Adam, asking him to drop the knife. They discharged a Taser on three occasions, and used force and restraint.

Adam was then taken to custody at Abingdon police station, however his blood sugar levels were very low. He was released by police with no further action, then was put in a South Central Ambulance Service ambulance. His physical condition was assessed, before he said he felt well and asked to get out. He was later reported missing.

Adam’s body was found weeks later on 13 June 2019, having died some time ago after using a ligature.

The family hope the inquest will explore:

  • The adequacy of the assessment and response to Adam’s mental ill health on 23 April 2019.
  • The circumstances leading up to Adam’s restraint, arrest and detention on 18 May 2019.
  • Whether force used by police was excessive.
  • The adequacy of the assessment of Adam in police custody and the ambulance, including his risk of suicide.
  • The adequacy of communication between agencies before and after Adam went missing.


For further information, interview requests and to note your interest, please contact Lucy McKay on 020 7263 1111 or [email protected]

You must contact the coroner’s court directly in advance of attending to arrange access in person or remotely. The inquest will be held at Oxford Coroner's Court, County Hall, New Road, Oxford, OX1 1ND.

Adam’s family are represented by INQUEST Lawyers Group members Chanel Dolcy of Bhatt Murphy solicitors and Kirsty Brimelow QC. The family are supported by INQUEST caseworker Selen Cavcav.

Other Interested persons represented are Oxford Health NHS Foundation Trust, Thames Valley Police, South Central Ambulance Service, Mountain Healthcare (who reviewed Adam Stanmore in police custody) and Berkshire Healthcare NHS Foundation Trust (who also reviewed Adam Stanmore in police custody).

Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests.