12 September 2019

Before HM Senior Coroner Rachel Griffin
Bournemouth Coroner’s Court
Town Hall, Bournemouth, BH2 6DY

Opening 16 September 2019
Scheduled for four weeks

Douglas Oak, 35, died on 12 April 2017, the day after contact with Dorset Police officers during a suspected episode of Acute Behavioural Disturbance (ABD). The inquest, opening on Monday 16 September, will examine the circumstances of his death including use of restraint by the police and the response of South Western Ambulance Service NHS Foundation Trust (SWAST).

Douglas was a company director, described by his family as a loving son, brother, brother-in-law, uncle and friend.  His father John Oak said, “This world is far worse off without our lovely son.  He was truly one of a kind. We know it will be tough for us all to have to relive what Douglas went through, but we hope that the inquest will bring us the answers we need.”

On 11 April 2017, Douglas had been behaving erratically and walking in and out of traffic when police arrived. Officers report suspected he was suffering from an episode of ABD and Douglas was restrained for a period of time before a SWAST ambulance attended. He was then taken to the Critical Care Unit in Poole General Hospital where he died the following day.

Douglas was one of 17 people to die following police restraint and use of force in England and Wales in the year 2017-18. Acute Behavioural Disturbance is a common feature in restraint related deaths in custody.

Anita Sharma, Senior Caseworker at INQUEST, said: “INQUEST sees a significant number of deaths following police restraint. This inquest serves a two fold function; to investigate the circumstances of Douglas’s death and to consider whether there is a risk of future deaths occurring. It is imperative that any such risks which the inquest identifies are responded to at a local and national level.”

The family are represented by Gus Silverman of Irwin Mitchell solicitors who said: “Any death following police restraint is of course a matter which needs to be investigated thoroughly.  This hearing will be an important opportunity for all the agencies involved to reflect on the circumstances in which Douglas died.”


For further information, interview requests and to note your interest, please contact INQUEST Communications Team: 020 7263 1111 or [email protected]; [email protected]

Douglas’ parents are represented by INQUEST Lawyers Group members, Gus Silverman of Irwin Mitchell Solicitors and Patrick Roche of Garden Court Chambers. The family are working with INQUEST caseworker Anita Sharma.

Other Interested persons represented are Dorset Police, South Western Ambulance Service NHS Foundation Trust, and Poole Hospital NHS Foundation Trust

For more information see Guardian reporting of the Pre-Inquest Review into Douglas’ death, September 2018.



  • The Independent Office for Police Conduct (IOPC) reported that, between 1 April 2017 and 31 March 2018, seventeen of the people who died in or following police custody or other contact were restrained or had force used against them by the police or others before their deaths. INQUEST Media Release, July 2018.
  • In the financial year 2018/19, the IOPC reported that six of the 16 people who died in or following police custody had force used against them either by officers or members of the public before their deaths, and a further eight had force used against them in ‘other’ deaths following police contact. INQUEST Media Release, September 2018


In October 2017 the landmark Independent review of deaths and serious incidents in police custody by Dame Elish Angiolini QC was published. Commissioned by Theresa May when she was home secretary. The review found that police practice must recognise that all restraint can cause death and made a series of recommendations on the use of force and restraint more broadly. The government’s Deaths in police custody: progress report in 2018 did not note any progress on use of force and restraint in policing.

Related recent cases

  • Darren Cumberbatch, 32, died in hospital in July 2017, nine days after use of force by police officers while he was experiencing a mental health crisis. Inquest jury returned a narrative conclusion, finding that the police’s restraint contributed to his death. Media release, June 2019.
  • Meirion James, 53, died of positional asphyxia following excessive restraint by police. The inquest jury also found that there has been failures to communicated ‘significant information’ and follow procedures. Media release, January 2019.
  • Duncan Tomlin, 32, became unresponsive after being restrained by police and placed into a police van. He died in July 2014. The inquest jury concluded that his death was contributed to by neglect. Media release, April 2019.  
  • Adrian McDonald, 34, died in December 2014 after being arrested, restrained, bitten by a police dog, Tasered and left in a police van struggling to breathe following reported erratic behaviour. An inquest into his death concluded that his death was caused by the “effects of cocaine and stress of incident”. Media release, November 2018.
  • Terry Smith, 33, died in November 2013 following detention and restraint by Surrey Police. An inquest jury concluded that neglect contributed to his death. They also found a serious failure to recognise the signs and symptoms of Excited Delirium as a medical emergency and noted the use of prolonged and excessive restraint. Media release, July 2018.