21st September 2017

Today a report examining how a different approach to policing people with mental health needs could have prevented James Herbert’s death in custody has been published by the Independent Police Complaints Commission (IPCC). With input from both the family and INQUEST, Six Missed Chances pinpoints six key opportunities for learning and change.

  1.  A missed chance to avert a crisis, during the day of the arrest where police were made aware of James’ emerging mental health crisis and responded multiple times to incidents involving his increasingly concerning and disorientated behaviour
  2.  A missed chance to de-escalate, at the roadside where the arrest and restraint took place
  3.  A missed chance to release the pressure, once the restraint began
  4.  A missed chance to get immediate mental health support, when the decision was made to take James to a police station rather than a medical facility
  5. A missed chance to check on James’ wellbeing, during the 30 mile journey from Wells to Yeovil where James was handcuffed and in leg restraints
  6. A missed medical emergency, on arrival at the police station where James arrived unresponsive and was carried by six officers into a cell

Examining each of these points, the report looks at what happened, what should happen and what might prevent best practice being followed, in order to consider what can be learnt in terms of national policing and recommendations. The full report is available here (PDF download).

Tony Herbert, father of James Herbert said:
“Whilst we remain extremely disappointed that neither Avon and Somerset Police nor any police officer involved was made accountable for James’s avoidable and tragic death, as they should have been, we are fully behind the IPCC’s decision to publish ‘Six Missed Chances’, a ground-breaking report about the six times that a different decision and course of action may well have saved James’s life. If this document informs police policy and training as it should, future lives will be saved.

We are grateful to INQUEST and particularly our Case Worker Victoria McNally, for being with us every step of the way for seven years and for bringing their knowledge and experience to bear by offering it to the IPCC in advising, suggesting and recommending throughout the drafting of the report. It speaks volumes for INQUEST’s expertise and commitment that ‘Six Missed Chances’ has the potential to be a really effective piece of work.”

Deborah Coles, director of INQUEST said:
“James was detained by the police for his safety.  He should have been treated as a patient in need of medical care. Instead he suffered a traumatic but entirely preventable death involving prolonged and brutal restraint. We welcome the publication of Six Missed Chances, a product of his family’s unwavering fight for change in response to a system that for 7 years has delivered little more than defensiveness, denial and delay.

There is an urgent need to change police practice and culture, to stop more needless deaths with all the devastating impact these bring to families and our communities. This report should mark a watershed in the training and practice of officers responding to those in mental health need. Officers must understand the dangers of stereotyping people with mental ill health, and be equipped to respond with empathy and humanity.

Safety, welfare and de-escalation must become the established policing response to those in crisis, if we are to see an end to deaths likes James’.  We call for a plan of action from police forces nationally to respond to the report and consider how this powerful case study can be used as a tool for change.”


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

  • Earlier this month Tony Herbert, James’ father spoke alongside Deborah Coles to the College of Policing and National Police Chiefs Council about his experiences at their conference on policing and mental health. You can read his presentation here
  • On 6 September a gross misconduct hearing on the actions of an officer involved in James’ death was dismissed by Avon and Somerset police (full information here).
  • The inquest into James Herbert’s death concluded in April 2013 and found serious failings. Full information on the conclusions of the inquest can be found here.
  • INQUEST casework and monitoring from 1990-2016 shows that the proportion of deaths involving restraint is over 3 x greater in cases where the person had mental ill health than where mental health was not a factor.
  • Reflecting a longer term trend, more than half of those who died in or following police custody in the last year were identified as having mental health concerns according to  IPCC annual statistics. The majority of INQUEST’s police related cases over the past five years have involved the death of vulnerable individuals in some form of mental health crisis.

INQUEST has been working with the family of James Herbert since his death. The family is represented by INQUEST Lawyers Group members Kate Maynard of Hickman and Rose solicitors and Alison Gerry of Doughty Street Chambers.

INQUEST is the only charity providing expertise on state related deaths and their investigation to bereaved people, lawyers, advice and support agencies, the media and parliamentarians. Our specialist casework includes death in police and prison custody, immigration detention, mental health settings and deaths involving multi-agency failings or where wider issues of state and corporate accountability are in question, such as the deaths and wider issues around Hillsborough and Grenfell Tower. Our policy, parliamentary, campaigning and media work is grounded in the day to day experience of working with bereaved people.

Please refer to INQUEST the organisation in all capital letters in order to distinguish it from the legal hearing.