Before H.M. Assistant Coroner Joanna Thompson
Norfolk Coroner's Court
10 October to 8 November 2022

Krystian Kilkowski died shortly after midnight on his 32nd birthday after being restrained by five police officers the previous evening in the hot sun during a summer heatwave.

Today, an inquest concluded, finding that Krystian died “a drug related death following amphetamine intoxication leading to acute behavioural disturbance which was exacerbated by a period of physical activity, and further complicated by serious failures in the methods of restraint”.

They also found that “operational failures in the emergency services led to delays in Krystian receiving timely critical care”.

Krystian was a fit and healthy Polish man who had been living in England for nine years. His family describe him as a very passionate and hard-working man who was always happy and smiling, with many friends and liked by all who met him.

On 10 August 2020, police officers from Norfolk Constabulary who attended Krystian’s home address thought he was behaving strangely and were made aware that he had taken drugs. Distressing video footage available showed how Krystian had gone from walking and talking to police officers and others outside his home, to being detained on a grass bank shortly after.

The footage shows Krystian being restrained mainly face down for over an hour with officers repeatedly pushing his head down towards the ground. He was clearly frightened for his safety and was expressing concerns that he was going to die. Despite this, and already being in handcuffs, he was taken to the ground where immediately two sets of leg restraints, and subsequently further methods of restraint, were applied to him.

The police said they detained Krystian because they had concerns about his mental health and proposed to take him to a place of safety under s136 of the Mental Health Act 1983. However, it was accepted that Krystian was not told of the reason he was being detained. Krystian was also not told why increasingly severe methods of restraint were being applied to him as he struggled against the officers’ uses of force.

During the prolonged restraint, Krystian was held mainly face down and his level of distress was visibly increasing such that he began biting his own arms and his tongue. His tongue injury was described by the pathologist as the worst she had ever seen. Police officers were waiting for an ambulance from EEAST to attend, but miscommunications contributed to significant delays in the attendance of the ambulance.

By the time the ambulance arrived, Krystian was bleeding and barely conscious, and an officer noted him to be turning blue. A paramedic’s evidence was that he was shocked by what he encountered and that the case of George Floyd immediately came to his mind. He said that Krystian’s condition was so critical that it was beyond his expertise and that Krystian required emergency critical care.

This did not arrive until after Krystian was already en route to hospital. Instead, the police’s restraint (which had been by this point ongoing for over an hour) continued for another 20 minutes or so before he was put into the ambulance where he subsequently collapsed. Expert evidence was that from that point he was likely beyond help and the hospital was unable to provide effective treatment. Sadly, Krystian passed away after suffering multi-organ failure some hours later.

The pathologist, Dr Fitzpatrick-Swallow, gave her expert opinion that the police restraint contributed to Krystian’s death. Although amphetamines were found in Krystian’s blood, the amount was not within the fatal range.

The medical cause of death which was agreed by all medical experts and confirmed by the jury was: (a) Multi-organ failure, (b) Hyperthermia and Rhabdomyolysis and (c) Complications arising during restraint of a man with acute behavioural disturbance and amphetamine intoxication following a period of physical activity.

Although the medical cause of death refers to Krystian’s presentation being of ‘acute behavioural disturbance’, expert evidence was clear that this is not a medical condition and that most people presenting in this way would survive.

Recent guidance from the Royal College of Psychiatrists, published on 26 September 2022, draws attention to the significance of restraint in the deaths of people subsequently said to be presenting in this way. In Krystian’s case, as agreed by the pathologist and the jury, the restraint played a part in his death.

The jury’s conclusions also noted that the police’s “approach lacked leadership” and their “decision making was inadequate”. The jury concluded there was “a serious failure to keep Krystian safe” which “contributed to his rapid physical deterioration during the restraint.” The jury’s findings reflect what was obvious from the distressing video footage of the restraint.

Jodie Anderson, Caseworker at INQUEST, who support the family said: "Krystian’s death is another shocking example of the lethal consequences of police officers dealing with people in mental health crises.

Krystian was in distress and needed care, not brutality. The failure to treat his rapidly deteriorating condition as a medical emergency meant that he was deprived any chance of survival.

We call for a widespread structural and cultural change in the way that those in acute mental health crisis are treated on the streets. A failure to acknowledge this growing problem will result in further unnecessary deaths following disproportionate use of force at the hands of police forces."

Eva Roszykiewicz, solicitor representing the family: “The response from Deputy Chief of Norfolk Constabulary following the inquest is indicative of a problematic policing culture and a refusal to learn from preventable deaths. Far from the jury’s conclusions, DCC Simon Megicks stated that his officers made every effort to get Krystian the help he needed.

An extremely concerned and diligent jury found that there was a serious failure of the officers to keep Krystian safe in direct conflict with their policy and training. Rather than engaging with the jury’s detailed findings, it appears DCC Megicks is more concerned with trying to shift the blame away from his officers. This provides no reassurance that another preventable death in these circumstances will not happen again.”



For further information, photos, and to note your interest, please contact Leila Hagmann on [email protected]. A photo of him is available here.

Krystian’s family are represented by INQUEST Lawyers Group members Eva Luna Roszykiewicz of Bhatt Murphy solicitors and Stephen Simblet KC and Fatima Jichi of Garden Court Chambers. The family are supported by INQUEST caseworker Jodie Anderson.

The other interested persons represented are the East of England Ambulance Service, Norfolk Constabulary and, separately, the officers involved in the restraint.