12 March 2021

Press release produced jointly with Hodge Jones & Allen

Before HM Senior Coroner Emma Whitting
Bedfordshire Coroner's Court
4 January - 12 March 2021

An inquest has today found that a series of omissions and failures by Bedfordshire Police and East of England Ambulance Service contributed to the death of Leon Briggs on 4 November 2013.   
The jury found, on the balance of probabilities, that there was a gross failure to provide Leon with basic medical attention and that there was a direct causal connection between this conduct and his death. They recorded a conclusion that his death was ‘contributed to by neglect’. 

Leon Briggs, from Luton, was 39 years old when he died on 4 November 2013 following restraint by Bedfordshire police officers. Today's conclusion marks the latest step in the family's fight for answers.

Leon had a mixed-race heritage. He was a father to two children. His family describe him as “a loving, son, brother and father, caring and genuine”. He had previously worked teaching computer skills to the elderly and as a lorry driver.
The jury criticised the restraint by Bedfordshire Police, which they found to be mostly in the prone position with the application of inappropriate use of force. They also criticised a failure to recognise Leon as a medical emergency, inadequate assessments and a failure to monitor him. They pointed to an unsatisfactory conveyance in the police van as well as miscommunication throughout. These failures contributed to his death.
The jury also found a number of serious failings by the East of England Ambulance Service. 
Leon had been moving erratically around the local area, with numerous witnesses describing that he appeared to have mental ill health and seemed ‘confused’ but not aggressive.  Bedfordshire Police initially arrived on the scene after a member of the public called 999, concerned for Leon's welfare. The caller asked for an ambulance as well as police as Leon “needed calming down”. 
The police control room, who could see Leon on CCTV, logged this as ‘an aggressive male’. Armed police officers arrived on scene and Leon was detained under section 136 of the Mental Health Act. He was quickly brought to the ground and restrained in the street by three officers. Leon was in prone restraint (face down) for over 13 minutes, and in handcuffs and leg restraints for 25 minutes. Staff from the East of England Ambulance Service arrived on scene, but did not assess or communicate with Leon. 
Leon was then taken in a police van to Luton Police Station, rather than the local hospital despite it being closer in distance. The custody team had been alerted that a ‘violent male’ was being brought in. Unable to walk, he was carried into a cell where he was restrained again then left unconscious for 6 minutes and 15 seconds, before becoming silent and unresponsive. At this point Leon was taken by an ambulance to hospital, where he was pronounced dead. 
Throughout the nine-week inquest, held by the Senior Coroner for Bedfordshire, Ms Emma Whitting, jurors heard evidence of a catalogue of failings that culminated in Leon's death. The inquest heard his primary cause of death was "amphetamine intoxication in association with prone restraint and prolonged struggling”, with a secondary cause of coronary heart disease. A medical expert told the inquest Leon would have survived, beyond reasonable doubt, if he had been taken to hospital rather than police custody.
The credibility of the officers’ accounts was called into question after the breach of a non-conferral order, initial statements from the officers were nearly identical when given.

At the conclusion of the inquest the coroner praised the family for the ‘complete understanding and courtesy’ they had shown throughout the process. The coroner said that Leon deserved to get the full services owed to him by the police and ambulance service. She said Leon had been “so very let down”.

The coroner also made the point that, unlike Bedfordshire Police, the EEAST had acknowledged their failures before the end of the inquest. The Coroner indicated that this was to their “credit” and that she hoped the Chief Constable would “reflect” on the implications of the findings. She gave a clear hint that she considered it would be appropriate to make a ‘Prevention of Future Deaths’ report linked to the police conduct.

A full statement was read on behalf of the family outside court, available here.

Margaret Briggs, Leon's mother, said: “Today marks a milestone in our fight for justice for Leon. After seven long years of waiting, those present during Leon's restraint have finally been made to explain their actions. 
“The conclusion of Neglect does not, I believe, reflect the evidence and I am disappointed that the jury did not return a conclusion of Unlawful Killing.  
“Over our long fight for the truth there has been no remorse shown by the police – in fact they have tried to disrupt the investigation at every turn, determined to cover their own backs. To this day, those police officers still have their jobs and livelihoods and no one has been punished for Leon’s death.  There has been no accountability or justice. The CPS must now reconsider bringing prosecutions. 
“We think that Leon’s race was a factor in the way he was treated by the police.  He was treated as someone who posed a threat rather than someone in need of help.  
Leon was also failed by the East of England Ambulance Service staff who made no attempt to help him or do their job to care for him.  They were faced with a man in crisis, who posed a medical emergency, and yet they failed to even check if he was all right.  
“I wouldn’t wish the pain we have suffered on anyone.” 

Anita Sharma, Head of Casework at INQUEST who has worked closely with the family, said: “Officers treated Leon’s obvious distress as aggression and violence. They used brutal and almost immediate force and chose not to seek clinical support, while the Ambulance service made no attempts to intervene. These actions and inactions are part of a pattern of inhumane treatment rooted in systemic racism.
“This damning conclusion is an important recognition of the seriousness of the system wide failures. The police will say that seven years on things have changed. Why then are Black men still subject to disproportionate use of force by police? Why are they more likely to die after police contact particularly when in a mental health crisis? And why have the police resisted scrutiny and accountability since his death by neglect.”

Jocelyn Cockburn, Partner at Hodge Jones & Allen solicitors said: “Given that Leon was a vulnerable person, detained for his own safety (not arrested) the level of force used against him is incomprehensible.  It should be no surprise that the family now question whether racial stereotyping by the police played a part in his treatment and ultimately his death.  
“Shockingly several years after the death, the police officers displayed little or no insight into the consequences of their actions.  Officers said they would do the same today. This shows an unmitigated failure on the part of the Chief Constable to take appropriate actions following the death. The attempts by Bedfordshire Police to obstruct the investigatory process from the very first moments (when officers conferred in preparation of their statements) have meant that there has been a failure to learn lessons. There has been no accountability.  

“The evidence heard during this inquest has been an important step towards learning lessons.  It is the interests of officers of Bedfordshire Police as well as the general public that the rights lessons are learned following this tragedy.

"The coroner made her view clear that the Chief Constable should reflect on the actions of the police – something that for over 7 years has not happened.

"There is every need for a prevention of future deaths report in this case as there are serious concerns that the police simply will not face up to the truth of what happened and the lessons that should be learned from it. This family’s fight for justice continues.”

Gimhani Eriyagolla, Solicitor at Hodge Jones & Allen, said: “While we still believe there was enough evidence for unlawful killing, the conclusion of neglect showcases how system wide failures were at fault for Leon’s death. However, it is shameful that it has taken nearly eight years to get to this result. There has been a continuous lack of accountability from the Bedfordshire Police, something which has only gotten worse through this inquest. Officers have fabricated accounts and excuses to cover up this injustice. 
“The issues presented in this case, such as the treatment of mixed-race person in custody, the dangerous restraint used on someone suffering from ill mental health, and the lack of medical intervention, shows a myriad of systemic problems from the Bedfordshire Police as well as failings by East of England Ambulance Service that are simply unacceptable.”



For further information, to note your interest, or to request an interview please contact:

Yellow Jersey PR who are working with the legal team:

To contact INQUEST’s communications team call Lucy McKay on 020 7263 1111 or [email protected]

A photo of Leon, provided by his family for media use, is available here

Leon’s family are represented by INQUEST Lawyers Group members Jocelyn Cockburn, Claire Brigham and Gimhani Eriyagolla of Hodge Jones & Allen solicitors, Dexter Dias QC of Garden Court Chambers and Adam Straw of Doughty Street Chambers. INQUEST has been working alongside Leon’s family since his death.

The other interested persons represented at the inquest are the chief Constable of Bedfordshire, six police officers (five officers and one detention officer who is now a PC), East of England Ambulance Service and the IOPC.

Section 136 of the Mental Health Act (1983) enables police to detain people who they think have mental ill health requiring ‘care or control’, to be taken to a ‘place of safety’ which could be a home, hospital or police station. 

Acute Behavioural Disturbance (ABD) is an umbrella term for a set of conditions, which can often be life threatening. ABD is regularly connected to restraint related deaths in custody, particularly where the person is experiencing a mental health crisis. Police guidance now associates the condition with symptoms including agitation, sweating, and insensitivity to pain. It is understood to be a serious medical emergency.

Positional Asphyxia: Positional asphyxia occurs when a person is placed in a posture that prevents or impedes the mechanism of normal breathing. If the person cannot escape from the position, death may occur very rapidly. It has been linked to deaths in police custody particularly the use of restraint in the prone position.


Case background:

  •       November 2013: Leon’s family released a statement shortly after his death sharing concerns.
  •       March 2016: The Independent Police Complaints Commission (IPCC, now the IOPC) referred the case to the CPS for a decision on whether criminal charges should be brought, following their investigation into the circumstances of Leon’s death.
  •       September 2018: CPS confirmed no charges would be brought following Leon’s death.
  •       February 2020: The IOPC withdrew directions to bring gross misconduct proceedings for five officers after Bedfordshire police force refused to provide evidence against its officers. 
  •       January 2021: The inquest into Leon’s death opened on 4 January at Bedfordshire coroner’s court. See the opening media release


Policy, data and other relevant cases:

The 2017 Angiolini Review on deaths in police custody found that long delays in the investigation and legal processes following deaths in custody are highly damaging to cases and extremely harmful for families, officers and for public confidence. 

The review also made a series of recommendations around the use of restraint including that National policing policy, practice and training must reflect the now widely evident position that the use of force and restraint against anyone in mental health crisis poses a life-threatening risk. 

Now more than three years on from this landmark review, action is awaited on these issues. See a recent INQUEST article exploring this (November 2020). 

The latest data on deaths in police custody and contact is available here. Deaths involving people with ‘mental health concerns’ continue to be a significant issue, with 18 people dying in or following police custody in 2019-20, 11 of whom were identified as having ‘mental health concerns’. 

Ethnicity and deaths in custody: Black people are subject to 16% of use of force by police, despite comprising 3% of the population (Home Office data on use of force, April 2018 to March 2019). 

Analysis of available data by INQUEST shows the proportion of deaths in police custody of people from Black and Minority Ethnic groups where restraint is a feature is over two times greater than in other deaths in custody. More information on race and deaths in custody is available on the INQUEST website.

Other recent deaths in police contact involving restraint and mental ill health:

  •       Moyied Bashir, a 29 year old man, was in a mental health crisis when his family called emergency services for support. His family report 24 Gwent police officers arrived and restrained Moyied, whose condition worsened. He was then taken by paramedics to hospital where he died on 17 February 2021. 
  •       Brian Ringrose, a 24 year old man, was arrested and taken to hospital by Thames Valley Police on 27 January 2021. After clinical discharge, officers restrained Brian before taking him to a police van where concerns were raised about his health. He was returned to hospital and died on 2 February 2021. The IOPC have announced five officers are under criminal investigation.
  •       Kevin Clarke, a 35-year-old Black man, was experiencing a mental health crisis when he died following restraint by Metropolitan Police officers in South London on 9 March 2018. An inquest in October 2020concluded his death was caused by Acute Behavioural Disturbance in a relapse of schizophrenia and contributed to by restraint and serious failures.

Also see recent updates on the deaths of Darren Cumberbatch, Douglas Oak, Mzee Shemar Mohammed-Daley, Sean Rigg, Thomas Orchard, Kingsley Burrell, and Seni Lewis, which involved mental ill health and restraint. 

As well as the above cases which involved mental ill health, the following recent deaths in police contact involved people from racialised groups (Black, Asian and Minoritised Ethnicities):

Mohamud Hassan, a 24 year old man of Somali heritage, died shortly after being released from the custody of South Wales police. He had been reported being extremely unwell when being transported to custody, where he was held overnight. There are concerns that force was used against him by police. He died on 9 January 2021. An officer has been given a misconduct notice. 

As well as Rashan Charles, Edson da Costa, Nuno Cardoso, all young men who died following police restraint in 2017.