25 January 2019

Before HM Assistant Coroner Paul Bennett
Pembrokeshire and Carmarthenshire Coroner’s Court
7 - 24 January 2019

The inquest into the death of Meirion James concluded yesterday, with the jury finding that he died of positional asphyxia following excessive restraint. This resulted in his death in the custody of Dyfed-Powys Police on 31 January 2015, after failures to communicate “significant information” and follow procedures.

Meirion was 53 years old and was a dearly loved son, brother and uncle. Fluent in several languages including his native Welsh, he had worked as a translator as well as a school teacher. He was passionate about poetry, literature and music. Meirion lived with bipolar disorder throughout his adult life. In late 2014, he stopped taking lithium, his primary psychiatric medication for the preceding 29 years, because of side effects on his kidneys. His mental health started to deteriorate.

On 30 January 2015 Meirion was involved in a road traffic incident near Llanrystud. Attending police officers described Meirion as behaving erratically, having “lost all sense” and appearing to experience an acute psychotic episode. He was detained under section 136 of the Mental Health Act 1983 and taken to Aberystwyth Police Station where, shortly after his arrival, it was feared that he had taken an overdose of medication.

Officers escorted Meirion directly to Bronglais Hospital, but failed to inform hospital staff that he was detained under section 136.  Because of this he was discharged later that day without a full mental health assessment, which is mandatory for those detained under section 136.  Whilst he was at Bronglais Hospital, Meirion’s sister phoned both the treating doctor there and Meirion’s GP, desperately hoping to secure a psychiatric assessment for him. 

In relation to 30 January 2015 the jury found that:

  • The detaining officer failed to inform the custody sergeant at Aberystwyth Police Station that he had detained Meirion under section 136 – and the related failure to secure a full mental health assessment for Meirion contributed to his death.
  • Insufficient weight was given to Meirion’s sister’s call to Bronglais Hospital.
  • As a matter of professional courtesy, the hospital doctor could have called Meirion’s GP to obtain further information and the GP could have called the hospital after his conversation with Meirion’s sister.

Shortly after his discharge from Bronglais Hospital, in the early hours of 31 January 2015, Meirion called 999 to report had he had assaulted his elderly mother.  The jury heard the harrowing recording of this call, in which Meirion could be heard in a state of acute distress repeatedly pleading for medical help for his mother.  Attending police officers gave disturbing evidence about dramatic fluctuations in Meirion’s mood and his repeated expressions of delusions about Satan and the Mafia.  

Meirion was arrested and taken to Haverfordwest Police Station where he arrived just after 5am.  He was placed on constant observations, with an officer sitting directly outside his open cell door.  Shortly before 8am Meirion was seen by a doctor, who – on the information she had at the time – advised the custody sergeant that the constant observations of Meirion could be stopped.  Instead Meirion was put on 30 minute intermittent cell checks. 

The jury heard distressing evidence that on 13 separate occasions between the reduction of the observations and the fatal restraint, Meirion could be seen on CCTV (not viewed by officers at the time) pulling clumps of hair out of his own head, as well as other clearly disturbed behaviour. Evidence suggested that the officers and custody staff members on duty viewed this behaviour as childish, rather than a worrying deterioration in Meirion’s mental health. One officer could be heard on CCTV describing Meirion as a “fucking idiot”.  Meirion’s requests to see a doctor again were ignored. 

At around 10.30am, an Inspector entered Meirion’s cell with a civilian staff member. A comment appeared to provoke Meirion to rush towards and out of the cell door.  An alarm was sounded and seven police officers and staff members restrained Meirion outside the cell.  Despite having been trained of the dangers of doing so, they restrained Meirion on his front in the prone position with pressure to his back and neck. Three of the seven had had training less than a fortnight before about the dangers of prone restraint and positional asphyxia, which highlighted the 2008 death of Sean Rigg who also died following restraint during a mental health crisis.  

The jury further found that:

  • Mr James died as a result of excessively long restraint in the prone position.
  • Overall, there was a “failure to pass significant information and follow procedures”, from the initial incident at the roadside on 30 January 2015 to the point of Mr James’ death.

Diana Vaughan-Thomas, Meirion’s sister, said: “Meirion was my much loved brother and a wonderful son and uncle to our mother and my children.  It’s been a painful 4 year wait for this inquest, and a tough few weeks hearing the evidence about what happened to Meirion.  He shouldn’t have died.  I hope that lessons will be learned so that this won’t happen to anyone else in the future, and that Meirion can rest in peace now.”

Deborah Coles, Director of INQUEST said: “There were many missed opportunities to safeguard the life of a man in mental health crisis. All the police officers knew about the risks of restraint and positional asphyxia and yet they continued to restrain Meirion in the prone position for an excessive length of time, resulting in his death. This case calls into question either the quality of the training or the officers’ adherence to it. That a man can die in this way despite repeated recommendations arising from previous deaths is utterly shameful.”

Clare Richardson of Deighton Pierce Glynn, solicitor for the family, said: “The jury in this case heard shocking evidence, both about the missed opportunities as Meirion’s mental health deteriorated in the days and hours before his death and about the fatal restraint on 31 January 2015.  Four years after Meirion’s death, this inquest jury has finally confirmed the link between the dangerous restraint and the death.  No family should have to wait this long.”



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

INQUEST has been working with the family of Merion James since his death. The family is represented by INQUEST Lawyers Group members Clare Richardson of Deighton Pierce Glynn solicitors, and Rajiv Menon QC of Garden Court Chambers.

Deaths involving police restraint and people with mental ill health:

  • In 2017-18 the Independent Office for Police Conduct (IOPC) reported that 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. Four people who died in or following police custody were detained under the Mental Health Act.
  • Six Missed Chances, a report by the Independent Police Complaints Commission (IPCC) in 2017 examined how a different approach to policing people with mental health needs could have prevented the restraint related death of James Herbert in 2010.
  • Analysis of INQUEST casework and monitoring from 1990-2016 showed that the proportion of deaths involving restraint is over 3 times greater in cases where the person had mental ill health than where mental health was not a factor.
  • Sean Rigg, aged 40, was suffering mental ill health at the time of his arrest and was restrained by Metropolitan Police Officers. He died at Brixton police station on 21 August 2008. The officers are currently facing gross misconduct charges relating on a range of charges including the method of restraint.
  • The inquest into the restraint related death of Terry Smith, who was arrested under section 136 of the mental health act and died in 2014, concluded in July 2018, finding neglect and multiple failures by Surrey Police contributed to his death.
  • In March 2018, Kevin Clarke, 35, was restrained by Metropolitan Police while experiencing mental ill health and died. The inquest into his death is awaited.
  • Thomas Orchard, 32, had mental ill health and a diagnosis of schizophrenia. On 3 October 2012 he was arrested and restrained by Devon and Cornwall Police. He died seven days later. The Office of the Chief Constable for Devon and Cornwall Police are facing criminal charges in relation to his death, and on 19 October 2018 pleaded guilty to charges under the Health and Safety Act. Sentencing is awaited.