16 November 2021

Before HM Coroner Louise Hunt
Birmingham and Solihull Coroner’s Court
2 –16 November 2021

Trevor Alton Smith, a 52 year old Black man, was fatally shot by police officers on 15 March 2019. He had been experiencing mental ill health. An inquest has today concluded finding his death was a ‘lawful killing’, with no criticism of the operation. The family are now raising serious concerns about the findings.

Trevor was a much loved father of two whose family describe him as a very bright, talented, creative individual who was full of charisma. He was a caring, kind, generous spirit whose heart belonged to his family.

Trevor experienced depression following the sudden death of his father, two years before his own. He had been under the care of Birmingham and Solihull Mental Health Trust services. Trevor’s mental health background was known to West Midlands Police, but not communicated prior to the operation.

The incident occurred in Trevor’s bedroom in Lee Bank, Birmingham during an intelligence-led operation by West Midlands Police Firearms Unit. The family acknowledge that there were grounds to seek Trevor’s arrest, but are concerned about the enactment of the operation at every level.

At around 5am on 15 March 2019, police officers opened the front door of Trevor’s flat. He was in bed and was repeatedly told to show both his hands. Police said he was not compliant, as one hand remained behind the duvet. Officers told the inquest they tried to gain compliance. Body worn camera footage showed their attempts at engaging, which included swearing at Trevor and telling him to “stop being a plonker”.

Eventually, Trevor discarded the duvet and appeared to move his hand. The officer involved reported that he believed when Trevor moved his hand he had a ‘black object’ which could have been a handgun. As a result, the officer made the decision to discharge his weapon.

Despite the extensive specialist training of the firearms officer, the gunshot was significantly off target. It initially missed Trevor, travelling downwards. It ricocheted off the bedframe, turned up, and hit him in the chest. This caused the fatal injuries.

There were then delays in an ambulance arriving, and issues with the police defibrillator. Trevor was declared dead at the scene. An imitation firearm was recovered at the property.

The inquest heard that there was consideration of ‘less lethal’ weapons, such as the use of Taser, but these options were not deemed viable. The jury found the fatal gunshot was fired in ‘self-defence’ by the officer.

After the incident, in identifying himself as the principal officer responsible for the shooting, the officer said of Trevor, “he is cream-crackered”.

In their evidence the family were particularly concerned and dismayed that firearms officers, who were granted anonymity for the inquest, consistently stated that - even with the benefit of hindsight and the loss of Trevor’s life - they would not have changed their approach.

Senior coroner Louise Hunt raised two issues arising from the evidence of the inquest, which she is considering making a report to prevent future deaths on. Firstly, that there was "no clear process to ensure officers are aware of updates to key information" from the Multi Agency Risk Assessment Conference (MARAC). Secondly, with regard to the CPR co-ordinator and the "lack of clear guidance and process in allocating a member of the team to co-ordinate resuscitation".

In a joint statement, Trevor’s family said:While acknowledging that within the parameters of the law, a ruling of ‘lawful killing’ is appropriate, we do not feel that the judgement exonerates West Midlands Police Firearms Operations Unit.

We are very disappointed that the jury found no opportunity to be critical of any aspect the police operation.

We have serious concerns about the operation including police conduct and use of inappropriate language, poor negotiating skills, decision-making, and leadership.

The highly trained, experienced officer who fired the fatal shot stated that he flinched, resulting in a downward trajectory, ricocheting upwards off the bed frame, changing direction and causing the fatal injuries to Trevor. This wayward shot is most disconcerting.

Our primary hope from the outset was for the inquest to provide answers as to what happened on the morning of 15 March 2019. Instead it has raised serious questions about how the police engage with people with mental ill health, as was the case for Trevor.

We leave the inquest dissatisfied with responses that the West Midlands Police had no other option but to shoot and kill Trevor. Further, we remain unconvinced that the West Midlands Police are sufficiently competent to effectively engage with people with mental ill health or that any tangible lessons have been learnt for future engagement with individuals from this most vulnerable group of our community.

We ask questions, we ask for answers, we ask for change and reform, so that another life may not be lost at the hands of WMP, and another family not need to suffer and grieve.”

Errol Robinson of McGrath and Co Solicitors, who represent the family, said: “If the police maintain that even if they had known about Trevor's mental illness they would have done nothing differently, it effectively means that in these circumstances someone exhibiting signs of mental illness is facing a death sentence.

The police still have not learnt how to deal with people who are mentally ill or display such signs. Until this is addressed, deaths like Trevor Smith’s at the hands of the police will continue to occur. This is most disturbing.”

Lucy McKay, spokesperson for the charity INQUEST, said: “This inquest heard seriously concerning evidence about the way in which Trevor was dealt with. West Midlands police have a history of fatal shootings, including just months before Trevor’s death. Their actions ultimately led to the premature death of a Black man with mental ill health. While that may be lawful, we cannot agree with the jury that no one was at fault. We must see urgent changes in the planning of firearms operations and de-escalation to prevent future deaths.”


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

Trevor’s family are represented by Errol Robinson of McGrath and Co Solicitors, and INQUEST Lawyers Group member Rajiv Menon QC. The family are supported by INQUEST Head of Casework, Anita Sharma

Other Interested persons represented are West Midlands police force, Birmingham and Solihull Mental Health NHS Trust.

West Midlands Police officers fatally shot Sean Fitzgerald in January 2019. The inquest into his death is awaited, but a firearms officer has been issued with a gross misconduct notice. More information.

In 1996, West Midlands police fatally shot David Howell, a 40 year old man who was experiencing mental ill health. This case also brought to light concerning evidence on the treatment of people with mental ill health. More information.