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The perils of recognising acute behavioural disturbance

Recognising the differences between acute behavioural disturbance and anti-social or criminal behaviour can help first responders determine…

Inquest touching the death of Mzee Mohammed Daley

Martin English advocated for the North West Ambulance Service NHS Trust at the 4-week jury inquest at Liverpool Coroners Court.

The media have reported on a number of recent inquests relating to the death of individuals under police arrest who have died, in part, from the effects of physical restraint, and the individual’s struggle against restraint (Cumberbatch; Douglas Oak). In each case, the individual was suffering from a controversial syndrome known as acute behavioural disturbance, which was previously termed excited delirium. The inquests have exposed the difficulties faced by first responder agencies, in particular police and ambulance personnel, in recognising that the person is suffering from acute behavioural disturbance rather than anti-social or criminal behaviour, and thereafter treating the individual as a medical emergency. The task of first responders is made all the more challenging due to the nature of the syndrome, which is a wide constellation of symptoms, which ultimately causes physiological and metabolic derangement leading to cardiorespiratory arrest. If the challenge were not difficult enough for first responders, physical restraint and a person’s struggle against that restraint can quickly exacerbate the condition, quicken the physiological derangement and hasten death. 

These cases, and others before them, have instigated changes this year to the way the College of Policing deliver training to rank and file officers on identifying acute behavioural disturbance and applying safe practices in minimising the level of restraint on such individuals. Indeed, as recently as this month, the Association of Ambulance Chief Executives have introduced new national clinical guidance for paramedics to assist with the recognition and treatment of acute behavioural disturbance.

The inquest of Mzee Mohammed Daley

The tragic case of Mzee was the most recent high profile inquest to put the spotlight on this difficult topic. Mzee was a young man suffering from ADHD, Autism Spectrum Disorder and Post-Traumatic Stress Disorder. On 13 July 2016 he suffered a psychotic episode, which resulted in Mzee running into Liverpool city centre from his home address, in possession of a knife, frantically running around the Liverpool One shopping complex. He was apprehended and physically detained by security staff and was soon arrested and handcuffed by attending police officers. An ambulance was called soon after and Mzee was taken to Royal Liverpool Hospital, but sadly within an hour of reaching hospital he passed away. The pathological finding was that Mzee had died from an acute psychotic episode, consistent with the syndrome known as acute behavioural disturbance. His death provoked a strong public reaction and resulted in a Black Lives Matters march in Liverpool in the days that followed, as well as a protracted IOPC investigation into the conduct of the attending police officers. During the course of the criminal and coronial investigations, expert evidence was obtained to scrutinise the actions of Liverpool One staff, police officers, ambulance staff and hospital clinicians. 


A number of attending police officers and ambulance personnel gave evidence during the four weeks of Mzee’s inquest, and not one witness stated that they had identified Mzee was suffering from acute behavioural disturbance, reinforcing the challenge faced by first responders. Indeed, the police officers giving evidence had not even considered acute behavioural disturbance was a possibility. 

The decisive difference in this case compared to other recent similar inquests was that despite not recognising acute behavioural disturbance, first responders did quickly recognise that Mzee’s condition was a medical emergency. After taking over the detention of Mzee, police officers immediately placed him in a recovery position, and requested an ambulance two minutes after their arrival. Attending ambulance staff quickly assessed Mzee as a medical emergency, providing emergency treatment in the ambulance and alerting the emergency department to have a resuscitation team on standby. The actions of the first responders, combined with the limited time-period of Mzee’s struggle against restraint prior to the ambulance arrival, resulted in the jury returning a conclusion of natural causes. The jury’s findings contained no criticisms of the actions of Liverpool One, Merseyside Police and North West Ambulance Service. 

For further information about this specific case, or for any other advice, please contact Martin English who advocated for the North West Ambulance Service NHS Trust at this 4-week jury inquest at Liverpool Coroners Court.

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