A senior coroner has raised concerns about how ambulance staff deal with people suffering from acute behavioural disturbances after the death of a company director in Dorset.

Doug Oak, 35, who was described by his family as loving and kind-hearted, was restrained by police in Poole after being spotted behaving erratically on the street following an ABD episode.

Police officers concluded that he was suffering from ABD, an emergency that is associated with sudden death in 10% of cases, and called for backup and medical help. But by the time paramedics arrived, Oak’s condition had worsened and he had a cardiac arrest. He died the following day.

At a pre-inquest review of the case, the senior coroner for Dorset, Rachael Griffin, expressed concern about how the case was dealt with by the South Western ambulance service NHS foundation trust (SWASFT) and made it clear she was not convinced changes had been made since Oak’s death that would mean a similar incident would now be dealt with more effectively.

She gave the trust two weeks to provide more details about its approach to ABD and said she might issue a “report to prevent future deaths” if she was not satisfied – an unusual step given that the full inquest on Oak is a year away.

On the afternoon of 11 April last year Oak was seen behaving oddly in Branksome, Poole. He was reported to be acting erratically and walking in and out of traffic.

A series of calls were made to the emergency services, and police officers who arrived on the scene concluded he was suffering from ABD.

The full inquest will consider how Oak was restrained, how the calls to emergency services were handled and how long it took paramedics to reach him.

One suggestion touched on during the pre-inquest review was that there was a breakdown in communication or understanding that led to a mistaken impression that Oak had taken a drug called ABDF rather than suffering an ABD emergency.

Another key point in the inquest will be whether the call should have been given a category-one priority, meaning the target for the emergency services to reach him would have been eight minutes. It is understood it took much longer, though the full timings have not yet been spelled out.

The Royal College of Emergency Medicine describes ABD (pdf) as a medical emergency often involving the presentation of violence and aggression and says affected individuals may suffer “sudden cardiovascular collapse and/or cardiac arrest with little or no warning”.

It adds: “The early recognition, intervention and proactive treatment of ABD, with a collaborative response between the emergency services (police, paramedics), is likely to result in fewer deaths.”

There have been a number of high-profile deaths associated with ABD following restraint by police, including that of Olaseni Lewis, 23, from south London. A jury last year identified a litany of failures by both police and medical staff that contributed to Lewis’s death.

Following an inquest on Kingsley Burrell, who died after being restrained in Birmingham, the Association of Ambulance Chief Executives said (pdf) a national protocol was being prepared on how to manage ABD patients before they reached hospital.

While the police have developed nationwide policies to ABD, it remains unclear how the 10 English ambulance trusts are approaching it. During the pre-inquest review on Tuesday, Will Pickles, a solicitor for SWASFT, said the trust had attended national forums on the subject and had issued bulletins to staff. But he said there was no national guidance that cases of ABD should be treated as category-one emergencies when allocating resources.

The coroner said: “If someone [now] was in the exact same position [as Oak] they wouldn’t be treated any differently. That’s the concern I have.” She added: “I still have concerns about the understanding by SWASFT of ABD.”

Patrick Roche, the family’s barrister, told the hearing the coroner’s concerns should be a wake-up call for the trust. He said: “The family of Doug are very keen that lessons are learned.”

Speaking after the pre-inquest hearing in Bournemouth on Tuesday, Oak’s parents, John and Christine Oak, said: “Douglas was a loving son and kind-hearted young man. We have been devastated by his loss and miss him greatly.”

The family’s solicitor, Gus Silverman of Irwin Mitchell, said: “Douglas’s family hope that any lessons which can be learned from the coroner’s ongoing investigation and the forthcoming inquest will be implemented swiftly.”

Neither SWASFT nor Dorset police would comment. The full inquest is likely to be heard by a jury in 2019. The Independent Office for Police Conduct is also investigating the case.



