Jurors decide prolonged restraint and lack of basic medical attention led to death of Kingsley Burrell, who was left handcuffed for hours on a hospital floor

A student who was detained under the Mental Health Act died as a result of neglect by police officers and ambulance staff who forcibly restrained him and left him handcuffed for hours on a hospital floor, an inquest jury has found.



In a damning verdict that sparked calls for an independent public inquiry, jurors at Birmingham coroner’s court ruled that Kingsley Burrell, 29, was failed by a series of police officers and medical workers when he was sectioned in March 2011.

Burrell was taken into custody after calling police to say he was being threatened with a gun while shopping in the centre of Birmingham. However, CCTV footage showed he was not being followed and he was detained under the Mental Health Act.

Burrell suffered a fatal heart attack four days later at the Queen Elizabeth hospital in Birmingham after a violent struggle with police officers in the back of an ambulance.

Facebook Twitter Pinterest Supporters and family members of Kingsley Burrell, outside Birmingham coroner’s court on Friday. Photograph: Richard Vernalls/PA

Jurors were told that Burrell had wet himself and was left handcuffed on the hospital floor for five or six hours while waiting to be assessed.

Following a six-week inquest, jurors found that prolonged restraint and a failure to provide basic medical attention led to Burrell’s death.

The jury said there was a “gross failure to provide or procure” basic medical attention in response to an obvious need before Burrell died of brain damage following a cardiac arrest on 31 March 2011.

Outside court, the student’s family called on the home secretary, Theresa May, to launch a robust public inquiry into the “systemic failings” and sought for 15 public officials – four police officers, two ambulance staff and nine mental health workers – who dealt with Burrell to be sacked.

His sister Kadisha Brown-Burrell, 32, told the Guardian the family felt a “sense of relief” following the inquest finding but she added that justice would only be served with a full public inquiry.

“There’s no closure. It’s too soon to say that. Until people are accountable for their actions then there will be no closure,” she said. “It doesn’t end here. The next step is a public inquiry to get accountability from 15 people.”

She said the family had “no faith, no trust” in the police and mental health services, and claimed “institutionalised racism” led to her brother being falsely stereotyped as a thug and a drug dealer.

She said: “He was concerned about that when I spoke to him. He said, ‘Why are they [hospital staff] asking me about class A drugs?’”

Desmond Jaddoo, a community activist and former Birmingham city council worker, said Burrell’s family were disappointed that jurors were not able to consider a verdict of unlawful killing.

But he said the inquest had highlighted “systemic failings” in the NHS, West Midlands police, Birmingham and Solihull mental health service and West Midlands ambulance service.

“We are now asking for a public inquiry and for the West Midlands police chief constable and police and crime commissioner to account for the actions of those four officers and for them to be dismissed,” he added.

“We are demanding that Theresa May fulfils the work she commenced during the last parliament into the effects of death in custody and mental health upon the Afro-Caribbean community by arranging a public inquiry into the systemic failings by four public authorities into the death of Kingsley Burrell.”



The inquest heard that the day before Burrell died he was left face down and motionless in a locked seclusion room for nearly half an hour with a blanket draped over his head and his trousers around his knees.

Jurors were told that medical staff failed to check on him despite noticing that his breathing had dropped. When they eventually checked, they found he had suffered a cardiac arrest. He never regained consciousness.

Four serving West Midlands police officers, who have not been suspended, are facing a misconduct hearing in June over the case after the Independent Police Complaints Commission recommended disciplinary proceedings.

In July, the Crown Prosecution Service said there was insufficient evidence to prosecute anyone over his death.



Chantelle Graham, Burrell’s partner, said: “Kingsley needed help and compassion but instead he was treated so brutally by police, ambulance staff and medical staff. It hurts to know that his last hours were filled with brutality and fear, and that no one had the courage to stop it. I never want to hear of this happening to another family. Kingsley will be badly missed by his children and his family.”

Birmingham coroner Louise Hunt said she would write to the relevant authorities to ensure national lessons were learned from what had occurred.



Garry Forsyth, West Midland police’s assistant chief constable, said: “We do not underestimate the impact Kingsley Burrell’s death in March 2011 and the subsequent investigation has had on both his family and the wider community.



“This week, myself and CS Emma Barnett, the commander of Birmingham West and Central local policing unit, met with family members and friends of Mr Burrell to listen to their concerns and extend our condolences for the death of Kingsley, and also to talk about what the force is doing moving forward to help vulnerable people.

“Crucial lessons have been learned from this tragic case and how the force manages people who are detained with mental and physical health needs.”

David Jamieson, the West Midlands police and crime commissioner, said he would question the force’s chief constable, Chris Sims, over the case.

He said: “First and foremost my thoughts today are with the family and friends of Kingsley Burrell. I offer my condolences to them. Clearly more lessons need to be learned by all the agencies involved so that these tragic incidents are not repeated. One death is one too many, whatever the circumstances.

“I will be asking questions of the chief constable to ensure that the verdict is examined thoroughly. In addition, I will be asking the force to bring a report to my public board meeting so that my board and I can scrutinise the case in detail and hold the police to account.

“We have introduced the mental health triage unit to make sure we are dealing with mental health sufferers appropriately, but I will be asking the chief constable further questions to make sure that the police are doing all that they can.”

Deborah Coles, director of the deaths in custody campaign group Inquest, said Burrell was “failed by all those who should have been there to protect him”.

Coles said: “For a man so obviously unwell to be restrained in such a brutal and terrifying way in a healthcare setting raises serious concerns about the culture and practice in policing and mental health provision. This begs the question of whether racism informed the way he was treated.

“Time and again we’re told that ‘lessons will be learned’ and yet we see the same shocking practice and system failures identified following previous deaths.

“The neglect and use of unreasonable restraint uncovered by this inquest must prompt the government to reaffirm its commitment to ensure police and mental health providers work together to respond humanely to people in crisis. We have no confidence this callous, indifferent and cruel treatment would not be replicated today.”