What happened
On the evening of 12 November 2013 Terry Smith, 32, was at his parents’ home in Surrey when he began to behave in a bizarre manner. He had taken amphetamines and was agitated, hallucinating, paranoid, incoherent, at times aggressive, overheating and extremely strong.
His parents judged he needed medical help and called 999 for an ambulance. The call handler did not identify that he was suffering acute behavioural disturbance. Two emergency medical technicians were sent, and Surrey Police were asked to attend.
Two officers chased and caught him, restrained him on the ground, handcuffed him and detained him under section 136 of the Mental Health Act. As he resisted, about six officers restrained him, leg restraints were applied, and a spit hood was placed over his head. He was put on the floor of the caged area of a police van and taken to Staines police station, arriving at 22.59.
The outcome
The inquest began on 12 February 2018 and was completed on 5 July 2018. The medical cause was multiple hypoxic organ failure and cardiorespiratory collapse, with amphetamine-induced excited delirium in association with restraint.
The jury found a serious failure to recognise the signs of excited delirium as a medical emergency, a failure to carry out an adequate assessment at any stage, inadequate training without any check on learning, and prolonged and excessive restraint. It found the death was contributed to by neglect.
The coroner issued a Prevention of Future Deaths report, 2019-0095, dated 21 February 2019, to seven recipients.
What went wrong
A police sergeant told the other officers this might be excited delirium. The officers said their training had never told them it was a medical emergency. The two ambulance technicians had no training on the condition at all and did not recognise it.
Police took him to a station rather than an accident and emergency department, and the technicians did not question that, though they had not examined him properly.
In the cell he said he could not breathe 13 times. A forensic medical examiner saw him for less than two minutes, knew what excited delirium was, and did not mention it. He stopped breathing in the van on the way to hospital.
What it teaches
Everyone present had a piece of the recognition and nobody had the whole of it. Training that teaches one agency a term and leaves the next without it produces exactly this: each service ticks its own box while the patient gets no assessment.
Recognition has to be spoken aloud and acted on by whoever holds the radio. A sergeant saying the words is the start of the response, not a note in passing.
Questions for the room
- A sergeant said the words “excited delirium” out loud. What should have happened in the next minute?
- He told officers 13 times that he could not breathe. What does an officer do with that?
- The call handler’s script could not recognise the condition. Who owns that script, and how long does a death wait for the next version?
Evidence and limits
Confidence: probable, on the vault record and the case précis. There is one source: the coroner’s published Prevention of Future Deaths report, the strongest class of document in the vault. The record notes that a second source should be added before external use, and the findings here are as the record summarises them.
The vault record dates the events to 13 November 2013; the précis puts the evening at 12 November, arriving at the station at 22.59. This page records the difference rather than resolving it.
No member of staff is named.
Our training on vulnerable and volatile people covers acute behavioural disturbance and the recognition that has to be shared between services.
Sources
Reviewed 20 October 2026.