What happened
On 4 November 2013 Leon Briggs, 39, a father of two from Luton, was moving erratically through the town. Witnesses described a man who appeared mentally unwell, “confused” but not aggressive. A member of the public called 999 for his welfare and asked for an ambulance too.
The police control room, watching on CCTV, logged the call as “an aggressive male”. Armed officers arrived and detained him under section 136 of the Mental Health Act.
He was brought to the ground and restrained prone in the street by three officers for 13 minutes, and in handcuffs and leg restraints for 25 minutes. Ambulance staff attended but did not assess him or speak to him. He was taken by police van to Luton police station rather than to the hospital, which was closer.
Unable to walk, he was carried into a cell and restrained again. He was left unconscious for 6 minutes and 15 seconds before he became silent and unresponsive. He died in hospital.
The outcome
The inquest sat for nine weeks before Senior Coroner Emma Whitting and concluded on 12 March 2021. The jury found, on the balance of probabilities, a gross failure to provide basic medical attention with a direct causal connection to the death, and recorded that it was “contributed to by neglect”.
The medical cause was “amphetamine intoxication in association with prone restraint and prolonged struggling”, with coronary heart disease secondary. A medical expert said he would have survived, beyond reasonable doubt, had he been taken to hospital.
The Crown Prosecution Service confirmed in September 2018 that no charges would be brought. In February 2020 the IOPC withdrew directions for gross misconduct proceedings against five officers.
What went wrong
The restraint was mostly prone, and the force and weight used against him were inappropriate. Officers did not recognise a medical emergency, failed to monitor him in the van or the cell, and made inadequate assessments.
The conveyance was unsatisfactory: one officer told the inquest that moving him from the ground to the van went against the approved technique.
Ambulance staff watched the restraint without speaking to him or offering the police medical advice. Communication between the two services failed, and each assumed the other was looking after him.
What it teaches
Two services each assumed the other was assessing him, and that is the whole failure. Recognition of a medical emergency is not a handover. A custody cell is the worst place to leave an unconscious restrained man alone.
The second lesson is weight: the jury found inappropriate weight was used on a man held prone on concrete. A hold reviewed on paper is still one person’s body weight on another’s back for thirteen minutes.
The third is the destination: the hospital was closer than the station.
Questions for the room
- He was face down on concrete for 13 minutes and witnesses heard him call out. What did the officers at his head do?
- You are the paramedic at an ongoing restraint. What must you do before you leave, and who do you tell?
- Five officers’ misconduct proceedings were withdrawn because the force would not provide evidence against them. What does that do to a training message?
Evidence and limits
Confidence: confirmed, on the vault record and the case précis. The record rests on four accounts, including the INQUEST and Hodge Jones & Allen release, Garden Court Chambers and BBC News, which agree on the sequence.
The inquest court is placed at Bedfordshire in one source and Milton Keynes in another, so it is not named here.
No officer is named, and no finding is made about any individual.
Our restraint reduction training covers positional risk, monitoring and the handover to ambulance crews.
Sources
Reviewed 20 October 2026.