What happened
Douglas Oak, 35, a company director, was living with his parents near Poole in Dorset. At around 3.30pm on 11 April 2017 neighbours heard him shouting for help outside the house. He was barefoot in the middle of the road and told a neighbour, “can’t you see them, they’re in the shadows trying to kill me”. He was not aggressive, but terrified.
A neighbour called 999 and asked for police and an ambulance. That ambulance request was never passed to ambulance control.
Two officers arrived. He ran around one of them and jumped into the passenger seat of the police car, asking for help. Both described forcing him out and on to the road, where they handcuffed him and applied leg straps. Neither had tried to calm him, and both accepted they used no de-escalation. He was held on the ground for almost an hour before paramedics reached him, suffered a cardiac arrest still restrained, and died the following morning.
The outcome
The inquest ran for five weeks at Bournemouth Coroner’s Court before the Senior Coroner for Dorset, Rachael Griffin, and concluded on 22 October 2019.
The jury found he died from the combined effects of acute-on-chronic cocaine intoxication, excitement, exertion, restraint and hyperthermia with terminal bronchopneumonia, and that restraint contributed. It found that control room staff in both services had not been trained to recognise acute behavioural disturbance.
The coroner made a Prevention of Future Deaths report, 2019-0352, on 24 October 2019. Dorset Police paid undisclosed damages while denying liability.
What went wrong
The neighbour’s request for an ambulance was never passed to ambulance control. Police control room staff had not been trained in acute behavioural disturbance, although Dorset Police had trained its officers two years earlier that such patients must be treated as a medical emergency.
Officers on the ground could not remember the name of the condition, so did not say it on the radio. When the two control rooms spoke, eleven minutes after the first request, neither operator understood the term. The call handler logged it as a drug overdose and the ambulance was given Category 3 priority, when the jury found severe acute behavioural disturbance should draw eight minutes.
What it teaches
The response clock starts in the control room. The officers recognised the condition and said so out loud, and a paramedic still took almost an hour to reach him, because the call-takers had never been taught the vocabulary.
Teaching officers to recognise a condition without teaching the call-taker is half a system. The test is whether the call-taker in the other service knows what the words mean and what they change.
Questions for the room
- An officer said “I think it is a medical episode” on the radio. What should that have triggered, and in what time?
- The two control rooms ended up with one calling 999 to reach the other. Who owns that failure?
Evidence and limits
Confidence: confirmed. The coroner’s Prevention of Future Deaths report 2019-0352, an Irwin Mitchell release carried by INQUEST, and BBC News were read, and agree.
They differ on detail: the call is timed at 4.09pm in one account and 16:10 in another, and the ambulance response as 40 minutes or category three. The record classes the restraint as prone; one account has him on his back, so position is not specified here. Handcuffs and leg straps come from the record.
No officer is named, and the record carries no conviction.
If your control room and frontline staff are not trained in the same language, our restraint reduction training covers the call, the response and the restraint.
Sources
- Coroner’s Prevention of Future Deaths report 2019-0352, Dorset, 24 October 2019
- INQUEST / Irwin Mitchell media release, October 2019 · `01_source_text/crazee-restrainee/2019-Inquest-concludes-into-death-of-Douglas-Oak-following-police-restraint-Inquest.txt`
- BBC News, 22 October 2019 · `01_source_text/crazee-restrainee/Significant-concerns-over-Dorset-restrained-man-s-death-BBC-News.txt`
Reviewed 20 October 2026.