What happened
Krystian Kilkowski was 32 and had lived in England for nine years. On 10 August 2020, during a heatwave, Norfolk Constabulary officers attended his home in Diss. They thought he was behaving strangely and were told he had taken drugs.
They detained him over concerns about his mental health, intending to take him to a place of safety under section 136 of the Mental Health Act 1983. He was never told why, nor why the restraint escalated.
He was taken to the ground already in handcuffs, and two sets of leg restraints were applied. He was restrained mainly face down for over an hour, with officers repeatedly pushing his head towards the ground. He said he was frightened he would die.
Police waited for an ambulance from the East of England Ambulance Service, and miscommunication caused a significant delay. By the time the crew arrived he was barely conscious and turning blue. The paramedic said he needed emergency critical care, which did not arrive until he was on his way to hospital. Restraint continued for about twenty minutes after the ambulance arrived. He died in hospital shortly after midnight, on his 32nd birthday.
The outcome
An inquest concluded on 8 November 2022. The jury found he died “a drug related death following amphetamine intoxication … further complicated by serious failures in the methods of restraint”. Operational failures in the emergency services delayed his critical care, and the police approach “lacked leadership”.
The medical cause was multi-organ failure, hyperthermia and rhabdomyolysis. The pathologist found the amphetamine level was not in the fatal range and the restraint played a part. No criminal proceedings against officers are recorded.
What went wrong
The call category set the length of the restraint. A man in acute behavioural disturbance, in heat, after amphetamine, was held face down while his condition deteriorated. Nobody treated the deterioration as a medical emergency until a paramedic arrived and said it was one.
The delay was made of ordinary things: a miscommunication over an ambulance, a request for critical care that arrived late. Each is small. Together they decided how long he stayed on the ground.
The trust’s review has since made detention under the Act plus physical restraint an automatic category one response, and upgraded the priority for suspected acute behavioural disorder.
What it teaches
The clock that matters is the clinical one, and it does not start when the ambulance arrives. It starts when the person goes to the ground.
Prolonged prone restraint while waiting for transport is an ambulance problem as much as a police one. A dispatcher who does not know a person is face down cannot upgrade the call.
Questions for the room
- At what point did the restraint stop being proportionate, and who could have said so?
- You are the dispatcher taking the call. What do you need to hear to make it category one, and how fast?
- Supervision was found lacking on the ground. What does leadership look like at minute twenty of a restraint?
Evidence and limits
Confidence: confirmed. The INQUEST release, a Garden Court Chambers release reproducing the same text, and the Eastern Daily Press report were read. The first two are one account from the family’s representatives. The newspaper confirms the trust’s review and the apology.
The inquest concluded on 8 November 2022, so the page can be cited outward. No coroner’s prevention of future deaths report was located.
Our vulnerable and volatile persons training covers acute behavioural disturbance, positional risk and the handover to an ambulance crew.
Sources
- INQUEST, “Krystian Kilkowski: inquest finds serious failures by police and ambulance service”, 8 November 2022
- Eastern Daily Press, “Ambulance trust makes changes after death of Krystian Kilkowski”, 11 November 2022
- Garden Court Chambers, “Krystian Kilkowski: inquest finds serious failures by police and emergency services”, 8 November 2022
Reviewed 20 October 2026.