What happened
A man was arrested on 27 January 2021. Concerns about his health during the arrest led to him being taken to hospital and placed in an induced coma.
The Independent Office for Police Conduct said officers later restrained him as he was being discharged and tried to put him into a van. He was already in handcuffs and limb restraints. Officers used equipment known as the Flexible Lift and Carry System, or FLACS, to carry him to the van. When he became unwell he was removed and taken back into the hospital. He died there on 2 February 2021.
The outcome
An inquest concluded on 24 April 2025 with a conclusion of unlawful killing. The coroner sent a prevention of future deaths report, reference 2025-0399 dated 1 August 2025, to Thames Valley Police, the hospital trust and the mental health trust.
The IOPC also told five officers they were under investigation for alleged gross negligence manslaughter and unlawful act manslaughter, with one facing an additional allegation of common assault. All five were served with gross misconduct notices over use of force and duties and responsibilities. No charge is recorded. Thames Valley Police suspended use of FLACS as a precaution.
What went wrong
What the sources establish is narrow. He was restrained as he was being discharged, carried to a van in a lift and carry system, and deteriorated in or around it. He was returned to the hospital he had just left.
Unlawful killing is the most serious conclusion an inquest can reach. Its reasoning sits in a prevention of future deaths report this entry has not read, so the page states the conclusion only.
What it teaches
A discharge from hospital is a clinical handover, not the end of an episode. If a person cannot be moved without restraint and a carry system, the question is not how to reach the van. It is whether they should be leaving at all, and who has decided they are fit to.
The second lesson is equipment. A lift and carry system is for moving someone who cannot walk. Used on a person already handcuffed and limb restrained, it does a job that should have been settled on the ward.
Questions for the room
- He was restrained as he was being discharged. What should have been agreed with the clinical team before he left the ward?
- You are the officer deciding how to move him to the van. What are the alternatives, and what would make you stop?
- The force suspended the equipment after the death. What does that say about the assessment before it?
Evidence and limits
Confidence: probable. What was read: the IOPC’s findings as reported by the BBC at the time, and a one-line mention in an INQUEST release on another case. The inquest conclusion is carried from the record’s citation of the coroner’s report, which this entry did not open, so the basis for the finding is not set out.
The record and the précis differ on the setting. The précis says he was restrained as he was being discharged; the record’s note places it in the emergency department and its setting field says the setting was not established. So the page says only that it happened in hospital.
The record was marked internal only while five officers remained under criminal investigation; it now records the inquest as concluded. The record restricts naming, so no name appears here, and nothing on this page is a finding about any individual.
Our [physical interventions training](/training-solutions/physical-interventions) covers restraint in health settings, handover and the decision to move someone.
Sources
- BBC News, 2021
- INQUEST, 2 December 2022 (this death is mentioned inside a release about a different case)
Reviewed 20 October 2026.