What happened
Scott Taylor, 31, had been unwell since 10 August 2022 with muscle stiffness, sweating, confusion, paranoia and psychosis, and had taken cocaine. On 12 August concerns were raised that he needed urgent medical attention and might have acute behavioural disturbance; he refused to go into hospital.
He jumped out of a car and ran into a social club in Basildon, extremely agitated, collapsing several times with apparent muscle stiffness. Patrons restrained him face down until police arrived.
Officers applied handcuffs and leg restraints and placed him on his side, suspecting acute behavioural disturbance, then called 999 for a medical emergency with active restraint on the floor. They were put on hold three times, and for 18 minutes the response stayed at category two while they watched him deteriorate. They decided to convey him themselves.
He was extremely unwell on admission, with rhabdomyolysis and acute kidney injury. He deteriorated into multiorgan failure, and life support was withdrawn on the evening of 13 August 2022.
The outcome
An inquest before Sonia Hayes, Area Coroner for Essex, concluded on 31 July 2025 with a narrative conclusion. He was probably suffering a rare neuroleptic malignant syndrome in the days before his death, with acute kidney failure progressing on 12 August, and symptoms consistent with acute behavioural disturbance and complications following cocaine use involving physical exertion and prone restraint.
The medical cause was multiorgan failure and rhabdomyolysis due to those complications with neuroleptic malignant syndrome. No prosecution is recorded.
The coroner issued a prevention of future deaths report, reference 2026-0092, dated 2 February 2026, to the East of England Ambulance NHS Trust, Essex Police and the Association of Ambulance Chief Executives, with responses due by 30 March 2026.
What went wrong
The trust’s procedure requires escalation to category one where there is active restraint, but that is not linked to acute behavioural disturbance and remains unclear to call handlers. The coroner found that a person confirmed with acute behavioural disturbance and in active police restraint is coded category two, while someone in the same circumstances who is sectioned gets category one. The difference turns on the Mental Health Act, not on presentation or clinical need.
She also found that special constables, often first on scene, may not get the same training, and that the restraints were not removed when he was unconscious, though neither would have changed the outcome.
What it teaches
The category, not the label, decides the response. Where a caller reports active restraint with suspected acute behavioural disturbance, the triage script has to reach category one without requiring the officer to know the trust’s terminology.
Saying the words down a phone is not the same as the system hearing them. A script that needs interpretation will fail at three in the morning, with a caller who is holding someone on the floor.
Questions for the room
- Police said “active restraint” and “acute behavioural disturbance” on the call. What should that have triggered?
- You are the call handler on the third hold. What do you do differently?
- The coroner found sectioned patients get a faster response than those who are not, in the same condition. What does that say about how the category is set?
Evidence and limits
Confidence: confirmed. The coroner’s prevention of future deaths report and the local press report were both read and agree on the sequence, the 18 minutes and the coroner’s concerns.
Proceedings concluded on 31 July 2025. No member of staff is named.
Our vulnerable and volatile persons training covers recognition of acute behavioural disturbance, and the decisions that come before anyone takes hold.
Sources
- Courts and Tribunals Judiciary · Prevention of future deaths report 2026-0092: Scott Taylor · 2 February 2026
- Echo News · Basildon man’s death ‘highlights Essex ambulance delays’ · 17 February 2026
Reviewed 20 October 2026.