What happened
On 3 July 2022 police were called to the YMCA accommodation in Nottingham where Kaine Fletcher, 26, lived, for a welfare check after concerns that he would harm himself.
He agreed to be taken to hospital by the officers. He then changed his mind and no longer believed they were really police. He was detained under the Mental Health Act, handcuffed, struck and restrained for about 30 minutes by numerous officers. An ambulance arrived and took him to the Queen’s Medical Centre, where he died.
The day before, officers had been called to his mother’s home during another mental health disturbance. It was discussed then that he should be sectioned, a decision his family supported, but under the guidance of a community nurse he was taken back to his accommodation. His condition deteriorated overnight.
The outcome
An inquest before Assistant Coroner Alexandra Pountney ran for four weeks and concluded on 25 July 2025. The jury found the level of restraint “appropriate” but the combined force “uncontrolled”. It found ineffective communication at the scene and a lack of clear leadership, said police should have considered how long he was kept in restraints, and found a “gross failure” in training across all the agencies involved.
The cause of death was the physical effects of exertion following restraint, combined with cocaine and other substances. The coroner issued two prevention of future deaths reports. No prosecution is recorded.
What went wrong
Under a joint policy with the East Midlands Ambulance Service, officers at the scene should have called an ambulance. It was not called until after the initial period of restraint, and officers giving evidence said they did not know the policy existed.
The jury’s finding is narrower than a verdict on force. Each officer’s force was judged appropriate. The combined effect was not.
The IOPC had earlier found the actions reasonable and proportionate, with no evidence of a criminal offence. The family have asked it to investigate again.
What it teaches
A welfare check that becomes a section and then a restraint is three different jobs in a quarter of an hour. The failure came before any technique mattered: nobody took command, nobody counted the officers, nobody called the ambulance, and nobody asked how long this had been going on.
Combined force is its own risk, and it is nobody’s individual decision. That is why the jury could find each officer’s force appropriate and the combined effort uncontrolled.
The day before belongs in the picture. The decision to take him home rather than section him was made with a community nurse, and his condition worsened overnight.
Questions for the room
- He agreed to go to hospital and then changed his mind. What does that moment require of the officers present?
- You are the most senior officer at the scene. What do you say in the first minute, and who calls the ambulance?
- The jury found individual force appropriate but combined force uncontrolled. How would a supervisor see that at the time?
Evidence and limits
Confidence: probable. The BBC’s report of the inquest and the coroner’s register were read. The two prevention of future deaths reports, 2025-0363 and 2025-0383, are cited in the record but were not read here; the earlier was issued while the hearing was still running. The conclusion date of 25 July 2025 is taken from the later one.
The record summarises the finding as gross failings by the police and others; the précis, closer to the reporting, has a gross failure in training across all the agencies. This entry uses the précis wording.
Proceedings concluded, so the page can be cited outward with that stated. No officer is named and no finding is made about any individual.
Our [restraint reduction training](/training-solutions/restraint-reduction-rrn) covers team response, lead officer roles and time limits on any hold.
Sources
Reviewed 20 October 2026.