“East of England Ambulance NHS Foundation Trust (EEAST) a”

The coroner’s concerns

– (1) East of England Ambulance NHS Foundation Trust (EEAST) a. Members of the public were restraining Scott Taylor on arrival of the police who quickly became concerned that Mr Taylor was exhibiting signs of Acute Behavioural Disturbance and made an emergency call to the ambulance service. The police, during the 999 call, were put on hold on three occasions by the ambulance service and became increasingly concerned about Mr Taylor’s deteriorating condition over an 18 minute period and confirmation that this remained a Category 2 call despite active police restraint with suspected Acute Behavioural Disturbance. Police decided to ‘scoop and run’ and urgently convey Mr Taylor to hospital due to the severity of their concerns. The EEAST Standard Operating Procedure requires escalation to Category 1 where there is active restraint, but this is not linked to Acute Behavioural Disturbance and remains unclear and may continue to cause confusion during triage by contact call handlers. b. The East of England Ambulance NHS Trust provide ambulance services across 6 counties and that also includes police/healthcare professionals reporting Acute Behavioural Disturbance and active 2 police restraint. There is concern that there is a different response applied and that this discrepancy between Category 1 and Category 2 responses is significant and could affect the survival of patients. Evidence heard from police trainers and expert witnesses is that Acute Behavioural Disturbance has a high rate of fatality and requires an urgent response, particularly where police officers with training in this condition are reporting to ambulance service and with active restraint. c. The EEAST updated training on Acute Behavioural Disturbance, active restraint and reports received from police and correct coding remains confusing with the policy and training handouts in December 2023 with discrepancies between those who are sectioned and those who are not. Persons confirmed with Acute Behavioural disturbance and in active police restraint being coded as Category 2 and those in the same circumstances and ‘sectioned’ will require a Category 1 response. The difference appears to be one related to the Mental Health Act and not the presentation or clinical requirements of the person. d. The EEAST documents continue to use the term ‘Excited Delerium’ interchangeable in some of the training materials and this may lead to confusion with contact handlers triaging calls. (2) Chief Constable of Essex Police a. Whilst it was not causative of Mr Taylor’s death, there appears to be a discrepancy in the training for Police Officers and Special Constables in the potential recognition and actions for Acute Behaviours Disturbance. Special Constables are a valuable resource for police forces and may often be first on scene as in this case and should receive the same training in the potential recognition and alert of potential life-threatening conditions. b. Whilst it would not have changed the outcome for Mr Taylor, arm and leg restraints were not removed by police officers in this case when it was understood that Mr Taylor was unconscious and when Mr Taylor was being conveyed to hospital. Police officers who gave evidence were not clear that this was a requirement of the policy. (3) Association of Ambulance Chief Executives a. It was agreed in evidence that the set of symptoms consistent with Acute Behavioural Disturbance amount to a medical emergency with a significant mortality risk. The evidence was that the Association of Ambulance Chief Executives set the Categories nationally that dictate the required classification for ambulance response to emergencies, however in some ambulance localities the required response is allocated Category 2 and in others Category 1. 3 This means that there is not a national standard for response Acute Behavioural Disturbance with active restraint.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2026-0092

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0