Metropolitan Police officers were found to lack compassion in “how to deal with mental health detainees” following an inquest into the death of Joseph Phuong.
On June 4 2015 police attended a suspected attempted burglary in Twickenham, where they encountered Mr Phuong – who they assessed was suffering from mental health difficulties.
The 32-year-old remained in the care of police officers for almost 22 hours while in transit, at Springfield Hospital, St George's Hospital and at Kingston Police station.
However, a short while after officers were able to transfer Mr Phuong, of Twickenham, into the care of mental health professionals at Springfield Hospital, he died.
An initial investigation, carried out by the Independent Police Complaints Commission (IPCC), into the circumstances surrounding police contact with Mr Phuong was completed in May last year.
The IPCC investigation concluded that none of the officers who came into contact with Mr Phuong had breached the standards of professional behaviour.
It also concluded that a number of officers exhibited “commendable conduct in the face of challenging circumstances” while the 32-year-old was in their custody.
On October 4 2017, an inquest jury found his medical cause of death unascertained and delivered a narrative determination.
Their findings were “critical of the medical assessment made of Mr Phuong while in police custody” and of the level of information handed over between shifts.
The determination also highlighted the “lack of fluency and compassion shown by officers in how to deal with mental health detainees and specifically acute behavioural disorder”.
However, the jury's critical determination concluded that “these failings did not contribute to Mr Phuong's death” on June 5 2015.
The IPCC recommended the force should consider if the current processes in place best capture information about a detainee's physical health when transferred from custody to a mental health institution.
The Metropolitan Police service “agreed with the proposed recommendations”, according to an IPCC spokesman on October 27.
IPCC operations manager Neil Orbell said: “MPS officers found themselves having to care for a vulnerable and clearly unwell man for a protracted period.
“The situation they found themselves in was challenging and the extensive CCTV we examined, covering their interactions with Mr Phuong, showed they recognised he was suffering a profound mental health breakdown and appeared to be doing their best to assist him.”
'Chaotic response to the medical emergency'
While the inquest jury said police officers did not contribute to Mr Phuong's death, they determined the admissions procedure at Tooting's Springfield Hospital was “unsatisfactory”.
Observations of Joseph were ruled to be “ineffective in several respects” and jury members found this “possibly contributed to his death”.
On top of this, they also found the “chaotic response” to the subsequent medical emergency “probably contributed to his death”.
Mr Orbell added: “It is my hope that any lessons learnt from the tragic death of Mr Phuong can help prevent further deaths in the future.
“The IPCC has recently issued national recommendations to policing authorities on how to treat members of the public suffering from mental health issues.
“My thoughts go out to Mr Phuong’s family and all those affected by his death.”
Keep up to date with the latest news in west London via the free getwestlondon app.
You can set up your app to see all the latest news and events from your area, plus receive push notifications for breaking news.