Police officers should not restrain people suspected of suffering from mental health problems, the police watchdog has said.
They should instead use containment and de-escalation techniques when dealing with members of the public who could be mentally ill, the Independent Police Complaints Commission (IPCC) said.
The recommendations are contained within a report, Six Missed Chances, which considers how a different approach could have prevented the death of former public schoolboy James Herbert.
Mr Herbert (pictured) died in custody in June 2010 after being held under the Mental Health Act having taken "legal high" NRG-1.
The 25-year-old, who started smoking cannabis as a teenager and also took cocaine, ketamine, ecstasy and LSD, was later seen acting strangely on the Bath Road in Wells, Somerset.
He was restrained by officers from Avon and Somerset Police and placed in the back of a patrol van.
Mr Herbert was driven more than 27 miles to Yeovil police station before being carried on a blanket into a cell, where he was left on the floor naked.
The data recovery engineer, from Wells, was later found to be unresponsive and was taken to Yeovil District Hospital by ambulance where he was declared dead having suffered a cardiac arrest.
Mr Herbert's death has been the subject of two investigations and an inquest, held in 2013, which found he died from "cardio-respiratory arrest in a man intoxicated by synthetic cathinones causing acute disturbance following restraint and struggle against restraint".
The IPCC investigation recommended Temporary Inspector Justin French, who was on duty at Yeovil police station at the time, should face disciplinary proceedings but earlier this month a misconduct panel dismissed allegations he had lied at Mr Herbert's inquest.
The Crown Prosecution Service decided no criminal charges would be brought against any police officer or the Avon and Somerset force in connection with Mr Herbert's death or the evidence given at the inquest.
Six Missed Chances looks at what could have happened, focusing on the missed opportunities and the unintended consequences and has made a series of recommendations to the National Police Chiefs' Council and College of Policing.
- Police officers responding to an incident involving someone with mental health problems should prioritise the welfare and safety of all those involved, including the patient.
- Officers should be effectively trained in verbal de-escalation as the default response to any incident involving someone with mental health problems.
- Officers should be trained to use containment rather than restraint when dealing with anyone who has, or appears to have, mental health problems.
- Each local force should ensure that it has in place robust, effective and relevant local protocols that support police officers in the discharge of their duties, backed by effective working relationships with other agencies on how to respond to incidents involving someone with mental health problems.
- Forces should develop clear processes for the recording and sharing of information about individuals who are known to, or are suspected to have mental health problems.
IPCC deputy chairman Rachel Cerfontyne said: "Whilst it is not possible to say what would have happened if the missed opportunities had been taken, it is clear the outcome could have been very different.
"In common with many other bereaved parents I have met in my role, James' parents hold a fervent wish to see something positive come out of their loss.
"They want the knowledge that their son's suffering was not entirely in vain, and that lessons can be learnt from James' story which will reduce the chances of other vulnerable people dying in similar circumstances.
"The welfare and safety of all those involved in an incident where someone is suffering from mental illness need to become the paramount consideration for police officers.
"While it is reassuring to see the significant changes Avon and Somerset Constabulary has made in its response to mental health issues in the last four years, such changes are not universal."
Family of mentally ill man welcome report recommendations by police watchdog
The family of a mentally ill man who died in police custody after being restrained have welcomed a series of national recommendations to prevent similar tragedies from happening in the future.
James Herbert, 25, suffered a cardiac arrest being detained under the Mental Health Act by officers from Avon and Somerset Police.
Mr Herbert's father, Tony, said the Independent Police Complaints Commission report, Six Missed Chances, highlighted six opportunities where his son's life could have been saved.
He said: "Whilst we remain extremely disappointed that neither Avon and Somerset Police nor any police officer involved was made accountable for James's avoidable and tragic death, as they should have been, we are fully behind the IPCC's decision to publish Six Missed Chances, a ground-breaking report about the six times that a different decision and course of action may well have saved James's life.
"If this document informs police policy and training as it should, future lives will be saved."
Mr Herbert, a businessman from Warwickshire, and his family have worked with campaign group Inquest to make submissions to the report.
"We are grateful to Inquest and particularly our case worker Victoria McNally, for being with us every step of the way for seven years and for bringing their knowledge and experience to bear by offering it to the IPCC in advising, suggesting and recommending throughout the drafting of the report," he said.
"It speaks volumes for Inquest expertise and commitment that Six Missed Chances has the potential to be a really effective piece of work."
The report highlighted six missed chances in the care the former public schoolboy received by the police on the day he died.
Deborah Coles, director of Inquest, said: "James was detained by the police for his safety. He should have been treated as a patient in need of medical care.
"Instead he suffered a traumatic but entirely preventable death involving prolonged and brutal restraint.
"We welcome the publication of Six Missed Chances, a product of his family's unwavering fight for change in response to a system that for seven years has delivered little more than defensiveness, denial and delay.
"This report should mark a watershed in the training and practice of officers responding to those in mental health need.
"Officers must understand the dangers of stereotyping people with mental ill health, and be equipped to respond with empathy and humanity.
"Safety, welfare and de-escalation must become the established policing response to those in crisis, if we are to see an end to deaths likes James'."
Avon and Somerset Police said it had already made "wide-reaching and fundamental" changes in the way it deals with people suffering with mental health problems.
Assistant Chief Constable Nikki Watson said: "All too often the police service has been the service of last resort for people in mental health crisis when all else fails and the events leading up to James' tragic death is a clear example of this.
"This is why we have to work together with our partner agencies to improve the multi-agency response so that people in mental health crisis are given the support they need and deserve.
"The Six Missed Chances report is a call to action for the police service nationwide and I'd like to reassure our communities that we've made wide-reaching and fundamental changes covering all the recommendations made."
Police and crime commissioner Sue Mountstevens added: "It is clear there were missed opportunities in the way the police dealt with James on that day.
"The police service nationally has learnt a great deal over the past seven years from this and other cases, however each death is an individual tragedy.
"It is vital that lessons are learned and a similar tragedy is prevented from happening again. It is of course important for bereaved families, local people, and for the police themselves that deaths in custody are independently investigated.
"However, it is not acceptable that it should take this long and all those involved should reflect on the additional suffering the delay has caused the family and officers' involved in this tragic case."
Chief Constable Mark Collins, the National Police Chiefs' Council's lead for mental health, said: "We were privileged to have Tony Herbert speak at our recent national mental health and policing conference, hearing first-hand of the circumstances that led to James' death. Our thoughts are with him and his family at this time.
"This report acts as a timely reminder to all of us about the missed opportunities for early intervention.
"We are committed to learning from this tragic incident.
"We support the Independent Police Complaints Commission's recommendations, many of which are either in process or have already been implemented."
Inspector Michael Brown, the College of Policing's lead on mental health, said: "Today's report challenges the police service to think differently about how we respond to incidents involving people in mental health crisis.
"We want to ensure that all frontline officers have the information and knowledge needed to support the decisions they make, often in very difficult and complex circumstances.
"However, this can only be achieved by all of the agencies and public services involved in this area working closer together to provide help for the most vulnerable people in society.
"We are reviewing the recommendations in the report and will continue to work with the national lead to improve the police service's response to mental health."
Copyright (c) Press Association Ltd. 2017, All Rights Reserved. Picture (c) PA Wire.