Kaine Fletcher

Before HM Assistant Coroner Alexandra Pountney for South Yorkshire (West) (sitting in Nottingham and Nottinghamshire)
Nottingham City and Nottinghamshire Coroner’s Court
30 June 2025 – 25 July 2025

Kaine Fletcher died aged 26 on 3 July 2022 after a period of prolonged restraint by officers from Nottinghamshire police who had been called to visit him for the purposes of a welfare check.

Kaine was born in Nottingham, the eldest of eight children. He was a devoted father and is dearly missed by his close-knit family and friends. His mother visits his grave every day.

At the time of his death, Kaine had been discharged from the care of the local mental health team without having received any treatment in spite of an urgent referral by his GP in February 2022.

On 2 July 2022, he called the police during a mental health crisis. He was seen by three police officers, a mental health nurse and two paramedics. Although there were clear concerns about his mental health, it was decided not to take Kaine hospital, despite pleas for help from his family.

Less than eight hours later, in the early hours of 3 July 2022, a member of Kaine’s family called 999 due to concerns that Kaine may have attempted to take his own life. She was told that there would be an eight-hour wait for an ambulance. The police were instead called to attend Kaine’s address to carry out a welfare check. 

Kaine initially agreed to travel to the hospital with police, but shortly after entering their police car became distressed and confused: he did not believe that the officers were real police officers and withdrew his consent to be taken to hospital.  The police responded by closing the door of the police car such that Kaine was detained, and soon escalated their use of force, including using a baton to force him into the car, and then prolonged restraint, which included the use of handcuffs, a baton strike and the application of three leg restraints and a spit hood, and involving as many as nine police officers. During this, several officers delivered blows to Kaine: with one officer striking Kaine to the jaw twice, others using knee and leg strikes, and much of this being simultaneous and despite Kaine being in handcuffs and leg restraints. Kaine had been restrained for approximately 30 minutes before police recognized that there was a medical emergency and called an ambulance. Kaine continued to be restrained by police officers in the ambulance and for some time after his arrival at the Emergency Department at Queen’s Medical Centre.

All of this occurred, as the inquest heard, in circumstances where Kaine should not have been being conveyed to hospital by police car or police van. The police policy is that the officers should have called for an ambulance when detaining someone for mental health reasons. All but one of the police officers who were present during the restraint on 3 July said they were unaware of that requirement until the inquest.

Despite the best efforts of medical staff, Kaine sadly passed away at 9.36am.

Having heard 4 weeks of difficult and distressing evidence the inquest jury concluded that a number of serious failings by the police contributed to Kaine’s death, including that:

• There was ineffective communication between the officers at the scene, between the supervisors in the control room and a lack of clear leadership on the scene.  The jury also found management and leadership failures “in all departments”;
• There was a “gross failure” in dissemination in training across all agencies. In particular, the police disregarded vital information, policies and training on section 136 and ABD – including the requirement to convey detained patients to hospital by ambulance;
• The decision by the Street Triage Team not to detain Kaine on 2 July 2022 following an inadequate assessment, a lack of engagement with Kaine and Kaine’s family, EMAS and other police officers at the scene was a “gross failure”; and
• Kaine was “lost in the system with no effective or practical treatment available. This was a gross failure in the care of Kaine”.

In the course of the inquest it became apparent that a state of confusion had existed for some years prior to the death between the police and ambulance services as to response times when a person had been detained and/or restrained by the police under the Mental Health Act.  That confusion created such a risk to life that the Coroner in the inquest took the exceptional step of issuing – before the inquest had even concluded - a report to EMAS and to Nottinghamshire Police urgently requesting that they resolve the matter in order to prevent future deaths. 

The Coroner issued a further preventing future deaths report following the conclusion of the inquest, highlighting six areas of concern including “a training issue within the police in relation to s.136 detentions and the correct mode of conveyance. Either officers do not know that they should call an ambulance, or they are ignoring their training/the instructions that they are given.”

Kaine’s family are represented by Erica San of Bhatt Murphy Solicitors instructing Stephen Simblet KC of Garden Court Chambers. The family are supported by INQUEST Senior Caseworker Jodie Anderson.

Kaine’s father Nathaniel Ameyaw said: “The last time I saw Kaine in the hospital, he was still being surrounded by police officers even though he was so critically unwell. He should have been surrounded by the people who loved him. Kaine just needed some help. Common sense could have changed this whole situation. Compassion, common sense and patience.”

Kaine’s aunt Letitia Fletcher said: “We all loved Kaine so much. We couldn’t give him the help that he needed. I wish that we had been listened to. I felt vindicated hearing the jury agree with what our family have been thinking for the past three years: Kaine was massively failed. If things went differently on the 2 July, there is a good chance that Kaine still would have been here.”

The mother of Kaine’s children Shannon Wright said: “Kaine was a really good dad. The worst day of my life was when I had to tell the children that their dad had died. It’s heartbreaking to know that Kaine won’t be there for their big milestones - starting nursery, prom, graduating from university, getting married. He will never be able to be a grandad. This will stay with the children for the rest of their lives.”

Erica San of Bhatt Murphy Solicitors said: “Kaine was a vulnerable man in crisis. He was not suspected of any crime, nor had he been aggressive to any of the officers before the use of force. There were numerous missed opportunities to de-escalate the situation but instead it appeared that once the initial decision was made to restrain Kaine – in circumstances where it should have been clear from the officers’ training that it was incredibly dangerous to do so – there was no ongoing consideration of the appropriateness of the protracted restraint. There was no real plan to convey Kaine safely to the hospital, and no one had oversight of the totality of the force used against him.

The evidence heard at the inquest painted a picture of chaos. The police were either unaware, or chose not to follow, important procedures for the safe and dignified treatment of mentally unwell people. Those have come about from learning from previous deaths and are designed for the safety of vulnerable people and the police themselves. It is very concerning that they were not followed in Kaine’s case.”

Jodie Anderson of INQUEST said: “When Kaine’s family called the police for help during a mental health crisis, the response they got was brutal. Kaine was handcuffed, hit with a baton, bound with leg restraints, and gagged with spit hood. One officer punched Kaine to the face to ‘distract’ him from self-harming. All of this, supposedly for Kaine’s own safety.

A year before Kaine’s death, INQUEST published a damning report which found that Black people are seven times more likely to die than White people following the police restraint. Yet again we see the deadly consequences of policing which treats Black men unilaterally as a threat needing to be contained, rather than vulnerable and in need of care.

This isn’t just about the police not following guidance and proper processes but about the law around police use of force being fundamentally unfit for purpose. The evidence laid bare yet again a culture within policing that prioritises violence over care. When will we accept that the police should not be the ones responding to people in mental distress?”

NOTES TO EDITORS
For further information or request for comment please contact Erica San at Bhatt Murphy on 020 7729 1115 or [email protected]

Kaine’s family are represented by Erica San of Bhatt Murphy Solicitors instructing Stephen Simblet KC of Garden Court Chambers. The family are supported by INQUEST Senior Caseworker Jodie Anderson.