Sean Rigg was forty when he died in āthe cageā in Brixton police station on 21 August 2008. He was a rap artist and singer, and had released a CD of his own music and lyrics. He was widely travelled and was considered to be a charming and intelligent person. Sean was black, he had a formal diagnosis of schizophrenia which was controlled by medication. His condition was usually well managed, enabling him to live an active, independent life, but could deteriorate rapidly if he ceased taking medication. Sean lived in a community mental health hostel in south London and was in regular contact with his family, particularly his sister, Marcia, who was considered to be an āintegralā part of his care team (Lakhani 2012). His consultant from the South London and Maudsley Trust (SLaM) considered him to be a physically fit and healthy person.
SLaM, who were responsible for Seanās duty of care stated that from 11 August 2008 he was āin need of acute treatment and that his placement in the community was unsafeā (Casale et al. 2013: 42ā3). SLaM failed to respond to multiple requests from the hostel to meet with Sean in the two weeks prior to his death. Hostel staff called police five times over a period of three hours on 21 August to request officersā attendance due to a relapse in his mental health condition which caused an extreme psychotic episode. Police did not attend the hostel, but did respond to an emergency call from a member of the public when Sean was seen acting oddly while semi-dressed outside a residential location. Four officers arrived in a van; they failed to recognise that he had mental health issues. He was arrested at 19.40 for allegedly assaulting a police officer and for an alleged public order offence (IPCC 2012b: 37). Thereafter, he was detained using handcuffs and prolonged prone restraint, following which he was also arrested for the theft of a passportāit was his own expired passport which he kept on his person for identification purposes (Casale et al. 2013: 59). He was then put into the back cage of a police van and driven at speed to Brixton police station. Upon arrival at 19.53 he was left in the van for ten minutes. He was then removed at 20.03 in a collapsed state and placed in a chain metal structure known as āthe cageā, adjacent to the custody suite but external to the building. The Forensic Medical Examiner (FME)1 attended him at 20.13 and requested that an ambulance be called. An ambulance was called at this point, but not an emergency ambulance. At 20.24 the FME was recalled as Sean was not breathing, and at this point an emergency ambulance was called. Officers attempted mouth to mouth resuscitation and used a defibrillator without success. Sean died after less than one hour in police custody. It took more than thirty minutes for anyone to administer medical attention to him.
As per the protocol, the Metropolitan Police Service (MPS) referred Seanās death to the Independent Police Complaints Commission (IPCC). An IPCC team of investigators arrived at Brixton police station around midnight on 21 August. At around 08.00 the following morning it was announced that an independent investigation would be carried out into Seanās death. The investigation report into his death concluded in February 2010 but was not made public until 15 August 2012. A coronerās inquest, heard in public, before a jury, began on 12 June 2012 and concluded on 1 August 2012, nearly four years after Seanās death. The inquest considered evidence that the IPCC did not find, did not seek or did not use. This evidence was gathered principally by Sean Riggās family. The result was a jury verdict that differed considerably from the findings of the IPCC investigation report. The purpose in opening this book with the death of Sean Rigg is twofold. First, to illustrate the types of events and issues that may lead to cases of DAPC. Second, to illustrate how different regulatory systems produce different investigations into such deaths, leading to a relational system of accountability construction in these cases. By relational I mean dependent upon the contexts in which accountability is constructed. By accountability construction I mean the processes and mechanisms that are used to produce accountability in cases of DAPC. The following section sets out aspects of both the IPCC investigation report into Sean Riggās death, and the inquest verdict recorded by the jury.
Relational Accountability in Cases of DAPC
The jury verdict in the coronerās court ran to three pages compared to the 162-page IPCC investigation report (IPCC 2012b). The IPCC report is striking in its level of empirical detail regarding witness statements and timings of events. Below, there is a brief discussion of issues covered by the jury verdict and IPCC report regarding mental health, restraint, Computer Aided Dispatch (CAD) response and securing evidence. It will become clear that different organisations using different processes construct different types of accountability, underlining the relational aspect of accountability construction in cases of DAPC.
Mental Health and Restraint
The coronerās jury criticised SLaM for failures or absences in communication, crisis planning, risk assessment and treatment. It stated that SLaM failed to put a crisis management plan into place and that there was inadequate risk assessment of Sean Rigg. Communication between members of Seanās clinical team and also between the team and his family was considered āless than effectiveā. Furthermore, they recorded that communications between police, SLaM and Penrose (the hostel provider) were āinadequateā. The IPCC investigation report makes little comment on SLaM, primarily because the remit of the IPCC is to focus on police action or omission rather than the wider circumstances which contributed to the death of Sean Rigg. Mental health issues are intimately linked with police interactions with marginalised groups, and with the issue of DAPC (Adebowale 2013). For the IPCC not to consider this issue suggests either a lack of knowledge or interest on their part; it suggests that the initial parameters that provide a framework for their investigation of these cases are at best flawed and at worst blinkered. By failing to consider the role of SLaM in the death of Sean Rigg, the IPCC overlooked why police were in contact with Sean in the first place. His death illustrates failings in two public services, as distinct to purely the police, and this is a consistent theme in cases of DAPC.
The jury stated that upon arrival at Brixton police station it should have been reasonable for the police to recognise there was cause for concern about Sean Riggās physical and mental health, and this should have led to an assessment of these conditions. That this did not occur represented: āan absence of actions by the Police and this was inadequateā. The failure to acknowledge issues relating to Seanās physical and mental health is linked to the role of police in these cases: are they enforcement officers or peace officers? Do they focus on the criminal justice aspect of their role when dealing with vulnerable groups, or do they focus first and foremost on the preservation of life and the welfare of the individual?
The IPCC report focuses on Sean Riggās alleged behaviour during transportation to Brixton police station, noting that three of the officers described him spinning around on his back and walking around the sides of the van walls on his feet, leading them to charge him with a public order offence (IPCC 2012b: 54). During the inquest this behaviour was demonstrated to be a physical impossibility by expert witnesses (Casale et al. 2013: 66). The IPCC report spent several pages discussing the inability of officers to acknowledge that Sean had mental health issues, noting that āit is of some concernā that they did not do so, despite describing his behaviour as āstrange by anyoneās standardsā (IPCC 2012b: 105). The inability of officers to recognise mental health issues meant they were not procedurally obliged to take into account Standard Operating Procedures (SOP) regarding mental health issues when approaching, arresting, restraining, transporting and caring for Sean Rigg in custody (IPCC 2012b: 110). Had they recognised mental health issues they would have had to conduct a risk assessment and attempted to de-escalate the situation rather than use restraint in the first instance. As noted above, the type of approach determines the type of actions (or omissions) that are adopted by officers.
The jury was critical of the police use of excessive restraint, stating that:
āThe length of restraint in the prone position was ā¦ unnecessary. It is the majority view of the Jury that this more than minimally contributed to Seanās death.ā
The level of force used during the restraint phase was deemed āunsuitableā. The jury criticised an absence of leadership and questioned whether: āpolice guidelines or training regarding restraint and positional asphyxia were sufficient or were followed correctlyā. In the IPCC report, restraint was assessed by an expert from the Association of Chief Police Officers (ACPO) commissioned by the IPCC. He noted that the recognition of āimpact factorsā such as mental health issues could have affected the officers use of restraint had they acknowledged the existence of such factors. The section concluded:
āThis investigation has uncovered no evidence to suggest that the techniques used by the officers and the level of force applied during the arrest of Mr Rigg was disproportionate or unlawful.ā (IPCC 2012b: 113)
The coronerās jury and the IPCC clearly have subjective differences in measurement and this points to one way in which accountability may be seen to be a relational concept. In this case, measurement criteria determining acts as proportionate and lawful might be quite different to those which assess acts in terms of whether or not they are legitimate and desirable.
Computer Aided Dispatch (CAD) and Scene of Death
The jury criticised CAD responses to emergency calls from the hostel as āan unacceptable failure to act appropriatelyā. Furthermore, the police response to these calls was āunacceptable and inappropriateā. Moreover, they stated that police failed to secure an ambulance as quickly as possible. The IPCC report sets out a detailed description of issues relating to CAD systems and operation. For example, the CAD operator notes on the CAD record, which would have been available to police on their Mobile Data Terminal (MDT): āhe must have mental health issuesā (IPCC 2012b: 77, italics as original). Official reports into cases of DAPC stress the importance of officers referring to existing records to access information when dealing with potentially vulnerable individuals (see, for example Leigh et al. 1998; Best et al. 2004; Hannan et al. 2010; ACPO 2012). A good deal of space is spent in the IPCC report discussing the general principle in CAD of sifting calls into levels of gravity, and of the overall response rates by the local borough police and MPS in general. The IPCC section on CAD response concludes apologetically: āUnfortunately, in many circumstances it is just not possible for the police performance to match up to the often unrealistic public expectation of themā (IPCC 2012b: 104). One may question how an organisation with a mission statement that states an intention to promote public trust in the police is able to record such an observation.
In the IPCC report, the inability of the police to secure both the scene of the arrest and the scene of death mildly concluded:
āIt does appear that little consideration was given to the evidential opportunities that may have existed at the site of the arrest.ā (Ibid: 122)
A number of pages discussing the issue of CCTV are prefaced with:
āThe whole subject of the CCTV at Brixton police station is an immensely complicated one.ā (Ibid: 123)
Yet the family of Sean Rigg were able to secure the CCTV footage from inside Brixton police station while the IPCC were apparently not. The issue of securing evidence is highlighted regarding the independence of the IPCC in a number of academic texts (see Savage 2013a, b; Smith 2009a, b) and official reports (Casale et al. 2013; IPCC 2013; HAC 2010). An independent review into the IPCCās investigation of Sean Riggās death criticised the eight-month delay in interviewing officers fully about circumstances relating to the death, stating: āIt is difficult to understand the lack of urgency accorded by the IPCC investigationā (Casale et al. 2013: 30).
After fifty-one pages of discussion the IPCC report made two findings, which appears remarkable in the context of a 163-page investigative report. One was that the CCTV at Brixton polic...