An independent report into the deaths or serious injuries of 55 mentally ill people in the past five years either in custody or in contact with the Metropolitan police, has found a catalogue of mismanagement and bad practices.
Among the findings were discriminatory attitudes, failures in systems, misjudgments or errors by individuals, limited resources, and poor co-ordination with other services.
The compilation of the report, by the Independent Commission on Mental Health and Policing, was further complicated by missing files and paper records. "This is clearly unacceptable for a 21st-century, customer-focused police service", the report's panel said.
Launching the report, Lord Adebowale, chief executive of the Turning Point mental health care provider, who chaired the commission, said: "Whilst a report like this cannot take away their suffering, I hope that those who receive this report ensure that the recommendations are implemented in the name of the families as citizens who have lost loved ones in terrible circumstances. They deserve the reassurance that other families will not suffer the same loss.
"I have been out on shifts with the police and the London ambulance service, so have seen at first hand that things can change and can change for the better."
The panel interviewed people with mental health issues, their relatives, NHS and social services staff, and serving police officers. People with mental health issues complained police treated them as criminals, and their families called for more engagement and more training for both officers and NHS staff. They also felt individuals with mental health issues were handled with too much force.
The report also found that the Met needs leadership that recognises the importance of public safety, respect for the mentally ill and the most vulnerable members of the public, or there would be more casualties like the 55 cases reviewed.
These included five deaths in police custody, 45 deaths either prior to or following police contact, and five cases of serious injury. It found that mental ill health is more common in London, affecting an estimated 18% of the population compared with 16% nationally, and according to one study 70% of prisoners have a mental disorder.
Mental health puts increasing demands on the Metropolitan police: in 2012, they received 61,258 calls related to mental health, 21,741 more than those connected with robbery, and 47,203 more than for sexual offences.
The victims in the cases are not named in the report. However in one, described as "the worst combination of poor leadership, lack of a clear strategy, policy, practice and co-ordination", after a series of increasingly alarmed calls by a hostel manager about a man acting bizarrely and out of control, the police only acted when it appeared a bystander could be injured.
The man was chased, restrained in the prone position for eight minutes — while struggling but not violently — and taken to a police station rather than hospital in a van. He was left without adequate care in a cage in the van, and then in a cell at the police station, where he was described as "feigning unconsciousness". He later died.
The report also found that the London ambulance service must respond to a clear mental health crisis as an emergency – even if the police are already present.
Many families and some mental health professionals told the commission they could not understand why there was not better liaison between agencies. The report said care pathways must be recognised and developed, and there must be greater operational cohesion, including inter-agency liaison within the NHS and clinical commissioning groups.
