On the 21st March, 22nd March and 23rd March 2023 evidence was heard touching the death of Daniel LYLE. He died on 20th March 2020 aged 46 years. Medical Cause ofDeath I (a) Multiple Injuries How, when, where Daniel LYLE came by his death; At about 0820 on 20th March 2020 Daniel Lyle who suffered from paranoid psychosis had a psychotic episode in the gru-den area outside Morgan House, Tachbrook Street, London SWI During the course ofthis episode he climbed approximately 30 feet up into a tree. Police officers tried to engage him in efforts to encourage him to come down safely from the tree, but he did not come down. During his time in the trre he displayed paranoid and delusional beliefs. Whilst moving within the tree Daniel feJI striking his head on the bard surface beneath the tree causing serious head and chest injuries. Despite effo1ts by police, fire brigade, ambulance and helicopter medical personnel to resuscitate him, Daniel died from h.is injuries in the garden area outside Morgan House, Tachbrook Street London. Conclusion of the Coroner as to the death: Accident Circumstances of the death: Extensive evidence was heard by the court in the form ofwritten and oral evidence, and I was able to view the body worn video evidence of police officers who attended a call to police about Daniel's behaviour that dav.

Ofparticular significance for the purpose ofthis report are the following matters: (I) Daniel suffered from paranoid psych~is and had done for many years. (2) Part ofthe,features ofhis psychosis were delusional beliefs. (3) On 208' March 2020 Daniel climbed high into a tree - over 25-30 feet above the ground whilst expressing delusional and psychotic beliefs that dead people were in the est.ate refuse bins. (4) Pol.ice officers attended and tried to encourage Daniel to come down from the tree for his safety. (5) He was approached and spoken to by more than one police officer until one officer PC took over communication. (6) Other officers remained present but tried to keep a distance away and did not try to interfere with the one officer communicating with Daniel. (7) PC the officer communicating with Daniel infonned the court that he had received some training from the Metropolitan Police service in relation to dealing with those with mental health issues, and had received other training in different forces. He told me that he had pieced together information on how to deal with someone displaying mental health issues as a "'patchwork" over I 5 years. He told me that training on the presentation ofsymptoms and strategies to deal with those in mental health crisis would be something he would value. He said that whilst he did have some training and there was overlap in officer safety training, he would value individual training specifically on symptoms, presentation and strategies to de-escalate situations involving those displaying mental health difficulties such as psychotic and other distressed behaviour. (8) Daniel underwent an acute psychotic episode beginning before he entered the tree and whilst he was in the tree. Whilst moving within the tree Daniel fell sustaining fatal injuries. (9) Inspector is the Central Mental Health and Adult Safeguarding team lead which sits within the Continuous Policing Improvement Command.

told me ofinitiatives and training developments addressing mental health within policing. accepted that bespoke refresher training for frontline officers in helpjng to deaJ with those suffering ment.al health epjsodes was in the process of being developed by the MPS. referred me to initiatives by the MPS Western Area Mental Health Team which had an element of training about the signs of mental ill-health and learning disorders, and general communication in a mental health crisis, and also referred to a one day course rolled out in 2018-19 for officers on mental health issues. Matters of Concern: ( 1) Whilst recognising that police officers cannot be doctors or nurses nor should they be, it is a concern that training for officers whether initial or refresher is not sufficiently focused on: (a) an understanding ofthe symptoms and presentation ofmental health conditions; (b) possible practical strategies informed by mentaJ health professionals and those suffering such conditions as will enable officers to optimise their decision making under the national decision making model.