Police officers who restrained a highly agitated man before he had a cardiac arrest had “insufficient knowledge” of acute behavioural disturbance (ABD), an inquest has concluded.
Mouayed Bashir, 29, who had mental health issues, died after being restrained with his hands cuffed behind his back and his legs bound together at his family’s house in Newport, south Wales.
ABD, which presents with symptoms such as extreme agitation, paranoia, rapid breathing and sweating, is a state that can be exacerbated by restraint and can lead to cardiac arrest.
A string of officers told the inquest that though Bashir, a registered carer, was exhibiting a number of telltale symptoms of ABD – and they had been trained to spot it – they did not recognise it.
The jury said: “We believe from the evidence we heard that there was insufficient knowledge and understanding around identifying some of the signs of acute behavioural disturbance.”
In a narrative conclusion, the jury said Bashir had taken an unknown quantity of cocaine that resulted in him developing symptoms “in keeping” with ABD. They gave the medical cause of death as “intoxication with cocaine and the effects of cocaine, following a period of restraint”. They said he was restrained “for his safety and the safety of others”.
Caroline Saunders, the senior coroner for Gwent, said she would write to the police to ask about ABD training, in particular a package from the College of Policing that instructs officers to “speak up, speak out” if they observe that a restrained person is in distress.
Outside court, Bashir’s brother Mohannad Bashir said: “We want ABD to be recognised and taken seriously. The family believe police training needs to be modernised, overhauled and updated.”
A second brother, Mohamed Bashir, said the family had had to move because they could not bear to be in the house where their loved one had been restrained.
Lucy McKay, from the charity Inquest, which has supported the family, said: “Mouayed’s family called for help for a mental health crisis. Police responded by restraining Mouayed without even attempting de-escalation or support.”
On 17 February 2021, Bashir’s parents became concerned about his behaviour. He had barricaded himself in his room and was smashing furniture and shouting.
They dialled 999 and pleaded for help. A Gwent police officer arrived at 9.01am and requested backup and an ambulance. The call was categorised by Wales ambulance service as amber 2 – serious but not life-threatening.
Officers managed to get into Bashir’s room at 9.07am. He was on the floor, thrashing about and making growling noises, the inquest heard. The police decided to restrain him.
At 9.27am a police medic arrived in the room. She was deeply concerned at Bashir’s condition. She told the jury: “I had never seen oxygen [levels] that low. I had never seen anyone sweat as much as Mr Bashir. He was clammy, chill to the touch.”
Concerns about his oxygen levels, his breathing and sweating were relayed to the ambulance service at about 9.31am and its response was changed to amber 1 – life-threatening. Twenty minutes later Bashir’s parents called the ambulance service themselves and said their son was unconscious. The call was upgraded to red – immediately life-threatening.
The paramedics reached Bashir’s side until 10.08am. He was finally transferred into an ambulance at about 10.37am, where he had a cardiac arrest. Bashir was taken to hospital and died that morning.
During a two-week inquest in Newport, the jury was told by experts that Bashir had been exhibiting signs of ABD and Gwent police had undergone training on recognising it.
The officers said they did not spot that Bashir had ABD. The police medic, asked if she thought at the time that she may have been dealing with ABD, said: “It did not cross my mind.”
In their submissions to the inquest, Bashir’s family said that when police decided to restrain Bashir, they did not consider they could be putting his life at risk.
After Bashir’s death, protests were held in Newport led by members of his family and Black Lives Matter activists.
Gwent police said evidence that emerged during the inquest showed that more knowledge of ABD would not have saved Bashir’s life as he was already beyond help when they arrived.
The deputy chief constable, Rachel Williams, said the restraint was proportional and added: “We will continue to develop our knowledge, understanding and training of ABD in line with national policing guidance.”
Liam Williams, the Welsh ambulance service’s executive director of quality and nursing, said: “We will be contacting the family again in the near future to ensure we have been able to answer any outstanding concerns or questions.”
Bashir was of Sudanese heritage and arrived in the UK when he was nine. His family said he was easygoing and popular but as an adult had mental health issues.
After the inquest, the Independent Office for Police Conduct said it was concerning that ABD “was not communicated as a potential impact factor in [Bashir’s] ill health to the ambulance service”.
It also said communication with Bashir’s parents by some officers at times “lacked empathy and compassion”, but did not find that the family was treated less favourably by police because of their race.
