Police officers who restrained a highly agitated man before he went into cardiac arrest had “insufficient knowledge” of acute behavioral disorders (ABD), an investigation has found.
Mouayed Bashir, 29, who had mental health problems, died after being held with his hands handcuffed behind his back and his legs tied together at his family’s home in Newport, South Wales.
ABD, which manifests with symptoms such as extreme agitation, paranoia, rapid breathing and sweating, is a condition that can occur aggravated by reluctance and can lead to cardiac arrest.
A series of officers told the inquest that although Bashir, a registered carer, showed some telltale symptoms of ABD – and they had been trained to recognize this – they failed to recognize it.
The jury said: “Based on the evidence we heard, we believe that there was insufficient knowledge and understanding around identifying some of the signs of acute behavioral disturbances.”
In a narrative conclusion, the jury said Bashir had used an unknown amount of cocaine, causing him to develop symptoms “consistent” with ABD. They cited “intoxication with cocaine and the effects of cocaine, after a period of restraint” as the medical cause of death. They said he was being held “for his safety and the safety of others.”
Caroline Saunders, Gwent’s senior coroner, said she would write to police to ask about ABD training, in particular a package from the College of Policing that instructs officers to “speak out, speak out ” when they perceive a subdued person in distress.
Outside court, Bashir’s brother Mohannad Bashir said: “We want ABD to be recognized and taken seriously. The family believes that police training needs to be modernized, revised and updated.”
A second brother, Mohamed Bashir, said the family had to move because they could not bear to be in the house where their loved one was being held.
Lucy McKay, from the charity Inquest, which has been supporting the family, said: “Mouayed’s family called for help due to a mental health crisis. Police responded by restraining Mouayed without even attempting to de-escalate or provide support.”
On February 17, 2021, Bashir’s parents became concerned about his behavior. He had barricaded himself in his room and was smashing furniture and screaming.
They called 999 and begged for help. A Gwent police officer arrived at 9.01am and requested reinforcements and an ambulance. The call was categorized by Wales Ambulance Service as amber 2 – serious but not life-threatening.
Officers managed to enter Bashir’s room at 9:07 am. He was lying on the ground, struggling and making grunting noises, the inquest heard. The police decided to restrain him.
At 9:27 a.m. a police medic arrived in the room. She was very concerned about Bashir’s condition. She told the jury: “I had never seen oxygen levels so low. I have never seen anyone sweat as much as Mr. Bashir. It was clammy and cold to the touch.”
Concerns about his oxygen levels, breathing and sweating were reported to the ambulance service at around 9.31am and the response was changed to amber 1 – life-threatening. Twenty minutes later, Bashir’s parents called the ambulance service themselves and said that their son was unconscious. The call was upgraded to red – immediately life-threatening.
The ambulance crew reached Bashir’s side until 10:08 am. He was finally transferred to an ambulance at around 10.37am, where he went into cardiac arrest. Bashir was taken to hospital and died that morning.
During a two-week inquest in Newport, the jury of experts were told that Bashir was showing signs of ABD and that Gwent Police had undergone training in how to spot it.
The officers said they had not seen that Bashir had ABD. The police doctor asked if she thought at the time that she might be dealing with ABD and said: “It didn’t occur to me.”
In their submissions to the inquest, Bashir’s family said that when police decided to restrain Bashir, they did not consider that they could endanger his life.
After Bashir’s death protests were held in Newport led by members of his family and on Black Lives Matter activists.
Gwent Police said evidence emerged at the inquest showed that greater knowledge of ABD would not have saved Bashir’s life as he was already beyond help when they arrived.
Deputy Chief Constable Rachel Williams said the restraint was proportionate, adding: “We will continue to develop our knowledge, understanding and training of ABD in line with national policing guidelines.”
Liam Williams, executive director of quality and nursing at the Welsh Ambulance Service, said: “We will be contacting the family again in the near future to ensure we have been able to address any outstanding concerns or questions.”
Bashir was of Sudanese descent and arrived in Britain at the age of nine. His family said he was easy-going and popular, but had mental health problems as an adult.