7 December 2021

Before HM Assistant Coroner Andrew Bridgeman
Manchester South Coroner’s Court

22 November – 6 December 2021

Gavin Brown died on 20 April 2019, eight days after he was restrained by members of the public and a door supervisor for over six minutes outside a pub. A jury inquest has concluded that he was unlawfully killed.

This is the second unlawful killing conclusion relating to restraint involving security staff in just over a month.

Gavin was a 29-year-old Black Caribbean man from Manchester. His family describe him as a “cheeky chappie” who enjoyed making people laugh. He was a sensitive person who was loyal and cared deeply for others. Gavin experienced a difficult childhood, spending time in foster care, but remained close to his family. He has two young daughters.

Gavin had experienced mental ill-health since 2010. He had a diagnosis of paranoid schizophrenia, which was being managed with medication. At the time of his death, Gavin was under a Community Treatment Order and was in the care of Greater Manchester Mental Health NHS Foundation Trust.

Gavin suffered a cardio-respiratory arrest after he was restrained by four people, including a licensed door supervisor, following an altercation at The Melville Hotel pub in Stretford, Manchester on 12 April 2019.

One member of the public exited the pub after the altercation had begun, at which point there were between five or six people already involved in restraining Gavin, holding down his body. No one requested assistance but this individual intervened and applied what was identified by eye-witnesses as a “rear naked chokehold” (a type of neck restraint which is commonly demonstrated in Mixed Martial Arts). 

The jury concluded that Gavin was held in the chokehold, which restricted his ability to breathe, for at least six minutes. Despite those restraining Gavin noticing a reduction in his resistance and movement and deeming that “the situation was under control”, the force of the neck restraint was not meaningfully reduced.

The jury also found that there were no attempts by those restraining Gavin to speak to him or check on his welfare. One of those involved in the restraint was a licensed door supervisor, who had received training on the risks of neck restraint and the need to monitor and respond to the condition of the person who is being restrained. Sadly this training was not followed.

Several witnesses also gave evidence that, as Gavin was being restrained on the ground, somebody stamped on his legs repeatedly, and one witness recalled that he was forcefully kicked in the stomach. Bruising was found in both places by the pathologist, in addition to bruising of the neck.  

Greater Manchester police officers arrived on the scene approximately seven minutes after the restraint began. They arrested Gavin, placing him in handcuffs whilst he was unresponsive, and rolled him onto his stomach. After a period of delay, officers realised that Gavin was unresponsive, at which point they had to remove the handcuffs before commencing CPR. Gavin was taken to Salford Royal Infirmary but ultimately died from his injuries.

After two weeks of evidence, the inquest concluded on 6 December 2021, finding Gavin’s death was caused by hypoxic/ischaemic brain damage due to out of hospital cardiac arrest in the context of physical restraint. The jury found that Gavin had been held in a restraint for a minimum of six minutes and 19 seconds by a male customer, and during this time no welfare checks were made. Their conclusion was that Gavin had been unlawfully killed.

Four individuals were arrested in relation to Gavin’s death, but following a review, the Crown Prosecution Service decided that there was insufficient evidence to bring charges against them for murder or unlawful act manslaughter, and no lesser charges were brought.  

In a joint statement, Gavin’s family said: Since Gavin’s death over two and a half years ago we have sought the truth about what happened on the night of 12th April 2019 outside the Melville Hotel in Stretford. We are relieved and grateful that a Jury has vindicated our longstanding belief that Gavin was unlawfully killed.

The inquest revealed major shortcomings in the police investigation into Gavin’s death, and has shed light on many of the questions we had about Gavin’s death, though it is clear to us that much of this evidence was available to the police all along. The Crown Prosecution Service (CPS)’s decision last year not to prosecute any of the individuals implicated in Gavin’s death was heart-breaking. We felt let down by the criminal justice system.

We are grateful for the Coroner’s indication that he will ask Greater Manchester Police to review the case, and we hope the CPS will now bring charges based on the evidence which has emerged during the Inquest.

We will hold Gavin’s memory in our hearts forever and will not give up on our fight for justice for him." 

Selen Cavcav, senior caseworker at INQUEST, said: “The use of physical restraint by anyone must be proportionate to the risk. Where trained professionals are involved, that should be even more clear given their duty of care. In Gavin’s case it appears that many of those involved lost sight of Gavin’s humanity, including the security guard. Yet even when police arrived, they too failed to see Gavin as a person in need of help and arrested an unconscious man.

This damning inquest conclusion is an important recognition of the family’s concerns, and must send a message to all security guards and police about their responsibility to protect not harm people.”

Lucie Boase of Broudie Jackson Canter solicitors, who represent the family, said: The inquest heard that Gavin died after being held in an MMA-style ‘chokehold’ for over six minutes by a member of the public acting out of drunken bravado, while a trained and SIA licensed door supervisor looked on and made no attempt to intervene or check on Gavin’s welfare. Gavin’s efforts to breathe were misinterpreted as signs of a struggle. Those restraining Gavin did not relinquish the pressure on his neck, even when he lay motionless on the ground.  Tragically, the neck compression caused Gavin to enter a cardiac arrest and to suffer irreversible brain damage. He died eight days later in hospital.

Despite the seriousness of the incident, no charges were brought against any of the individuals implicated in Gavin’s death.  Given the evidence, which was available to the police, it is very hard to understand why this was the case. It is a shame that Gavin’s family had to wait until now to obtain answers about what happened; the fact that the jury felt able to reach a conclusion of unlawful killing is testament to the thorough investigation carried out by HM Coroner, Mr Bridgman. The family will now look to Greater Manchester Police to reconsider the case and refer it to the CPS.


For more information, photographs, and to note your interest contact Lucy McKay on [email protected] or 020 7263 1111

The family is represented by INQUEST Lawyers Group members Lucie Boase of Broudie Jackson Canter Solicitors and Frederick Powell of Doughty Street Chambers.  

The other interested persons are Greater Manchester Police, Greater Manchester Mental Health NHS Foundation Trust, the Security Industry Authority (SIA), two door supervisors and three members of the public who were involved in the restraint.


Inquests are not criminal proceedings, they are intended to examine and establish the cause of death. However, previously the standard of proof for some conclusions (formerly known as verdicts) at inquests was the criminal standard – ‘beyond reasonable doubt’.

In November 2020 a decision by the Supreme Court in the case of R (Maughan) v. HM Senior Coroner for Oxfordshire established that the standard of proof for all conclusions at inquests, including unlawful killing, should be lowered to the civil standard.

Other relevant conclusions:

  • In November 2021 the inquest into the death of Michael Thorley, who died following a period of restraint by a hospital security guard while he was a patient in 2017, found he was unlawfully killed.

  • In October 2021 the inquest into the death of Lewis Skelton, who was fatally shot by Humberside police in November 2016, found he was unlawfully killed.
  • In February 2021 the inquest into the death of Jack Barnes, who died following restraint by public transport staff acting partially in a security role, concluded his death was an unlawful killing.