11 February 2022

Before HM Coroner Graeme Irvine and a jury
Walthamstow Coroner’s Court
17 January – 11 February 2022

Jason Lennon was experiencing a mental health crisis when he was subject to restraint by security guards inside London’s ExCeL centre on 31 July 2019.

The inquest into his death today concluded with the jury making serious and wide ranging criticisms of East London mental health services engaged in Jason’s care prior to the incident, and of the ‘excessive’ and ‘unreasonable’ restraint used by licensed security guards.

The jury found that, “Jason Lennon died of a cardio respiratory arrest which he suffered at the Excel Centre in London on 31 July 2019 due to restraint in the prone position following an acute psychotic episode.” This is the fourth inquest in the past year in which restraint by security staff has been criticised and found to contribute to a death.

Background

Jason was a 37 year old Black man, born and raised in Jamaica, who came to the UK to work in the early 2000s. He is described as a kind and loving individual who is deeply missed by his daughter, mother, brother and church community in London. Jason was living in supported accommodation at the time of his death, and under the care of East London NHS Foundation Trust mental health services.

The jury heard that in September 2002 Jason suffered a brain injury. He was later diagnosed and began receiving treatment for a schizophrenic illness.  In the 5 years before his death he had required inpatient care five times, and his relapses followed a predictable pattern each time. He had previously responded quickly and well to medication and inpatient treatment. 

Towards the end of July 2019, Jason’s support workers identified the signs of a further relapse. They brought Jason to his community mental health team, Newham Community Recovery Team (CRT). The inquest heard evidence that in the days before Jason’s death, there were issues with preparation, assessments and planning by this team, and that they did not appreciate the urgency of his situation.

On the morning of 31 July 2019, Jason was seen behaving strangely and recklessly in and around London’s ExCeL centre, potentially putting himself and others at risk. He was in fact experiencing an acute psychotic episode. Just after 7.30am, Secure-Ops Security guards inside the venue brought Jason to the ground and restrained him with considerable force and in the prone position for about 5 minutes.

Security guards are licensed by the Security Industry Authority (SIA) and are trained that ground restraint, particularly in the face down position, is dangerous and should be avoided.

The Metropolitan police arrived on the scene at around 7.35am and found Jason unresponsive. They commenced CPR at around 7.39am. An ambulance arrived on the scene and Jason was taken to Newham General Hospital where he was pronounced dead at 9.31am.

The jury ultimately concluded that the security guards had used excessive force in effecting the restraint and had failed to respond to the fact that Jason was becoming unresponsive. They found that too many people had been involved in the restraint and that no one had led or managed this, or checked Jason’s vital signs. 

Conclusions

The jury found that Jason died from cardio respiratory arrest due to restraint in the prone position following an acute psychotic episode. In a narrative conclusion, they made serious criticisms of both the mental health services and security guards.

The jury concluded that a number of errors by Newham CRT caused or contributed to Jason’s death. They said the management of Jason’s care, the assessment of risk he posed to himself and others, and plan formulated for Jason’s care were all inadequate. The jury also identified missed opportunities to put Jason on a Care Programme Approach, and for Jason to benefit from the care of the home treatment team.

They found the communication with Jason’s supportive living provider was ineffective, and his care was not discussed at multi-disciplinary meetings as it should have been. The jury further noted that outpatient reviews were too far apart. In fact, the inquest heard that when he was brought to the CRT on 29 July 2019, Jason had no upcoming appointments scheduled at all.

Regarding the restraint, the jury found that the force used in restraining Jason was unreasonable and this more than minimally contributed to his death. They commented, “Although the degree of force used to bring Jason to the ground was appropriate in the circumstance, the manner in which Jason was restrained on the ground was unreasonable. The degree of force used to maintain the restraint on the ground [was] excessive, as Jason was restrained in the prone position.”

The jury found that the use of the prone position during this time rendered the restraint unsuitable. They found that the risk assessment was inadequate. It had been the evidence of the security guards that Jason was breathing and communicating when the police took over, but this version of events was rejected by the jury, who concluded that he had suffered a cardiac arrest during the restraint.

The jury also found that, having restrained Jason in this unsuitable position, the security guards' failed to manage the impact on him, which also caused or contributed to Jason’s death. They said, “The manner in which Jason was restrained… was not endorsed by SIA training as there was an imminent risk of positional asphyxia [when breathing is inhibited]”. They did not accept that Jason’s vital signs had been monitored by security staff. 

They commented, “There was no clear leadership or management of the restraint by any staff involved in the restraint or from any supervisors or managers and too many people were involved in the restraint on the ground.” Finally, the jury concluded that Secure Ops staff involved knew or should have known that there was a risk of death which was “reasonably foreseeable in the circumstances”.

Jason’s mother, Vevine Lennon, said: “Jason was a loving and thoughtful son. Everyone who knew him described him as smiling, gentle and kind.  The mental health teams should have done better and we are heartbroken to have lost Jason in such a violent and shocking way as a result – we pray this doesn’t happen to anyone else. His daughter Dejeanne and I miss Jason terribly.”

Carolynn Gallwey, solicitor for Vevine Lennon said: “It should have been clear to Jason’s mental health team in the days leading up to his death that he was relapsing and needed urgent care. His family have not received any satisfactory explanation as to why this was not provided, or indeed any reassurance that this wouldn’t happen again. The security guards who then forcibly pinned him face down to the ground while he was ill and distressed were trained to know just how dangerous that was and they did it anyway. This death should simply not have occurred.”

Lucy Mckay, spokesperson for the charity INQUEST, said: “Security guards clearly have a role in initially responding to incidents like this. They must be adequately equipped and able to do so safely and effectively, without putting lives at risk.

There have been four recent inquests on preventable restraint related deaths involving security staff. Yet there is not yet any accountability, despite the duty of care these staff and the companies employing them have.

Urgent action from the Security Industry Authority is required to ensure other licensed staff are reminded of the risks of prone restraint and their responsibilities. While police and authorities must ensure action is taken to hold those responsible for deaths to account.

Ultimately though, Jason’s ill health should never have been allowed to escalate to this crisis point, putting him and the public at risk. East London NHS Foundation Trust must respond to the concerns raised by this inquest, and ensure action is taken to prevent future harms and deaths.”

ENDS

NOTES TO EDITORS
For further information, interview requests and to note your interest, please contact Lucy McKay on 020 7263 1111 or [email protected]

The family are represented by INQUEST Lawyers Group members Carolynn Gallwey of Bhatt Murphy solicitors and Fiona Murphy of Doughty Street Chambers. They are supported by INQUEST caseworker Caroline Finney.

Other Interested persons represented include the Metropolitan Police Service, East London NHS Foundation Trust, Secure Ops Security, the Security Industry Authority, the ExCel Centre, Look Ahead (accommodation) and the Independent Office for Police Conduct.

Other cases involving security guards:

• In December 2021 the inquest into the death of Gavin Brown, who died in 2019 eight days after he was restrained by members of the public and a door supervisor for over six minutes outside a pub, concluded his death was an unlawful killing.
• 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 May 2021 the inquest into the death of Paul Reynolds concluded that the actions of security officers, including neck and prone restraint, were “dangerous, deliberate and unlawful acts” which contributed to Paul’s death.
• 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.
• In 2013, at the inquest into the death of Jimmy Mubenga following restraint by G4S security guards during a deportation flight, the jury concluded unlawful killing. The security guards were subsequently charged with manslaughter but found not guilty, despite critical evidence.