30 March 2017

Before HM Senior Coroner for Manchester City, Mr Nigel Meadows
Manchester Civil Justice Centre
27 February – 29 March 2017

The inquest into the death of John Ahmed concluded yesterday with the jury finding that prison officers used unlawful force against him, leading to his death. It is extremely rare for restraint deaths to occur in prison, and the conclusion from the jury is significant in highlighting deeply concerning failings.

John, a 42-year-old father of four, died following restraint by prison officers, whilst a remand prisoner at HMP Manchester on 29 July 2015. On the morning he died, John had been exercising in the prison yard with a fellow prisoner, who was seen to pick up an item and hand it to John.  John was led into a wing corridor to be searched by two prison officers.
What followed was disputed at the inquest, however it was determined that a struggle soon ensued between John and the prison officers. John was then subject to multiple uses of force in three separate locations over a matter of approximately twenty minutes. The officers repeatedly described John’s behaviour as violent and/or aggressive, however the jury rejected this narrative and criticised the officers for their failure to employ appropriate de-escalation techniques or take account of John’s risk factors - most notably his weight.

The jury found that at almost every stage the officers had acted disproportionately and unlawfully, referring particularly to their actions in moving John between locations in a bent-over position with his hands behind his back, and keeping him handcuffed in prone, face-down restraints on the ground, in contravention of Prison Service guidance and policy.
Ultimately during the third period of restraint John began foaming at the mouth and making gurgling noises before becoming unresponsive. However, the officers kept John in wrist locks whilst checking on his welfare. The jury concluded that this was unlawful. An ambulance was called and CPR was carried out, however John was pronounced dead on arrival at a nearby hospital.

In addition to their findings on the use of force by prison officers, the jury also concluded that the supervising member of healthcare staff failed to carry out any appropriate checks on John’s physical wellbeing during the various periods of restraint. They also identified omissions on the part of the prison drug and alcohol clinicians in failing to refer John to the prison mental health team.

Following the inquest, the Coroner indicated he would make a Prevention of Future Deaths Report to draw attention to the lack of guidance in place for healthcare staff regarding their role in restraint - a situation which he deemed “untenable”. He will also be following up his concerns about the lack of CCTV coverage of the areas where the restraints took place. The Coroner also directed that the transcripts of the evidence of two officers will be referred to the police over concerns about significant inconsistencies in their evidence under oath.

John and Margaret, John’s mother and father said:  
“We are very pleased with the findings of the jury and the performance of our legal team. We are happy that the truth was established through the inquest - particularly the jury’s finding that at no stage did John offer any violence or aggression, and that his death was not attributable to drug use. We hope that the prison authorities will address the concerns raised by Mr Meadows, and that future deaths can be prevented.”

Charles Myers of Minton Morrill Solicitors said:
“This is a tragic case whereby prison staff have acted in a heavy-handed, disproportionate and unlawful manner, failing to take into account clear and obvious risk factors in their decision-making around the use of force. It is also incredibly unfortunate that some officers appear to have tailored their evidence at the inquest to fit a particular narrative about John, which the jury have unanimously rejected.

It is concerning to say the least that there is such a lack of clarity on the nature of the role of healthcare in supervising the use of force by prison officers - the fact that this has apparently been under review for over ten years suggests that the issue has been ignored for quite some time. It is hoped that the coroner raising this issue through official channels will lead to proper consideration by NHS England of appropriate policy and training for all prison healthcare staff.”

Deborah Coles, Director at INQUEST said:
“John died as a result of the unlawful use of force by prison officers. That he died at the hands of those who should have been protecting him is deplorable. This inquest has heard disturbing evidence about the failure of prison staff to adhere to their own guidance that restraint should be the last resort and that prone restraint carries inherent risks.

Restraint related deaths are extremely rare in prison and this inquest points to the need for an urgent review by NOMS and NHS England into use of force, to ensure that health care and prison staff are fully aware of their roles and the need for safety of prisoners to be paramount during any restraint. Given the ongoing concern about drugs in prison and the potential for restraint to be used, it is essential that these issues are addressed urgently.”

INQUEST has been working with the family of John Ahmed since his death in 2015. His family are represented by INQUEST Lawyers Group members Gemma Vine and Charles Myers from Minton Morrill solicitors and barrister Ifeanyi Odogwu of Garden Court Chambers.



For further information, please contact: Lucy McKay on [email protected] or 020 7263 1111

INQUEST provides specialist advice on deaths in custody or detention or involving state failures in England and Wales. This includes a death in prison, in police custody or following police contact, in immigration detention or psychiatric care. INQUEST's policy and parliamentary work is informed by its casework and we work to ensure that the collective experiences of bereaved people underpin that work. Its overall aim is to secure an investigative process that treats bereaved families with dignity and respect; ensures accountability and disseminates the lessons learned from the investigation process in order to prevent further deaths.

Please refer to INQUEST the organisation in all capital letters in order to distinguish it from the legal hearing.