5 November 2021

Before Area Coroner Zak Golombeck
Manchester City Coroner’s Court

18 October to 2 November 2021

Michael Thorley was 41 years old when he died on 22 December 2017, following a period of restraint by a security guard at Wythenshawe Hospital in Manchester, where he was a patient. The inquest into his death, concluded on Tuesday (2 November) with the jury finding that he was unlawfully killed.

The jury also concluded that it was not necessary for the security guard to restrain Michael when he did; and there was a failure by nursing staff to monitor Michael’s condition during the restraint. Both these factors were found by the jury to have probably caused or contributed to Michael’s death.

Further, the following issues were found to have possibly contributed to his death:

• The force used during restraint was unreasonable, disproportionate and/or excessive.
• The Trust did not make appropriate security arrangements in respect of Michael.
• There were errors in Michael’s clinical management.

Unlawful killing conclusions in cases involving security guards are rare, but increasingly likely after the standard of proof required for inquest conclusions was lowered in November 2020 (see notes).

Michael had a loving family who describe him as a gentle, caring person. He was an avid Manchester United fan. He worked in many jobs, including in warehouses and working with cars. He was a people person who loved the social banter and camaraderie in such roles. He spent time caring for his mother during her first diagnosis of breast cancer. She fought hard for justice for her son, but sadly died in August 2020.

Michael was admitted to Wythenshawe Hospital, run by Manchester University NHS Foundation Trust, after attending A&E on 19 December 2017. He was complaining of shortness of breath. Initial investigations indicated he may be suffering from an infection, and he was transferred to a bed in the Acute Medical Unit.

Michael was also treated for a significantly increased heart rate and started on an alcohol withdrawal regime. This involved the prescription of a sedative used in withdrawal treatment (chlordiazepoxide) and monitoring of withdrawal symptoms. It was accepted by medical staff during the course of the inquest that formal monitoring in this respect did not take place as it should have done. 

Initially it appeared Michael was improving. However, during the afternoon of 21 December 2017, he started to exhibit behaviour consistent with delirium. Just after 11pm Michael called 999 and reported to police that he did not feel safe in hospital. A nurse told the call handler that Michael was in fact safe. Michael told nursing staff he did not know why he was there or what was happening. He wanted to go home.

Around 1.23am Michael pulled the emergency cord whilst using the toilet. Staff attended and found he was having a seizure. Following the seizure Michael became very agitated and a decision was taken to call security. Two security guards initially attended. In evidence at the inquest they described Michael as appearing confused.  They were later replaced by one security guard who was deployed to carry out bed watch.

At the time of Michael’s death, the role of bed watch was not defined. Guards required a license of the type a bouncer at a nightclub would need, a Level 2 Door Supervisor Security Industry Authority (SIA) License. The Trust specified no further training for guards to fulfil the role in a hospital setting. They also had no policy on dealing with the use of physical intervention, i.e. restraint.

While the security guard undertook bed watch, Michael started to stand at the window and shout ‘help’ to a passer-by whilst banging on the glass. A nurse reported that the security guard was ‘trying to restrain’ Michael to move him away from the window. The nurse told him to leave Michael alone, fearing that physical intervention would make things worse.

Following an apparent altercation with Michael and the nurse, Michael continued to stare out of the window and bang on the glass. This prompted the security guard to use force to try and get Michael to sit or lie down. An altercation ensued and Michael was forced onto and restrained on the floor. The security guard noticed that Michael became exhausted but continued to restrain him.

A member of nursing staff intervened after noticing that Michael was no longer moving, and found that Michael was not breathing. He had suffered a cardio-respiratory arrest.  Michael was pronounced dead after lengthy resuscitation attempts.

In breach of the Trust’s own suspicious death investigation protocols, there was a period of approximately five hours before the hospital referred the incident to the police. The family were not informed of the death until the following morning.

In a joint statement, Michael’s family said: “The 22^nd of December 2017 is a day etched in our memories forever. It has been a long four years fighting for justice and for Michael’s voice to be heard, driven by our Dad. The only comfort we have is that Michael is now with our late mum.

We hope more than anything that things will change with restraint being undertaken by security guards on vulnerable patients in care settings. Comprehensive training should and must be undertaken. The family would like to thank our legal team for all their help in getting the right conclusion of unlawful killing. Michael is missed always and will never be forgotten. He was taken from us too soon.”

Clair Hilder of Broudie Jackson Canter solicitors, who represent the family, said: “Michael was in hospital because he was acutely unwell; his challenging behaviour was as a result of delirium possibly contributed to by failings in his clinical care. Of course it is appropriate that hospitals require security staff, however its important they are properly trained.

The role of bed watch is not comparable to a bouncer on the door at a nightclub, yet this was the only qualification the Trust specified someone needed to undertake the role at the time of Michael’s death.

Ultimately, physical intervention should be a last resort and bed watch guards should have a clear understanding of the increased risk it poses to patients in hospital who as a result of their medical conditions are vulnerable. Where such restraint takes place it is important medical staff understand the role they should take to ensure their patient is kept safe.”

Deborah Coles, Director of INQUEST, said: “This unlawful killing conclusion is a condemnation of Manchester University NHS Foundation Trust for their unsafe policy for security guards. Michael suffered unnecessary restraint at the hands of a security guard, as medical staff failed to monitor and keep him safe.

The dangers of restraint are well known, particularly on people experiencing delirium, and the circumstances of Michael’s death are sadly all too familiar. We hope this damning inquest sends a strong message to hospital Trusts nationally, to ensure the same killing of a patient in crisis never happens again.”

ENDS

NOTES TO EDITORS

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

The family are represented by INQUEST Lawyers Group members Clair Hilder and Charlotte Halsted of Broudie Jackson Canter solicitors and Frederick Powell of Doughty Street Chambers. They have been supported by INQUEST Caseworkers Natasha Thompson and Nancy Kelehar.

Other interested persons represented at the inquest were Manchester University NHS Foundation Trust, Kingdom Security (who employed the security officer), the Security Guard, Greater Manchester Police, and the Security Industry Authority (SIA).

UNLAWFUL KILLING CONCLUSIONS AT INQUESTS

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 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.

• Historically, there have been three further unlawful killing verdicts in inquests involving agents of the state such as security guards or prison officers (excluding police). In 2013 at the inquest into the death of Jimmy Mubenga following restraint by G4S security guards during a deportation flight. In 1998 at the inquest into the death in prison of Alton Manning. And in 1993 at the inquest into the death of Omasase Lumumba.
  
  
• Since INQUEST began monitoring this in 1990, there have been ten unlawful killing conclusions or verdicts at inquests or inquiries into the deaths of people following police custody or contact. Three of these conclusions were later quashed or overturned.