2 February 2024 

Before HM Coroner Caroline Saunders
Gwent Coroner’s Court, Civic Centre, Newport NP20 4UR
Scheduled 15 January – 2 February 2024 

Mouayed Bashir, a 29-year-old Black man, died following restraint by Gwent police in February 2021 in Newport, Wales. An inquest has today concluded finding his death was caused by cocaine intoxication, contributed to by Acute Behavioural Disturbance (ABD) following a period of restraint. 

Mouayed had Sudanese heritage and grew up in Newport. His family describe him as an extremely kind and generous person, who was dedicated to his faith and his family, particularly as a registered carer for his mother.  

His favourite thing to do was to host barbecues in the summer. He was popular and cheeky, often hosting gatherings for his friends. He loved music, from traditional Sudanese music to hip-hop.  

On the morning of 17 February 2021, Mouayed was experiencing a mental health episode after having taken cocaine. Concerned for his welfare, his parents called the GP. Upon their advice, they called emergency services asking for help. The police, not an ambulance, were sent. 

The first police officer arrived at 9am, with more arriving over the next hour. They informed the control room an ambulance was required. Mouayed had barricaded himself into his bedroom and was very distressed. Police forced entry and restrained him. The inquest saw body-worn camera footage of the incident. Officers can be heard saying Mouayed was “going crazy” and “beserk”. 

When officers entered the small room, Mouayed was lying on the ground in his underwear, kicking out in distress. The officers immediately discussed restraining him. They acknowledged that he appeared to be experiencing a “mental episode. 

Police handcuffed Mouayed behind his back, his ankles and knees were strapped, and officers physically restrained him. The footage shows Mouayed continued to be distressed, twitching, moaning and crying out.  

Before entering the property, police had been made aware of warning markers on Mouayed’s records, and as a result believed that he may have drugs or weapons. During their evidence to the inquest an officer described Mouayed’s behaviour as “very aggressive”. His family’s perception was that he was distressed and in need of help. 

Forty-five minutes after the first officer entered the room and around 35 minutes after restraint commenced, Mouayed became unresponsive. Evidence to the inquest considered the presentation of Acute Behavioural Disturbance (ABD), which is an umbrella term used by police and medical services for a set of symptoms amounting to a medical emergency. 

Police guidance associates ABD with symptoms including bizarre behaviour, removing clothes, agitation, and sweating. ABD is regularly connected to restraint related deaths in custody, particularly where the person is experiencing a mental health crisis. There is controversy around the term ABD (see notes). 

Police and paramedics at the inquest reported that they had been trained in ABD, but did not at the time recognise signs of it despite Mouayed’s presentation. However, two officers were shown on body-worn camera footage discussing the possibility of ABD, and almost all the officers recorded ABD on the use of force forms they completed post-incident.  

At 9.31 officers conveyed concerns around Mouayed’s low oxygen levels and presentation to the ambulance service, who upgraded the urgency of the call. At 9.50 the police informed the ambulance service that Mouayed was unconscious. 

Paramedics arrived at the property at 10.04, over an hour after police first attended. 

The leg straps remained in place as Mouayed was assessed and plastic handcuffs were used. Mouayed was removed from the house to go to hospital, but there was difficulty in moving him.  

At 10.37, shortly after being transferred to the ambulance, Mouayed went into cardiac arrest. He was taken to hospital but could not be resuscitated  

The coroner directed that the jury should not comment on issues that did not directly cause Mouayed’s death in their narrative conclusions, including the issue of whether or not he should have been restrained. 

The inquest into Mouayed’s death has today concluded with a short factual narrative finding that he “took an unknown quantity of cocaine this resulted in him developing symptoms in keeping with ABD”.  

The jury concluded that police officers restrained Mouayed for his safety and the safety of others. The jury believed there was insufficient knowledge around identifying some of the signs of ABD. They said throughout the restraint Mouayed’s condition was deteriorating.  

Mohannad Bashir, Mouayed’s brother speaking on behalf of the family, said: “First, the family thanks the jury for its diligence and for recording some key failings in its conclusions.

We have received so much love and support from the community throughout our campaigning 

It has been three years since Mouayed died. We, the family, seek three things:  closure, justice and accountability.  

We knew justice wasn’t going to be served through an inquest. We were seeking accountability in these proceedings. What we take from this is the fact that failings around identification of ABD have been recognised.  

We want ABD to be recognised and taken seriously in South Wales and Wales as a whole. We think the evidence has shown, and those agencies have accepted, they need to do better. 

We want better communications between agencies, such as the police and the ambulance. There is no excuse for both agencies not to recognise ABD and use one language to speak to one another; communication between the two agencies needs to be worked on. They need to understand each other when they communicate emergencies concerning ABD.    

The family believe police training needs to be modernised, overhauled and updated. 

We entered this process thinking changes would be identified and put in place  

We are disappointed by the evidence of police that suggests they do not urgently see the need to overhaul their approach to people with ABD in Wales. 

Finally, we want the Welsh government to consider making a policy to go back and review multi-agency approaches so that they work together using much better processes to avoid further death.” 

Lucy McKay, from the charity INQUEST, said: Mouayed’s family called for help for a mental health crisis. Police were sent. Before even entering the property, officers were thinking more about criminality than care.  

Despite being aware of his mental ill health, police responded by restraining Mouayed without even attempting de-escalation or support. They saw his behaviour as ‘aggressive’ not distressed. 

This follows a national pattern of disproportionate use of force against Black men in mental health crisis by the police. Despite longstanding awareness of this issue, it is clear that the police’s culture and current approach is still not fit for purpose. 

Care and de-escalation must be prioritised in place of dangerous restraint by all professionals charged with responding to situations like this. This is yet another reminder of why police cannot and should not be first responders to people in mental health crisis. 

ENDS

NOTES TO EDITORS 

For further information, a photo, and interview requests please contact [email protected] or 020 7263 1111  

Follow the family campaign pages Justice4Mouayed on Twitter and Instagram  

The family is represented by INQUEST Lawyers Group members Meghan Curran of One Pump Court Chambers, Kate Maynard and Daniel Machover of Hickman and Rose solicitors and Fiona Murphy KC of Doughty Street Chambers. They are supported by INQUEST Caseworker Luana D’Arco. 

Other Interested persons represented are Gwent Police, Independent Office for Police Conduct (IOPC), Ambulance Service NHS Trust (WAST) and Mouayed’s GP Practice. 

Acute Behavioural Disturbance (ABD), the Royal College of Psychiatrists report, is a term often used to describe a situation in which a person is extremely agitated and distressed, and in such a state of agitation that they may be at risk of a potentially fatal physical health emergency. Physical restraint is thought to significantly increase the likelihood of poor outcomes in this group of people 

There has been a move in the UK towards ‘ABD’ as a broader umbrella term for a patient presentation of severe agitation, distress and signs of physiological deterioration of unknown cause.