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Inquest touching on the death of CR

28/04/2023

Daniel Walker, instructed by Caroline Hayward, represented the Security Industry Authority (‘SIA’) in a seven-day Coroner’s Inquest before HMAC Christopher Long at the Lancashire and Darwen Coroner’s Court, sitting at Preston County Hall.


On 4th April 2021 a member of the public contacted the police concerned about the behaviour of CR. CR was behaving strangely, appeared to be hallucinating and was asking for help. The police arrived, spoke to CR and decided to take him to the Royal Blackburn Hospital where he had requested to go. On arrival at the Royal Blackburn Hospital, CR attended at Accident & Emergency. CR had a complex mental health history, inclusive of diagnoses for paranoid schizophrenia and personality disorder. Whilst awaiting results from tests that had been carried out CR became erratic and was described as ‘attacking’ a nurse on the ward. As a result of this, a security guard was called to attend the incident.


HMAC Long found that CR was ‘restrained after lunging at a security guard who was endeavouring to de-escalate the situation’. The restraint began in a standing position before moving to a seated position and then to the recovery position on the ground. The restraint was monitored by numerous health care staff. The restraint was found to be ‘reasonable, necessary and proportionate in order to prevent further harm’.
CR became unresponsive and went into cardiorespiratory arrest. The cardiorespiratory arrest was found to be contributed to by a combination of factors, namely: (a) the period of increased exertion and agitation caused by his own behaviour; (b) the period of increased exertion and agitation in resisting being restrained; and (c) several underlying health issues that made CR more prone to cardiac issues. Despite lifesaving treatment being delivered at the scene and over the following weeks, CR deteriorated and did not recover.


In reaching the narrative conclusion and specifically in relation to restraint, HMAC Long was assisted by expert restraint evidence touching upon SIA approved training standards and outcomes, the method of restraint used in line with those training standards and opinion evidence on the use of force in the circumstances. No adverse findings were made against the SIA.

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