Mouayed Bashir

PFD Report All Responded Ref: 2024-0079
Date of Report 12 February 2024
Coroner Caroline Saunders
Coroner Area Gwent
Response Deadline est. 8 April 2024
All 1 response received · Deadline: 8 Apr 2024
Coroner's Concerns (AI summary)
Ambiguity in police officers' recognition and communication of Acute Behavioural Disturbance (ABD) during restraint potentially undermined critical 'Speak Up and Speak Out' principles in emergency situations.
View full coroner's concerns
At the inquest all the police officers who attended MB gave evidence and they all stated under oath that they did not consider that MB was suffering from ABD at the time. However, when completing the Use of Force forms afterwards, all bar one of the officers involved in restraint indicated that ABD had been an impact factor. There is an ambiguity which could not be properly explored at the inquest, largely due to the passage of time. However, this suggests that officers may have thought about ABD but did not mention it to others, which would be contrary to the “Speak Up and Speak Out” principle. This is a principle, the inquest heard, that is critical to ensuing that the voices of junior officers are heard in these difficult and potentially life-threatening situations.
Responses
Heddlu Gwent Police Police / Law Enforcement
8 Apr 2024
Action Taken
Gwent Police confirms national training on Acute Behavioural Disturbance (ABD) has been reviewed and a new learning package introduced from 14 February 2024, incorporated into mandatory Public and Personal Safety Training and First Aid Training. From 3 April 2024, frontline officers will receive bespoke standalone specific ABD training, emphasizing the "Speak Up and Speak Out" principle. (AI summary)
View full response
Dear Ms Saunders

Re: Response to the Regulation 28 Report to Prevent Future Deaths Inquest touching upon the Death of Mr Mouayed Bashir

I am the Deputy Chief Constable of Gwent Police and I write of behalf of the Chief Constable to respond to the Report to Prevent Future Deaths issued under Regulation 28 of the Coroner’s (Investigations) Regulations 2013, following the tragic death of Mr Mouayed Bashir on 17 February 2021.

May I also to take this opportunity to reaffirm the comments I made at the conclusion of the Inquest on behalf of Gwent Police to extend my sympathies to the Mr Bashir family for the loss of their loved one.

Turning to our response, for ease of reference, I have repeated below the information you have requested be provided to you: -

“Confirmation as to whether the training on ABD has been reviewed and the principle of “Speak Up and Speak Out” enshrined therein, reflecting the acknowledged difficulties in identifying ABD even by experienced officers.”

I confirm that the national training for all police officers on Acute Behavioural Disturbance (ABD) has been reviewed. The College of Policing has introduced a new learning package, specifically on ABD. The training package consists of an ABD PowerPoint which has been uploaded onto the “College Learn” system and made available to police officers and relevant police staff officers from on 14 February 2024.

I have attached the training package consisting of Power Point Presentation and accompanying Training Notes, which you will see is extensive. I confirm that training package this has been incorporated into the mandatory Public and Personal Safety Training programme and First Aid Training. This in effect means that from 14 February 2024 all officers and relevant police staff will have access to important updated training. In addition, as from 3 April 2024 onwards, in Gwent Police all frontline police officers who have only recently completed their mandatory Public and Personal Safety Training and First Aid Training will receive bespoke standalone specific ABD training using the College of Policing Power Point. The training as a whole fully reflects the acknowledged difficulties in identifying ABD even by experienced officers. The combination of slide 11 and the accompanying training notes evidence that the principle of “Speak Up and Speak Out” is enshrined in ABD training. In this regard, may I draw your attention to Slide 11 in the Power Point. In this slide, under the heading “Restraint Considerations” there are the following bullet points: - ƒ Where practicable avoid restraint. ƒ Where practicable use a Safety Officer/s to monitor the subject. ƒ Avoid any position that restricts breathing. ƒ As soon as possible, sit person up or allow person to find most comfortable position. ƒ All “speak up and speak out” if concerned. The last point is emboldened and in red so that it is clearly emphasized to all officers. In addition, the accompanying training notes state: - “Any person involved in the restraint irrespective of rank, role, or length of service should speak up and speak out if they identify any issue or concern in regard to the wellbeing of the person. Other officers may be too focused on what they are doing and might inadvertently miss key signs.” I hope that this response addresses the concerns that you set out in your report, and I am grateful to for you bringing them to our attention.
Sent To
  • Gwent Police
Response Status
Linked responses 1 of 1
56-Day Deadline 8 Apr 2024
All responses received
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Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

Report Sections
Investigation and Inquest
On 25/02/2021, an investigation was opened touching upon the death of Mouayed Mamoun Bashir. The investigation concluded at the end of the inquest on 02/02/2024. The conclusion of the inquest was recorded as a narrative conclusion in the following terms: On the 17th February 2021, Mouayed Mamoun Bashir took an unknown quantity of cocaine. This resulted in him developing symptoms in keeping with Acute Behavioural Disturbance (ABD). Mouayed barricaded himself in his bedroom and was heard banging, shouting and breaking objects. At 08:50, Mouayed’s family were concerned for his welfare and proceeded to contact emergency services. At 09:01 the first police officer arrived and informed the control room that the ambulance was required. Gaining entry Mouayed was agitated, police officers restrained him for his own safety and for the safety of others. We believe from the evidence we heard that there was insufficient knowledge and understanding around identifying some of the signs of Acute Behavioural Disturbance. Throughout, Mouayed’s condition was deteriorating, police officers and family continued to update the ambulance service. An ambulance arrived at 10:04. The priority was to transfer Mouayed to hospital, but it was difficult to manoeuvre him out of the house. Shortly after he was transferred into the ambulance at 10:37, Mouayed went into cardiac arrest.

Police and paramedics commenced cardiopulmonary resuscitation (CPR) and conveyed Mouayed to the Grange University Hospital, Llanfrechfa, where the clinicians continued to attempt to revive Mouayed. Sadly, they were unsuccessful and Mouayed died at 11:41 on 17/02/2021. In conclusion, Mouayed’s death was caused by cocaine intoxication, this was contributed to by the effects of ABD following a period of restraint.

The medical cause of death was: 1a) Intoxication with cocaine and the effects of cocaine, following a period of restraint.
Circumstances of the Death
The circumstances of Mouayed’s death are best described in the narrative conclusion. As you can see the jury have referenced the police’s knowledge of ABD in their conclusion.
Action Should Be Taken
I should be grateful if the following information be provided to me:

Confirmation as to whether the training on ABD has been reviewed and the principle of “Speak Up and Speak Out” enshrined therein, reflecting the acknowledged difficulties in identifying ABD even by experienced officers.
Copies Sent To
Welsh Ambulance Trust IOPC
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.