Mouayed Bashir inquest concludes after three weeks

POLICE officers who restrained a Newport man before he died had “insufficient knowledge and understanding” of his condition, a jury inquest has concluded.

Mouayed Bashir died on February 17, 2021, after being restrained by Gwent Police officers in his Maesglas home and suffering a cardiac arrest in an ambulance on route to the Grange University Hospital.

Senior coroner for Gwent Caroline Saunders asked jurors to provide a “narrative conclusion” on the circumstances leading to Mouayed’s death. After hearing evidence from witnesses at Newport Coroners Court, the jury concluded the officers had restrained Mouayed out of concern for his safety and the safety of others.

They also found “insufficient knowledge and understanding” of acute behavioural disturbance, or ABD, which describes a collection of symptoms presenting as extreme agitation. They attributed Mouayed’s death to cocaine toxicity and the effects of ABD following a period of restraint.

The family of Mouayed Bashir pictured during a protest following his death. (Image: Newsquest)

The court heard that Mouayed, who moved to Newport with his family in 2005, had taken cocaine for at least four years before his death. He received voluntary support from the Gwent Drug and Alcohol Service in 2017 and admitted the use of cocaine and heroin to his GP in 2020.

On January 16, 2021, he was the victim of a stabbing in the Pill area of Newport. He suffered a stab wound to his upper thigh and received surgery at the University Hospital of Wales, Cardiff.

Mouayed’s younger brother Mohamed picked him up from hospital after he was discharged and took him to his girlfriend’s house to recover. His family were not able to visit him at hospital due to Covid restrictions.

The court heard that Mouayed was “paranoid” and Mohamed helped him move into their parents’ house. In the following weeks, the family’s GP – Bellevue Group Practice – made various attempts to contact him and address concerns his wound was infected.

Mouayed, who moved to the UK from Pakistan at the age of nine, was also struggling with an ongoing immigration case. His father, Mamoun, suggested his son should move to Sudan as the uncertainty made his mental health issues “evolve”.

On the evening of February 16, Mohamed offered to massage his brother’s injured knee but he was still concerned about the stab wound and pointed out a lump, which he believed to be a sign of infection.

That night, Mouayed reported a high temperature and took multiple showers. The court heard that Mouayed repeatedly told his brother, whom he had woken up – “Sorry, bro” – while his father called for medical help.

Mouayed's brothers, Mohamed and Mohannad, spoke after the inquest (Image: Sam Portillo)

Mamoun terminated a call to the GP when Mouayed’s mother Mahasin Khalil raised the alarm about Mouayed’s behaviour in his room. At 8.50am, Ms Khalil called the emergency services and told them her son needed the hospital. Mamoun took over the call and clarified the need for police.

Around ten minutes later, the first Gwent Police officer arrived at the family’s home and relayed Mamoun’s request at the door for an ambulance.

More officers arrived at the address, against which Gwent Police had a “critical marker”, while Mouayed had “warning markers” for drugs and firearms. Mouayed had barricaded himself in his room, where he could be heard shouting and breaking objects. His parents told officers he was “hurting himself” and worried he might jump from the window.

When they managed to open the door, officers found him lying on the floor wearing only underwear with his head in an open wardrobe and kicking out when they tried to approach. The room was “ankle deep” in clothes and parts of a broken bed were among the debris. Officers decided to restrain him with handcuffs and fast straps around his knees and ankles. They turned him onto his side and set about clearing the space.

Before restraining him, they described Mouayed’s behaviour as “berserk” and asked his parents whether he had taken drugs. Body-worn camera footage shown to the jury showed him writhing in the restraints, screaming and making other incoherent moans.

A rally held in Newport following the death of Mouayed Bashir (Image: Newsquest)

At 9.31am, officers conveyed their concerns to the Welsh Ambulance Service (WAS) about Mouayed’s low oxygen levels – which they took with an officer’s personal oximeter he had purchased after his own illness, high temperature and heavy breathing.

WAS upgraded the call to an “amber one” rating, indicating his symptoms were life-threatening. In the minutes that followed, Mouayed appeared to lose responsiveness and police medic PC Charlotte Davies asked for his handcuffs to be removed.

At 9.50am, Mouayed’s parents called the ambulance service, reporting their son to be unconscious. At this point, WAS upgraded the call to the most urgent categorisation of red, cases where “every second matters” in their response. One officer told Mamoun to terminate the call and said he was being “very argumentative” to the handler. Mamoun hung up and called his son’s name several times, eliciting no coherent response.

An ambulance arrived at 10.04am. After removing gear from the back of the vehicle and donning personal protective equipment, the paramedics reached Mouayed’s side at 10.08am. They found Mouayed had very low levels of consciousness, checked his airways and prioritised getting him to hospital.

Police helped to move Mouayed out of his room and down the narrow staircase with a special transfer chair, using “loosely applied” plastic cuffs to stop him from flailing his arms. Shortly after entering the ambulance, he suffered a cardiac arrest. Under the instruction and watch of the paramedics, who went about other time-sensitive tasks, police officers took it in turns to perform CPR.

Among these tasks was sending a pre-alert to the Grange University Hospital in Llanfrechfa, where they arrived at 10.58am. Mouayed was taken immediately into the resuscitation area, where there were unsuccessful attempts to revive him. His death was confirmed at 11.41am.

Post-mortem toxicology reports found cocaine and benzoylecgonine, the main by-product of cocaine once it has been metabolised, in Mouayed’s body. They also found diazepam, olanzapine, paracetamol, and naloxone, which is administered to reverse the effects of opioids.

Asked about the police's use of restraints, paramedic Zoe Lambert said it gave her an "opportunity to be safe" and conduct her medical assessments while kneeling close to Mouayed on the floor.

Gwent Police received annual training on ABD, where they watched videos and PowerPoint presentations about recognising the symptoms. The possibility that Mouayed was suffering from ABD was not mentioned inside the house but, in the days after his death, all but one officer listed it on use of restraint forms.

Officers were trained to contain cases of ABD where possible, rather than exercise restraint. The court heard how even the police's presence in the room could have exacerbated Mouayed's state. In giving her directions to the jury, coroner Ms Saunders found no evidence that containment was an option.

Speaking after the inquest, Mouayed’s older brother Mohannad said: “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.”

An investigation into how police handled the 999 call on the day Mouayed died was also carried out by the Independent Office for Police Conduct (IOPC), and presented its conclusions after the inquest ended. It found the use of restraints was "reasonable", but officers "lacked empathy and compassion” at times when speaking to his family.