Security guards used ‘unreasonable’ force to restrain man, 37, with mental health issues who died while being pinned to the ground at London’s Excel Centre during a psychotic episode, inquest rules
- Jason Lennon, 37, suffered a cardiac arrest while being restrained in July 2019
- He was held to floor after pursuing member of public into London’s Excel Centre
- Police handcuffed him before rolling him over and realising he was unconscious
- Coroner has slammed failures and flaws in assessing Mr Lennon’s mental health
- Inquest heard he was deemed ‘stable’ two days before the psychotic episode
Security guards used ‘unreasonable’ force to restrain a man with mental health issues who died while being pinned to the ground at London’s Excel Centre during a psychotic episode, an inquest has ruled.
Jason Lennon, 37, was acting in a ‘delusional, agitated and paranoid’ manner, assaulting bystanders and walking into traffic, during an acute relapse in July 2019.
Police received 13 separate 999 calls in the just 35 minutes before Mr Lennon was restrained by security after pursuing a member of the public into the conference centre.
He was held in a prone position by ‘five large males’, who pinned several parts of his upper and lower body to the floor, an inquest heard.
When police arrived, they handcuffed Mr Lennon and rolled him over, but soon realised he was not breathing and had no pulse.
Officers removed the handcuffs and began emergency CPR, but Mr Lennon died in hospital less than two hours later having suffered a cardiac arrest while being restrained.
An inquest into his death at Walthamstow Coroner’s Court concluded earlier this month, with a jury arriving at a narrative conclusion that failures in Mr Lennon’s mental health care and the duration, location and ‘unreasonable’ force used by security to restrain him had contributed to his death.
Acting Senior Coroner for East London Graeme Irvine has penned a prevention of future deaths report, published on Monday, slamming failures and flaws in the assessments of Mr Lennon’s mental health in the days prior to his death.
Jason Lennon, who had a history of mental health issues dating back to an attempted suicide in 2002, was enduring a psychotic episode when he was restrained
Mr Lennon was rushed to hospital after suffering a cardiac arrest while being restrained, but died in hospital less than two hours later
The inquest heard Mr Lennon lived in supported accommodation and had a medical history of anoxic brain injury and enduring schizophrenic illness.
In 2002, after being remanded into custody at Feltham Young Offenders Institute, he had tried to hang himself after claiming he was the victim of a sexual assault. He was treated at hospital, where it was found he had sustained a brain injury.
The following year, he was diagnosed with a schizophrenic illness and in 2011 was deemed unsuitable to live outside supported accommodation in the community.
He was sectioned in 2017 when he walked into traffic asking drivers to kill him and his mental health fluctuated over the following four years.
This included periodic relapses, resulting in acute psychosis that caused an increasing risk of harm to both himself and others.
On the morning of July 28, 2019, Mr Lennon assaulted another resident at his supported accommodation, with staff assessing that he was in relapse.
He was described as ‘delusional, agitated and paranoid’ before staff reported the incident to police and the local mental health service – the East London Foundation NHS Trust Community Recovery Team.
A drop-in review was arranged for the following day, but Mr Lennon left the meeting before its conclusion. However, nursing staff assessed that he was stable and ‘not in crisis’.
On July 31, Mr Lennon left his accommodation at 6.55am and made his way to Prince Regent’s Lane in Plaistow.
Thirteen 999 calls were made regarding his conduct over a 35-minute period in which members of the public reported Mr Lennon acting in an ‘unusual and confrontational manner’, including assaulting bystanders and walking into traffic.
The Excel Centre in east London, where Mr Lennon died while being pinned to the floor by security guards
The inquest heard an assault on an Asian man was captured on CCTV, with a delivery driver stopping to intervene and allow the victim to escape, before Mr Lennon walked into the path of a bus.
Police were directed to the Excel Centre, where Mr Lennon then had pursued a member of the public before being restrained by security staff at around 7.29am.
Officers arrived at six minutes later, but Mr Lennon was found unresponsive and CPR was immediately commenced prior to the arrival of paramedics.
He was then transported to hospital, but was pronounced dead at 9.31am.
Acting Senior Coroner Mr Irvine has slammed the ‘flawed’ review of Mr Lennon’s mental state that failed to identify that he was in relapse two days prior to his death.
He said expert psychiatric evidence had indicated Mr Lennon was a ‘suitable candidate’ for a ‘Care Programme Approach mental health pathway’ that would have reduced the risk of his mental health deteriorating, but mental health services failed to effectively monitor whether he was on an appropriate pathway.
East London Foundation NHS Trust carried out a serious incident investigation report into the events leading up to his death, but Mr Irvine said the subsequent action plan ‘was found to have been incomplete by February 6 due to errors attributable to the Trust’s governance team’.
He also highlighted ‘individual failings by staff’ within the trust’s community recovery team that ‘fell below standards set by their regulator’.
East London NHS Foundation Trust has been contacted for comment.
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