What happened
Kenneth Severin was 25, with paranoid schizophrenia, and homeless when he was arrested. He was remanded to HMP Belmarsh in the autumn of 1995 and placed in the health care centre.
On the night of 25 November 1995 officers were called because he was shouting and banging on his door. He had been agitated since 22:00. The decision was taken to move him to a strip cell. A struggle began when he was told he could not take his personal stereo. Five officers held him using Control and Restraint. He was placed in ratchet cuffs behind his back and carried, still struggling, upstairs to a strip cell, where seven officers took part. There he was placed face down on a mattress, stripped, and uncuffed.
His pulse was checked twice and seemed fine. The officers left. He was found still, naked, on his stomach, his hands in the position they had held when cuffed.
The outcome
An ambulance was called and resuscitation failed. The inquest was adjourned from October 1996 and resumed on 2 January 1997. On 13 January the jury reached a majority decision of 9:2 that death was caused by positional asphyxia following struggle and restraint. The verdict was open. No prosecutorial outcome is recorded.
Three post-mortems agreed on positional asphyxia; the third, instructed by the Prison Service, put the bruising down to muscle tearing.
What went wrong
Nobody with medical knowledge was consulted before he was moved to strip conditions, though the guidelines said it should. The principal officer knew nothing about him and did not ask medical staff. The strip was contrary to prison regulations and could not be justified within them.
The officers had no training in the danger of placing someone face down with his hands cuffed behind his back. The officer responsible for Control and Restraint training had never heard of positional asphyxia until he attended the inquest. The report records that a circular issued in 1993, after the death of Omasase Lumumba at Pentonville, never reached the officers or the trainer.
His behaviour was treated as discipline, not illness. He had faced two adjudications, one for refusing to move his cup from the observation hatch.
What it teaches
Positional asphyxia is a training fact, not an exotic one. Face down, hands cuffed behind the back, weight on the back: that combination kills, and an officer who has never been told cannot see it.
Restraint in prison is a health intervention when the person is psychotic. The strip cell was a punishment decision taken with no clinical information about him.
Somebody knew, wrote it down two years later, and it never arrived. A piece of paper that does not reach the people applying the technique protects nobody.
Questions for the room
- His pulse was checked twice and seemed fine. What else would you have needed to see before leaving that cell?
- You are the officer in charge when a prisoner will not give up his stereo. What do you do next, and who do you call before the strip cell?
- A circular on restraint risk sat unread after a previous death. Whose job was it to know it had not reached staff?
Evidence and limits
Confidence: probable. The coroner’s inquisition was not obtained. The date rests on an INQUEST release issued on the day of the verdict and on a Guardian report two years later. The narrative comes from an archive report by United Campaigns for Justice quoting inquest evidence; the Prison Service’s inquiry was never published. The report gives two dates for his remand.
No member of staff is named, and none was prosecuted.
Our physical interventions training covers positional risk, and the monitoring that has to continue after a hold is released.
Sources
- United Campaigns for Justice, Death in Prison Custody: report on the death of Kenneth Severin · archive, no date held
- INQUEST, 13 January 1997
Reviewed 20 October 2026.