What happened
Jason Lennon, 37, was born and raised in Jamaica. He had suffered a brain injury in September 2002 and later began treatment for schizophrenia. In the five years before his death he needed inpatient care five times, and his relapses were predictable. He lived in supported accommodation, under East London NHS Foundation Trust.
Towards the end of July 2019 his support workers saw signs of a further relapse and brought him to Newham Community Recovery Team. On 29 July he had no upcoming appointments.
On the morning of 31 July 2019 he was seen behaving strangely and recklessly at the ExCeL centre, in what was in fact an acute psychotic episode. Just after 7.30am, Secure-Ops guards brought him to the ground and restrained him prone with considerable force for about five minutes. Metropolitan Police officers arrived at 7.35am and found him unresponsive. CPR began at 7.39am, and he was pronounced dead at Newham General Hospital at 9.31am.
The outcome
An inquest before HM Coroner Graeme Irvine and a jury at Walthamstow Coroner’s Court ran from 17 January to 11 February 2022. The jury found that he died of a cardio-respiratory arrest suffered at the ExCeL centre due to restraint in the prone position following an acute psychotic episode.
In a narrative conclusion they found the restraint “excessive” and “unreasonable” and more than minimally contributory to his death. It was the fourth inquest in a year in which security restraint contributed to a death.
What went wrong
The guards had been licensed by the Security Industry Authority and trained that ground restraint, particularly face-down, is dangerous and should be avoided. The jury found that the manner of restraint was not endorsed by that training, because of the imminent risk of positional asphyxia.
They rejected the guards’ account that he had been breathing and communicating when police took over, concluding that the cardiac arrest happened during the restraint. Too many people were involved, no one led or managed it, and the jury did not accept that his vital signs had been monitored. They found the risk of death was reasonably foreseeable.
What it teaches
The gap that kills is between licensed training and practice under pressure. These guards had been taught that prone restraint is dangerous and did it anyway, at a venue with no clinical lead, no leader and no observation.
Training that is not backed by a named person in charge, and a rule about when a restraint ends, does not survive the first difficult incident. A venue that expects security staff to lay hands on people needs to decide in advance who takes command, how the person is monitored, and who calls an ambulance.
Questions for the room
- He was prone for about five minutes with several guards involved. Who was in charge, and what would that person have been watching?
- You are the guard who first takes him to the ground. At what point does your plan change, and what tells you it must?
- The venue had no clinical lead and no vital-sign checks. What should a venue’s restraint policy require before staff lay hands on anyone?
Evidence and limits
Confidence: confirmed, but on one readable source. The NFPS page holding the findings returned HTTP 500, so nothing here rests on it. The INQUEST release carries the narrative conclusion, the timings and the criticisms in full.
Proceedings concluded on 11 February 2022, so the page may be cited outward. No member of staff is named, and no finding is made against any guard.
Our physical interventions training covers restraint positions, positional asphyxia and the monitoring that has to run throughout a hold.
Sources
- INQUEST, Press release: conclusions in the inquest into the death of Jason Lennon · 11 February 2022
- NFPS, Inquest findings into the restraint-related deaths of Michael Thorley and Jason Lennon (video) · 2022 (not read: page returned HTTP 500)
Reviewed 20 October 2026.