What happened
On 7 March 2023 police were called to a gym after 999 calls reporting a man behaving erratically. The initial reports said he was trying to “fight people” and appeared to be having a mental health episode.
Two Metropolitan Police officers found him in the shower area of the men’s changing room and recorded acute behaviour disturbance. He did not respond to their orders and both officers Tasered him a number of times. He was eventually handcuffed.
Five more officers arrived in answer to a call for urgent assistance. They restrained him face down for six minutes, then moved him onto his side. After he appeared to try to bang his head on the ground he was returned to face down and held for a further eight minutes, until the London Ambulance Service arrived. Paramedics decided he was very unwell. He was taken to hospital and sectioned under section 136 of the Mental Health Act.
The outcome
The case was referred automatically to the Independent Office for Police Conduct because of his injuries, and a complaint was made during the investigation.
The IOPC found no indication that any of the seven officers had committed a criminal offence or behaved in a way justifying disciplinary proceedings, and no case to answer for misconduct or gross misconduct. It suggested reflective practice reviews: for the five restraint officers on acute behaviour disturbance, positional asphyxia and the National Decision Model, and for the first two on Taser and mental health. It identified no organisational learning.
What went wrong
The investigation had CCTV from inside the gym, body-worn video, paramedic and eyewitness accounts, statements from all seven officers, and Taser and use of force expert reports. What it records is the finding: 14 minutes face down in total, six and then eight, after repeated Taser discharges, in a man already identified as being in acute behavioural disturbance.
The decision to return him to his front is the one to sit with. He was on his side, the position that gives a chest wall room to move. He banged his head, and he was put back.
What it teaches
Returning a person in acute behavioural disturbance to prone because they are head-banging trades a visible risk for an invisible one. A bang to the head is seen. A compromised airway is not.
Fourteen minutes face down after repeated Taser discharges is a positional asphyxia scenario. Two controls would change it: a safety officer with authority to call the position, and a rule that prone is time-limited.
The third lesson is the phrase “no organisational learning”. Seven officers, fourteen minutes and repeated Taser use produced nothing the force needed to change.
Questions for the room
- He was moved onto his side and then put back. What did the second prone period buy, and what did it cost?
- You are the safety officer. At what minute do you call for a change of position, and who hears you?
- The regulator identified no organisational learning. Do you agree, and what would you have asked it to examine?
Evidence and limits
Confidence: probable. This rests on a single primary source, the IOPC’s investigation summary published on 9 August 2024, reference 2023/190479. It gives the timings and a stated outcome. No press report of the incident was found, so nothing here has been checked against independent reporting.
The IOPC does not name the man or the gym, and this entry does not either. The injuries that triggered the automatic referral are not described, and the page does not speculate about them.
No officer was charged or disciplined. The reflective practice recommendations are the regulator’s only action and are not findings against anyone.
Our [vulnerable and volatile persons training](/training-solutions/vulnerable-volatile-persons) covers acute behavioural disturbance, positional asphyxia and the decision to return someone to prone.
Sources
Reviewed 20 October 2026.