What happened
Azrar Ayub was 24 and had a diagnosis of schizophrenia. He had been detained under the Mental Health Act at Prestwich Hospital in November 2000, after a conviction in 1999 for which he was sentenced to eight years. On 28 May 2004 he was a patient at the Edenfield Unit, the secure psychiatric unit at the hospital in Prestwich, Greater Manchester.
He was restrained by staff and sedated, and then placed in a seclusion room. He was later found collapsed there and could not be revived.
His family instructed a second post-mortem by a specialist in restraint injuries, which reported extensive bruising. Police interviewed twenty members of staff. The trust offered condolences and declined to comment further.
The outcome
An inquest jury at Rochdale Coroner’s Court found that the way he had been restrained was “inappropriate” at times, and that a member of staff had “unintentionally” knelt on his back. In a two-page narrative verdict the jury added: “It is the jury’s opinion that there has been an attempt to conceal the carrying of Mr Ayub, the (unintentional) kneeling upon his back and the degree of observation and assessment.”
They found that his illness, together with the physical and psychological exertion brought on by prolonged restraint, contributed to his death. The family said they were considering legal action. No prosecution or regulatory penalty appears in the sources opened.
What went wrong
Two failures sit side by side. The first is physical: a knee on the back during a prolonged restraint, applied to a man who was then sedated and left in seclusion, so that the position and the observation afterwards both mattered.
The second is evidential. A jury found that the carrying of him, the kneeling, and the degree of observation and assessment had each been the subject of an attempt to conceal. A restraint that is not accurately recorded cannot be reviewed, and a record that leaves out what was done cannot be investigated.
What it teaches
A knee on the back during prolonged restraint is the positional asphyxia lesson. Weight on the back of a person held face down makes breathing harder with every minute it continues, and sedation afterwards does not undo that.
The finding about concealment is the documentation lesson that belongs beside it. What gets written down, and by whom, is part of the restraint itself, not an administrative tail to it.
Questions for the room
- The jury found the kneeling was unintentional. Does that change anything about the risk to the patient, or about what should happen next?
- You are writing the post-incident report and a colleague’s account leaves out the position. What do you do with that?
- Observation in seclusion was one of the three things the jury found had been concealed. Who checks that observation happened, and against what record?
Evidence and limits
Confidence: confirmed, with a gap. The inquest findings are reported by the Manchester Evening News. The death, the restraint, the sedation and the seclusion were reported at the time by the Institute of Race Relations, whose article returned an access error and could not be read.
Those facts, and the second post-mortem, the bruising and the twenty interviews, therefore rest on the vault record. No conclusion date is given: the narrative verdict is reported, but no coroner’s record or prevention of future deaths report was located.
No member of staff is named, and this page makes no finding against any individual.
Sources
Our physical interventions training covers positional risk in a restraint that runs long, and the record that has to survive a coroner’s court.
Reviewed 20 October 2026.