What happened
Philmore Mills was admitted to Wexham Park Hospital in Slough on 21 December 2011 with a chest infection and an irregular heartbeat. His condition worsened over the week that followed; on Boxing Day, when his family visited, he wore an oxygen mask.
In the early hours of 27 December he woke, got out of bed, became confused and shouted at staff. Nurses did not summon doctors and called police for assistance. Officers asked two security guards to help cuff him.
Putting him face down on the floor took less than a minute, and moving him back to bed took less than 30 seconds. He died moments later, on the floor beside the bed.
The outcome
The inquest ran for four weeks at Reading Town Hall, from 8 February to 8 March 2016. The jury found the police decision to take a seriously ill man to the ground and handcuff him face down was a contributory factor in his death.
The cause was cardiorespiratory collapse due to hypoxia, with severe lung and heart disease, in association with restraint. Jurors found lack of oxygen “for a significant period of time” led to his agitated state, and there was “lack of medical support”.
Senior Coroner Peter Bedford called for a national review of police use of restraint. Two officers had been cleared at a misconduct hearing the previous year; the Crown Prosecution Service found insufficient evidence to charge.
What went wrong
The hospital’s report, written after the death, concluded his confusion was “dealt with as a security emergency rather than as a medical emergency”. Nurses had not made the half-hourly observations hospital policy required once his health deteriorated.
The jury found communication between the officers and Mr Mills “inadequate”, and no discussion between police and nursing staff about a course of action after the restraint. Coroner Bedford noted that Thames Valley training made officers aware of broken bones as a risk of the take-down, but not the risk of death.
What it teaches
A patient with severe lung and heart disease is the highest-risk person in the building to hold face down, and the decision is usually taken by people not treating the disease. The question is not whether he is struggling, but whether his lungs can afford it.
Duration is not the whole of the risk. Under a minute was enough. A short hold is not a safe hold if the person cannot breathe through it.
The earlier failure is the observation. Lack of oxygen was building before anyone touched him, and confusion in a deteriorating respiratory patient is a medical sign. Calling the police stops it being treated as one.
Questions for the room
- The whole take-down lasted under a minute. What did anyone check about his breathing in that minute?
- You are the officer called to a confused man on a respiratory ward. What do you ask the nurse before you take hold of him?
- Nurses did not call a doctor and called police instead. What did the ward’s escalation plan say, and who had tested it?
Evidence and limits
Confidence: confirmed on the prevention of future deaths report, reference 2016-0110, by Senior Coroner Peter Bedford, dated 17 March 2016.
The coroner’s report gives his age as 55; the record and press say 57, used here.
Proceedings concluded on 8 March 2016. No officer is named.
Our restraint reduction training starts with the person’s medical condition: what makes a hold dangerous before it begins, and who has to be asked first.
Sources
- Courts and Tribunals Judiciary · Prevention of Future Deaths report 2016-0110, Senior Coroner Peter Bedford · 17 March 2016
- The Guardian · Calls for review of police use of restraint over lung cancer patient’s death · 8 March 2016
- INQUEST · Neal Saunders inquest concludes (summarises this case) · 2 December 2022
Reviewed 20 October 2026.