What happened
On 27 March 2011 Kingsley Burrell, 29, called police from Birmingham city centre to say he was being threatened with a gun. CCTV showed that nobody was following him. He was detained under the Mental Health Act and restrained for about four and a quarter hours with rear handcuffs and leg straps, under threat of a taser.
On 30 March police and a dog unit were called to the hospital holding him, and he was restrained again, with the same equipment and the same threats. On the way to another facility an ambulance worker put a blanket over his head as he lay face down on a trolley. He had been struck with batons and punched.
He was left face down and motionless in a locked seclusion room for about 28 minutes, a blanket over his head. When staff went in he had suffered a cardiac arrest. He died at the Queen Elizabeth Hospital on 31 March 2011, four days after detention, without regaining consciousness.
The outcome
A six-week inquest concluded in May 2015. The jury found neglect: prolonged restraint and a failure to provide basic medical attention had contributed to the death. It found a “gross failure to provide or procure” basic medical attention for an obvious need, that unreasonable force contributed, and that officers lied about how he came to be left in seclusion.
The Crown Prosecution Service concluded there was insufficient evidence to prosecute anyone over the death. Three officers were charged with perjury and perverting the course of justice, and were acquitted on 4 October 2017. A misconduct panel heard three weeks of evidence on use of force and honesty in December 2018.
What went wrong
The same hold was applied twice, four days apart, and no source records anyone reviewing whether it had worked the first time.
Then the end. He was face down with a blanket over his head and his breathing had been seen to slow. Nobody went in for around 28 minutes. When somebody did, the response was slow: a working defibrillator was not found quickly and the ambulance call was delayed.
What it teaches
Four days between the restraint and the death does not break the chain. The inquest treated the failure to give basic medical attention as part of the same event as the hold, and that is the lesson: the duty does not end when the hands come off.
Face down with something over the head is the position that kills people, and the position in which the person cannot be seen. If the only person who can look in is the person who applied the hold, and they have left the room, nothing is being monitored.
Monitoring needs three things: somebody watching breathing and colour, a time limit on the observation, and somebody with authority to open the door.
Questions for the room
- He was left face down with a blanket over his head. What could anyone outside that door have seen?
- Your detainee’s breathing has slowed and the room is locked. What triggers going in, and who decides?
- The same hold was used twice, four days apart. What was supposed to notice the first had not worked?
Evidence and limits
Confidence: confirmed. Sources read: The Guardian’s report of the inquest on 15 May 2015, and INQUEST’s release on the 2018 misconduct finding. The judicial record of the inquest, Burrell 2015-0472, is listed in the vault and could not be read: the PDF has no text layer.
He was detained on 27 March 2011 and died on 31 March 2011. Both sources agree.
No officer was convicted of any offence connected with the death: the criminal trial ended in acquittals and a misconduct panel followed. Both facts belong on this page.
Our physical interventions training covers the holds in this case, and the monitoring that has to go with them.
Sources
Reviewed 20 October 2026.