What happened
Michael Thorley, 41, was admitted to Wythenshawe Hospital in Manchester after attending accident and emergency on 19 December 2017 with shortness of breath. He was treated for a significantly increased heart rate and started on an alcohol withdrawal regime: a sedative, chlordiazepoxide, with monitoring of symptoms. Medical staff accepted at the inquest that the formal monitoring did not happen as it should have.
During the afternoon of 21 December he began to behave in a way consistent with delirium. Just after 11pm he called 999 to say he did not feel safe in hospital; a nurse told the call handler he was safe.
At around 1.23am he pulled the emergency cord in the toilet, and staff found him having a seizure.
The outcome
The inquest at Manchester City Coroner’s Court ran from 18 October to 2 November 2021 before Area Coroner Zak Golombeck. The jury found that Michael was unlawfully killed.
It found it was not necessary for the guard to restrain him when he did, and that nursing staff failed to monitor him during the restraint. Both probably caused or contributed to the death. The force used was unreasonable, disproportionate and excessive. The trust did not make appropriate security arrangements, and there were errors in clinical management which may have contributed. It took about five hours to refer the death to the police, in breach of its own protocols.
What went wrong
Bed watch required a Level 2 Door Supervisor licence, the type a nightclub bouncer needs. The trust specified no further training for a hospital setting, and had no policy on physical intervention.
A nurse saw the guard trying to restrain Michael and told him to leave Michael alone, fearing that restraint would make things worse. After a further altercation the guard used force to try to get him to sit or lie down. He noticed Michael had become exhausted and kept restraining him. No nurse was monitoring.
Clinical monitoring of the withdrawal regime had already been accepted as not done properly; the delirium that followed was handled as a security problem.
What it teaches
This is split responsibility in its purest form. The guard holding the patient was not a clinician and had been given no training to be one. The nurses who could read the signs were not at the restraint.
A bed watch is a clinical observation task with a security label. The deterioration has to belong to a named nurse, not whoever stands nearest.
A Level 2 Door Supervisor licence tells you what a person may lawfully do, not what they will notice. Nobody in that role had been asked to read exhaustion as a symptom.
Questions for the room
- The nurse told the guard to leave him alone, fearing restraint would make it worse. What should have happened next, and who should have said it?
- You are the guard on bed watch. The patient is standing at the window shouting. What is in your remit, and what is not?
- A Level 2 Door Supervisor licence was the only qualification specified. What does that say about how the role was designed?
Evidence and limits
Confidence: confirmed. INQUEST’s account of the inquest conclusion was read in full. The independent recording of the findings, listed as the second source, failed to fetch and is not relied on.
Unlawful killing conclusions are rare; the standard of proof for inquest conclusions was lowered to the civil standard by the Supreme Court in November 2020.
Proceedings concluded on 2 November 2021. No member of staff is named, and none was prosecuted.
Our physical interventions training covers what a hold requires around it: monitoring, duration, and who has the authority to end it.
Sources
- INQUEST · Michael Thorley conclusion · 4 November 2021
- NFPS · Inquest findings into the restraint-related deaths of Michael Thorley and Jason Lennon (not retrievable) · 2021
Reviewed 20 October 2026.