Jury concludes that death of Mark Kentish was caused by a period of restraint that was “inappropriate in both method and duration”

Friday 1 June 2018

The family of Mr Kentish were represented by Clare Richardson and Althia Stephens of Deighton Pierce Glynn Solicitors, Bristol and Sean Horstead, Counsel, Garden Court Chambers.

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The inquest into the controversial death of Mark Kentish came to a close on 30 May 2018 at Gloucester Coroner’s Court. The jury concluded that his death was caused by a period of restraint that was “inappropriate in both method and duration”, carried out by a Security Industry Approved (SIA) security guard who “had little understanding of the potential risks and consequences of restraint”.

Mark died shortly after midnight on the 23rd June 2016, following a period of restraint at the hands of two security guards (one described as an “off-duty gate-keeper”) in an unlit lane leading to a remote and semi-derelict business site in the Gloucestershire countryside. The 55 year-old father of six, a plastering contractor from Birmingham, had been in the area to visit his disabled father with his mother, and had then attended a local village pub where he had several drinks with his cousin. He left shortly after 10:30 pm in his Range Rover, telephoning his fiancée to tell her that he was intending to drive home to Birmingham. He did not make it home. He appears to have stopped en route, minutes later, in the access lane to the Stowfield Business Park, possibly to go to the toilet.

He was approached by an apparently Security Industry Authority accredited guard and a colleague. An altercation ensued during which Mark suffered a blunt trauma head injury and was restrained for some 13 minutes. There were no other witnesses to the altercation and no CCTV. Police and medical assistance were called, but shortly after the arrival of the police, Mark’s condition deteriorated. With the ambulance service en route, Mark stopped breathing and, despite best efforts at resuscitation he died at the scene.

After 7 days of evidence, the accounts provided by the security guards (including varying claims that Mark was restrained because he had assaulted one of them, had repeatedly threatened to kill them and had attempted to pull down a fence to gain access to an electrical power station) were all comprehensively and decisively rejected by the jury who, in a detailed and damning narrative conclusion found:

Due to conflicting accounts and the unreliability of the security guards’ evidence, the jury are unable to determine a reason for Mr Kentish to be restrained. Also due to (their) conflicting accounts, we are unable to establish the exact sequence which led to Mr Kentish ending up on the floor, but believe it more likely than not that he came to be there through an uncontrolled descent, following a confrontation with the security guard and off duty gatekeeper.

He was restrained in a way that was inappropriate in both method and duration ....the security guard had little understanding of the potential risks and consequences of restraint. It is likely that the restraint resulted in the restriction of his ability to breath, exacerbated by struggle against restraint.

There is evidence of a failure in both professional practice and conduct on the part of the security company and its employees.”

The jury concluded that the medical cause of death was principally “1a: stress and struggle against restraint”, with further contributing factors being Mark’s high BMI, his somewhat enlarged heart, coronary artery atheroma and the consumption of alcohol and cocaine. It should be pointed out that the cocaine levels were described by the coroner as at “an extremely low level”, and in the toxicology report as “trace”.

At the conclusion of the inquest, Assistant Coroner Caroline Saunders announced that she would be preparing three Regulation 28 Prevention of Future Death Reports to address her concerns that the evidence indicates the SIA continues to certify people for the role of security guard without ensuring a programme for training or refresher training in relation to restraint risks or positional asphyxia. In the light of a number of previous factually closely related deaths and the subsequent issuing of PFDRs, she intends to write to the Home Office to raise her concerns that there appears to have been no action taken to address the potential flaws in the SIA regulatory system to ensure mandatory restraint related refresher training. She also announced her intention to write to the company that employed the security guard to identify what measures they intend to take to ensure that their apparently SIA ‘badged’ staff are, in fact, properly trained.

The family released the following press release at the conclusion of the Inquest:

After two years of anguish it is with huge relief and gratitude to this jury that the family and friends of Mark can finally see that the truth has come out, of how he met his death. Mark was our big, loveable, larger than life gentle giant.

The jury have concluded, as we felt all along, that there was no need for the security guards to confront him that night, let alone put him on the road and restrain him in the way that the Jury described was “inappropriate in both method and duration”. The jury have concluded that it is likely that this unnecessary and inappropriate restraint restricted Marks’s ability to breathe and directly contributed to his death that night.

The jury have also identified a failure on the part of the security company and its employees. It appears that the Security Industry Authority instead of ensuring high standards of security staff, are simply handing out badges to people with no understanding of the life threatening risks involved in using restraint.

The family are delighted that the Coroner is going to write to express the concerns we share with her to the Security Industry Authority and the Home Office. We demand urgent action to prevent any further unnecessary tragedies like this and to stop any other families experiencing what we have been, and continue, to go through.

If the wholly unnecessary death of our lovely Mark can achieve anything by way of change, that would be at least some small consolation.”


Sean Horstead is a member of the Garden Court Chambers Inquest Team.

The inquest has been reported on in the media, including in the BBC.

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