Ibrahima Sey – a Gambian asylum seeker, died in the early hours of Saturday 16th March 1996, after having been taken from his home to Ilford Police Station in East London.
He was suffering from a mental illness, the effects of which have been described variously by the labels “excited delirium” or “acute exhaustive mania”. The police arrived at the his home in response to a call for help from Amie as a result of his strange behaviour which had alarmed her to the extent that she had jumped out of a window, leaving the two infant children behind with him.
He eventually came out of the house to be conveyed to Ilford Police Station without any struggle on his part, primarily because his friend, Mr Pa Ebou Ndimbalan, who had arrived at the scene in response to a prior call for help from Amie, was allowed to accompany him.
However, upon their arrival in the rear yard of the police station, the arresting officers refused to allow Mr Ndimbalan to accompany Mr Sey into the police station. Evidence from Mr Ndimbalan as well as some of the officers themselves has described the events that followed : while Mr Sey was still pleading that Mr Ndimbalan should be allowed to stay with him, he was set upon by six to eight officers, one of whom grabbed him in a bear hug from behind while others grabbed his arms and legs so that he was brought down to the ground, and he was then rolled onto his stomach for his hands to be cuffed behind his back.
Mr Ndimbalan did not see anything further, because he was ushered away from the scene. However, the evidence from the officers themselves suggests that the sequence of the subsequent events was as follows:
On two successive attempts to raise Mr Sey to his feet, his legs seemed to buckle and give way, so that he ended up face down on the ground where he seemed to go limp on each occasion while officers continued to hold him down.
On the third attempt to raise him, he was still on his knees, with his hands still cuffed behind his back, when one of the officers sprayed him with CS which hit him in a stream around his nose and mouth, and he was seen to lick off the solvent as it dripped down his nose.
Once he was on his feet, his head was pushed down towards his knees so that he was doubled over, with his hands still cuffed behind his back, and in that posture he was walked backwards into the police station until he collapsed in a corridor.
He was then carried face down and feet first for the rest of the distance into the custody suite where he was placed face down on the floor with his hands still cuffed behind his back. Some four to six officers continued to hold him down by his head, arms and legs – including two officers with their feet on his legs – for the next 15 minutes or more. It was while he was still restrained in this position that he suddenly became relaxed and, after being checked, was found not to be breathing.
In consequence, an ambulance was called, and the ambulance crew have described their surprise and shock to find Mr Sey still on the floor of the custody area with his hands were still cuffed behind his back when he was showing no signs of life whatsoever. They took him to hospital where he was pronounced dead.
The purported reason for Mr Sey’s arrest is said to be suspicion of threats to kill and assault on Amie. She later explained to the jury at the inquest into her husband’s death, that there was no prior history of violence in the marital relationship, and even on the day such violence was minimal: the purported reasons for the arrest were founded upon her account to the officers she called to the scene, describing Mr Sey’s strange behaviour that evening, insofar as he had been talking and chanting in a bizarre manner, throwing things about the house including items that went in her direction, and her fear that he might harm himself, herself or her children in his unpredictable state of mind. She explained that the deceased had a history of some kind of mental instability which went back some 3 or 4 years, including a breakdown in Sweden in 1992 and a further breakdown in his native Gambia in 1994, but there had been no similar episode since his arrival in this country in May 1995. The officers who answered her call for help were specifically informed about the mental history, and indeed it was on this account that Mr Ndimbalan was allowed to accompany him in the van to the police station. Their later decision to separate Mr Ndimbalan from the deceased was the spark but for which the death might not have occurred.
A post mortem examination took place on the evening of Saturday 16th March, conducted by Dr Michael Heath on behalf of the Coroner, in the presence of Dr Robert Chapman and Dr David Rouse for the Commissioner and the Police Federation respectively. The provisional cause of death upon that examination, pending the results of more detailed pathological and toxicological tests, was said by Dr Heath to be that “the deceased collapsed following a period of exertion and was suffering hypertensive heart disease”, and that “there was no evidence that the CS spray contributed in any way to the death”. Toxicology tests showed that no drugs or alcohol were found to be present in the deceased’s body.
By late 1996, however, the official opinion as to the cause of death had been revised to be expressed as “acute exhaustive mania” by Dr Heath on the basis of consultations with Dr Henry Kennedy, consultant forensic psychiatrist at Chase Farm Hospital. Both of them gave evidence suggesting that Mr Sey suffered some kind of a “sudden death” purely as a result of his mental illness. As for the supposed hypertensive heart disease, Dr Heath was forced to concede that there was no basis for the diagnosis in the first place, and the Coroner directed the jury that Mr Sey did not suffer from any abnormality of the heart whatsoever.
These findings and opinions were disputed from the outset; an examination and analysis carried out on behalf of the deceased’s family by Professor Bernard Knight and Dr Nathaniel Cary, consultant forensic pathologists at the Cardiff Royal Infirmary and Papworth Hospital respectively, and Dr Maurice Lipsedge, consultant psychiatrist at Guy’s Hospital. In general terms, they gave evidence that the role of the CS spray in the cause of death could not be dismissed out of hand, given that it is said to be effective as a control agent precisely because it is designed to cause respiratory problems; that the most likely mode of death in this case is positional (or restraint) asphyxia, with the effects of CS or exhaustion due to mental illness as contributory factors rather than causes of death in themselves; and that the suggestion that the mental illness might somehow lead to “sudden death” without any other intervening factor such as the restraint is simply not borne out by experience or reported literature.
Similarly, both Dr Rouse and Dr Chapman confirmed their opinions that the restraint was a significant contributory factor in the death, as has Dr James Cairns, the Deputy Chief Coroner for Ontario in Canada who was called to speak about the experience of similar cases in North America.
On the wider context of this case, the evidence heard by the jury confirmed and touched upon the now widespread recognition of the potentially fatal dangers of restraint in the face down position within the Metropolitan Police as well as other forces throughout the country.
Following the deaths of Richard O’Brien in April 1994 and Wayne Douglas in December 1995, both of whom were found to have died as a result of positional or restraint asphyxia, officers throughout the Metropolitan Police, including those involved in Mr Sey’s death, had received warnings and guidance which leave no room for doubt that ignorance of the relevant issues could not be pleaded on behalf of the officers in this case.
Another relevant consideration is the fact that at the time of Mr Sey’s death the use of CS spray was on a six-month trial which commenced on 1 March 1996 – only some two weeks before the incident – involving 2,300 officers in 16 police forces throughout England and Wales. The Home Secretary and the Association of Chief Police Officers (ACPO) have since approved the general issue of CS spray, despite grave concern and reservations expressed in many quarters within the police forces as well as amongst the public at large about the safety of the device. Two forces – Surrey and Hertfordshire – withdrew from the trials because of safety fears, and a third force – Northamptonshire – banned any training on the use of the device for similar reasons… According to news reports, a leaked ACPO document, circulated to police forces on 4 January 1996, acknowledged the health risks involved in the use of CS spray, and noted the fact that the research carried out on the it has been far from comprehensive. It would appear that ACPO and the Home Office chose nevertheless to press ahead with the trials and the subsequent general issue of CS spray – in full knowledge of the identified health risks – on the grounds that they were not prepared to wait for the development of a safer alternative.
Ibrahima Sey left a widow, Amie Sey, and two infant daughters, Maimuna and Ramatulay
The inquest into the death of Ibrahima Sey at Ilford Police Station on 16th March 1996 concluded on Thursday 2nd October 1997. The jury sitting with the Walthamstow Coroner at Snaresbrook Crown Court from 1st September heard extremely disturbing evidence about the treatment of this mentally ill man by police officers. The inquest raised serious concerns about the role of the police station as a place of safety and the nature of the restraint used on him, including the then newly issued CS spray.
The consensus amongst the numerous and eminent pathologists who have given evidence is that the restraint in the prone face down position would have impaired breathing sufficiently to cause death. The jury decided that the nature and the extent of the force used in the restraint was so unreasonable and unnecessary in the circumstances so as to render the death an Unlawful Killing.
On 1st October 1998 the Crown Prosecution Service announced that no officers would be charged over the death of Ibrahima Sey, despite the unanimous verdict returned (to a standard of criminal proof) by the inquest jury.
Lifted from the website of Inquest, the organisation which campaigns around deaths in custody.
An entry in the 2016 London Rebel History Calendar – check it out online