Finding into death of Hizir Ferman

35y · Male·Cardiorespiratory arrest in the setting of acute agitation and physical and chemical restraint

Hizir Ferman, aged 35, died at Middleton Prison following forcible extraction from his room by SESG officers using CS gas and physical restraint. He was held prone with hands cuffed behind him, a shield on his back, and additional downward pressure applied, initially in the bathroom for over six minutes, then positioned upright when moved outside. Post-mortem examination revealed cardiorespiratory arrest. The coroner found that hypoventilation from restraint in the prone position—compounded by prior violent struggle, CS gas exposure, and the terminal event of being sat upright—was the primary cause of death. Nursing staff failed to recognise his critically unconscious state, perform adequate assessment (blood pressure, oxygen saturation), or call an ambulance. Clinical lessons include: the danger of prone restraint with additional pressure, especially without medical assessment; failure to escalate care when patient is unconscious; inadequate communication between security and medical staff; lack of specific training for nurses on restraint asphyxia and cell extraction incidents.