Published Date: 30.11.2023

A Police Ombudsman investigation has identified ‘multiple failings’ in how police managed the risks faced by a 36-year-old Belfast man who died after being restrained by officers while under the influence of cocaine.

Gerard McMahon, from the Short Strand area of the city, died in hospital on 8 September 2016, 14 hours after being handcuffed and restrained in a face down prone position by police officers.

Police had responded after being alerted to an altercation between Mr McMahon and taxi drivers near the Grand Opera House in Great Victoria Street.

Two officers were disciplined for failing to summon an ambulance more quickly after becoming concerned for Mr McMahon’s health. He later suffered a cardiac arrest.

One of those officers was also disciplined for discharging CS Spray at Mr McMahon while the officers were attempting to restrain him. The officer’s two colleagues were also affected by the spray. The Coroner at Mr McMahon’s inquest in 2021 described the use of the spray as ‘not just unwarranted but also irresponsible.’

However, Police Ombudsman, Mrs Marie Anderson, has expressed disappointment that the PSNI decided not to implement a number of other disciplinary recommendations made following enquiries by her office.

These related to the way in which Mr McMahon had been handcuffed and restrained, and a delay in officers administering cardio-pulmonary resuscitation (CPR).

Although Mrs Anderson recognised that the three officers involved in Mr McMahon’s restraint had made determined and extended efforts to save Mr McMahon’s life, she said her enquiries had identified a series of concerns.

She recommended that all three should face misconduct hearings which would have allowed “the evidence to be tested and the full range of disciplinary sanctions to be considered.” 

She described as “unsatisfactory” the PSNI’s decision not to hold misconduct hearings as recommended, to implement disciplinary sanctions against only two officers in relation to only some of the identified failings, and to take no action against the third officer.

However, she welcomed “a positive response” from the PSNI to recommendations for changes in police procedures as a result of lessons learned during her investigation.

These recommendations were made within four months of Mr McMahon’s death “to ensure improvements to policing practice at the earliest opportunity.” They included recommendations for improved training to help police officers better identify and respond to Acute Behavioural Disorder, a life-threatening condition often associated with drug use, which Mr McMahon had experienced prior to and while being restrained.

During their enquiries, Police Ombudsman investigators obtained accounts from almost 50 civilian and police witnesses, and sourced and examined 47 pieces of relevant video footage, mostly recorded by CCTV cameras in Belfast city centre.

They established that Mr McMahon had left a nightclub at around 2am and spent the following two hours and 40 minutes walking around the city centre. He was partially clothed, appeared disorientated and fell a number of times.

Police received a number of calls from concerned members of the public between 2.45am and 3am. No police crews were initially available, and when officers arrived at the scene at around 3.30am, Mr McMahon had left the area.

At 4.46am, police received a report that taxi drivers were being attacked close to the Europa Hotel in Great Victoria Street. Within five minutes, four police officers had arrived. Three dealt with Mr McMahon while another left to get a cell van from Lisburn Road Police Station.

Mr McMahon was handcuffed to the front and placed on a step outside the Grand Opera House. He tried a number of times to stand up, and within a few minutes a struggle ensued during which one of the officers discharged CS spray at him. 

Two of the officers were affected by the CS spray discharged by their colleague as they struggled to control Mr McMahon. Mr McMahon was taken to the ground where all three officers restrained him in a face down position. Leg restraints were subsequently applied.

In total, Mr McMahon had been restrained on the ground for around five minutes when the officers realised he had become unresponsive. It was a further three minutes before officers commenced CPR, although in the interim they tried to use a defibrillator which advised “do not shock.”

Having examined the evidence, Mrs Anderson concluded that there had been “a lack of planning and communication” between the officers involved in restraining Mr McMahon. She said a failure to react appropriately to the developing situation had exposed Mr McMahon to the risks associated with being restrained in the prone position for an extended period of time.

“When Mr McMahon first showed signs of resistance, the handcuffs should have been moved from the front of his body to the rear,” said Mrs Anderson. “This would have allowed the officers to exercise a greater degree of control and may have avoided the need to restrain him in a face down position. 

“The officers also had no clear plan as to how long Mr McMahon would be restrained in the prone position, and whether that would have been until a cell van arrived from Lisburn Road or until the arrival of additional police resources.”

Mrs Anderson also criticised the delay in officers administering CPR, having first attempted resuscitation using a defibrillator. However, she noted medical evidence that the delay would have “contributed minimally” to Mr McMahons death, and that death would have been likely even if CPR had been started immediately.

“The discharge of CS spray at Mr McMahon was also unjustified and irresponsible, not only affecting Mr McMahon, but the officer’s colleagues as well,” added Mrs Anderson.

The Police Ombudsman’s investigation also identified failings by two police officers based in the PSNI’s Urban Call Management Centre. The officers were the subject of measures designed to improve their conduct for failing to request CCTV coverage of Mr McMahon following reports that he was potentially a risk to himself and others in the hours prior to being detained by police.

Mrs Anderson added: “This was a tragic case involving the death of a young man. I note the comments of the Coroner at Mr McMahon’s inquest who stated that my investigators had ‘discharged their duty impeccably and to a very high standard.’

“The investigation led to lessons being learned from tragic circumstances, and the improvement of policing via a number of recommendations which were accepted by the PSNI.”