Jose Luis Ferreira Leite was being treated on a medical ward whilst detained under mental health powers. After becoming agitated he was held face down for more than 15 minutes by security guards while a healthcare assistant sat on him. Following delays in summoning help he suffered a cardiac arrest and died. An inquest concluded on 14 July 2026 that the force used during this “high risk” restraint was both excessive and inappropriately prolonged.
The jury also identified multiple “gaps” in the care offered to Luis in the week before he died, by police, mental health services and his GP. They found that once he was admitted to Ealing Hospital there were further failures of communication, planning and prescribing, including concerning Luis’s hearing impairment. They identified multiple failings and “an absence of clinical leadership” in how the hospital dealt with Luis when he became agitated, including a failure to anticipate and identify that he was experiencing an acute behavioural disturbance, and a failure by staff to understand the dangers of restraint.
Luis’s family are represented by Carolynn Gallwey, Catherine Shannon and Mavi Salvatori of Bhatt Murphy, instructing Raj Desai at Matrix Chambers.
