Sis118 chief: Prone restraint and pepper spray likely contributed to Bologna death of Abderrahim Fakir
Mario Balzanelli, president of Italy's emergency medical system Sis118, says the 42-year-old Moroccan man could have been saved if a doctor had been called immediately, and warns that prolonged prone restraint can be lethal.
The death of Abderrahim Fakir
Abderrahim Fakir, a 42-year-old Moroccan national, died on 21 July during a police intervention in Bologna. The incident lasted approximately 38 minutes. Officers restrained Fakir in a prone position, with his face and chest pressed to the ground, and used pepper spray moments before immobilising him. The Bologna prosecutor's office has opened an investigation, and an autopsy is expected to be assigned on 22 July to a panel including a forensic pathologist, an emergency medicine specialist, a toxicologist, and possibly a cardiologist.
Medical alarm over prone restraint
Mario Balzanelli, president of the Italian Society of Emergency Medical System 118 (Sis118), stated that prolonged prone restraint with weight on the back can be lethal. He explained that the position blocks chest expansion and diaphragm movement, preventing the person from hyperventilating to expel excess carbon dioxide. The resulting CO2 buildup acidifies the blood and can cause cardiac arrest.
The prone position can kill. Physical restraint prolonged in the prone position, with the weight of operators on the chest and compression of the neck, can kill.
Balzanelli noted that the death is rarely simple suffocation. Three factors converge: the intrinsic physiological cascade from extreme agitation (arrhythmias, ischemia, lactic acidosis, hyperthermia), the mechanical restriction of breathing from the prone position, and the effects of pepper spray.
The physiology of restraint death
According to Balzanelli, the first causal line is the state of agitation itself. The body, flooded with catecholamines and under extreme muscular effort, can develop malignant arrhythmias, ischemia, lactic acidosis, rhabdomyolysis with potassium release, and hyperthermia. This cascade alone can stop the heart even without any restraint. The second is the prone position: with the weight of one or more officers on the back, the person cannot expand the chest and diaphragm. When hyperventilation is needed to clear excess CO2, the respiratory mechanics are blocked. CO2 accumulates, blood acidifies further, and the heart fails. Neck compression worsens the situation. The third is the pepper spray, which can cause airway spasms.
Pepper spray and asthma
Fakir's family has reported that he suffered from asthma and had previous hospitalisations for respiratory problems. Balzanelli said that oleoresin capsicum, the active ingredient in pepper spray, can trigger laryngospasm and bronchospasm, closing the airways. This effect is especially dangerous for asthmatics.
The oleoresin capsicum can cause laryngospasm and bronchospasm, with closure of the airways, effects that become dangerous especially in those who suffer from asthma.
The combination of these factors, he said, typically leads to cardiac arrest presenting as pulseless electrical activity or asystole. Balzanelli stressed that the window to prevent death is narrow: immediately removing the person from the prone position.
The window to avoid it, or to make it much less probable, is narrow and coincides with a simple gesture: immediately remove the person from the prone position.
Call for medical response
Balzanelli argued that acute psychomotor agitation is a medical emergency, not a public order problem. He said that if a doctor had been on the scene promptly, Fakir could likely have been saved through sedation.
With the timely arrival of a 118 doctor, in all probability, Abderrahim Fakir could have been saved: faced with a strong state of psychomotor agitation, the doctor could have sedated the subject, for his own protection and preventing more serious consequences.
Sis118 is calling for protocols that always activate a medical team with a doctor and nurse in cases of acute agitation, and for joint training between law enforcement and emergency medical services.
Investigation next steps
The Bologna prosecutor's office will assign the autopsy on 22 July. The examination is expected to clarify the role of the pepper spray and the exact cause of death. The investigation is ongoing, and no charges have been announced.
