The death of a church caretaker who died after being restrained in police custody more than a decade ago is to be examined by an inquest jury, a coroner has ruled.
Thomas Orchard, 32, suffered a cardiac arrest after being held down, handcuffed and placed in restraints – with a webbing belt wrapped around his face for five minutes and two seconds.
He died in hospital seven days after being arrested and brought to Devon and Cornwall Police’s Heavitree Road custody unit in Exeter in October 2012.
Custody sergeant Jan Kingshott and civilian detention officers Simon Tansley and Michael Marsden were acquitted of manslaughter by gross negligence following a six-week trial at Bristol Crown Court in 2017.
Later, the office of the chief constable of Devon and Cornwall Police pleaded guilty to breaches under the Health and Safety at Work Act and were fined over £230,000.
Exeter and Greater Devon Coroner’s Court heard the inquest into Mr Orchard’s death would begin in November before a jury and would be held under Article 2 of the European Convention on Human Rights.
It means the scope of the inquest will be expanded to examine whether the state breached its duty to protect Mr Orchard’s right to life.
The inquest heard Mr Orchard, who had paranoid schizophrenia, began to suffer a deterioration in his health and from September 28 was seen by several different medical professionals.
Senior coroner Philip Spinney said the jury would hear background evidence of that deterioration.
“This will include his diagnosis, management of his condition through medication, compliance with his Clozapine regime and the effects of not taking the medication,” he said.
Mr Spinney said the court would be assisted by evidence from a psychiatrist who could give expert evidence about Mr Orchard’s care.
“It is plain that the deterioration in Thomas’s mental health is a significant issue in this case and I would like to also examine further issues of communication, of risk information and the decision to move to a formal Mental Health Act assessment,” he said.
“I would also like to fully examine the relationship between Thomas’s mental health and the cause of his death.”
Mr Orchard was experiencing a mental health crisis when he was arrested in Exeter city centre at 11am on October 3 after being abusive to members of the public.
He was dealt with by seven police officers, handcuffed and restrained around his legs before being driven to the custody suite.
Sgt Kingshott, Mr Tansley and Mr Marsden, who were on duty there, insisted their actions towards Mr Orchard were proportionate and lawful.
None recognised that Mr Orchard was mentally ill and did not check how long he had been physically restrained for – 18 minutes by that point.
Mr Orchard appeared to attempt to bite an officer as he was taken through the door into the holding area of the custody suite.
He was held down by three officers. Mr Tansley called for an emergency response belt (ERB) and wrapped it around Mr Orchard’s face.
Devon and Cornwall Police had authorised the US-made restraint device for use across the face to prevent spitting or biting.
A risk assessment by the force did not identify or refer to any risks to detainees when the belt was used around the head.
Mr Orchard was carried to a cell and placed chest-down on a mattress, where he was searched while handcuffed, in restraints and with the ERB around his face.
The ERB and restraints were then removed and Mr Orchard was left alone in the locked cell – where he lay motionless for 12 minutes before custody staff re-entered and commenced CPR.
The court heard Mr Orchard was restrained for a total of 22 minutes, with the ERB around his face for five minutes and two seconds. He died in hospital on October 10.
A pathologist found he died from severe hypoxic-ischemic brain damage, caused by a prolonged cardio-respiratory arrest “following a violent struggle and period of physical restraint”.
In the health and safety case, a judge ruled they could not be sure that the ERB was a contributory factor in Mr Orchard’s death.
During the inquest, Sgt Kingshott, Mr Tansley and Mr Marsden will be “interested persons” meaning they can participate in the hearing.
Also listed as interested persons are four other officers who were involved in Mr Orchard’s detention, restraint and transportation.
A further pre-inquest review will take place on a later date.
