Before Assistant Coroner James Dillon
Kent Coroner’s Court, North West Division
Archbishop’s Palace, Maidstone

5 June 2019 – 11 June 2019

The inquest into the death of Carl Maynard, who collapsed and died in Tonbridge Police Station on 13 October 2017, concluded yesterday afternoon with a critical narrative conclusion. The inquest jury found that ‘failing to take Carl directly to hospital’ represented a ‘missed opportunity to increase Carl’s chance of survival’. They also rejected the Kent Police officers’ initial justifications for entering his property, which did not meet the legal standards required. The cause of death was found to be acute cocaine intoxication.

Carl, 29, was born in Chatham in Kent. His family described him as being ‘deeply creative with an abundance of imagination’ and was a loving father to his young daughter.

The inquest heard that on 1 October 2017 an allegation of domestic common assault was made against Carl. During the afternoon of 13 October 2017, three Kent Police officers attended Carl’s property and a decision was made to force entry to arrest him. The inquest was told that the justification for entering the property must be pursuant to section 17 of the Police and Criminal Evidence Act (1984), which authorises entry for the purpose of arresting for an indictable offence or to save life and limb.

Evidence was heard that, on arrest, Carl was seen by an officer pushing two fingers down his throat and gagging. Despite being repeatedly questioned by the officers as to whether he had ‘taken’ anything, both Carl and his partner denied that he had swallowed drugs and he was taken to custody. At 4.23pm he collapsed in the fingerprint room and revival attempts were unsuccessful. The pathologist found an empty plastic bag within his stomach and concluded that he had died from acute cocaine intoxication.

Returning a narrative verdict, the jury rejected the officers’ justification for entering the property as Carl was arrested for common assault, which is not an indictable offence, and there was no evidence that his partner was at risk at the time. They also concluded that “…the arresting officers were plainly suspicious that Carl Maynard had swallowed something and told Carl that they would have taken him to hospital if he had but then accepted his account that he had not swallowed anything, did not seek medical treatment and took Carl to Tonbridge Police Station. The possibility of successful medical treatment was highly unlikely, however the chances of Carl’s survival would have been higher in a hospital rather than police custody. Failing to take Carl directly to hospital… represents a missed opportunity to increase Carl’s chance of survival”.

Kent Police’s policy at the time of Carl’s death was that officers who may suspect a detainee of having swallowed a substance should inform the custody sergeant, and take them to hospital if necessary. During the course of their investigation, the Independent Office for Police Conduct (then under the name IPCC) took the unusual step of issuing a learning recommendation to Kent Police before their report was completed. Kent Police therefore changed their policy shortly after Carl’s death to ensure that anyone suspected of swallowing a substance should be taken directly to hospital.  

Denise Kelly-Mills, Carl’s mother, speaking on behalf of the family including his sister, step-father and daughter, said:Ever since Carl died, we have been deeply concerned at the officers’ accounts and their apparent disregard for their duties and obligations. We are pleased that on hearing the evidence the jury returned a conclusion which is consistent with the complaints that we have raised from the outset.

The jury’s conclusion supports our belief that Carl’s home was unlawfully entered by the police as a result of which he made a rash decision which cost him his life. We will never understand why the officers didn’t take him to hospital. That decision meant that Carl was denied the opportunity to seek medical help and he died on a police station floor.

We have also been shocked that none of the officers used their body worn video cameras despite the policy making clear that there was a strong presumption that they should do so. This failure has denied our family the opportunity to really know what happened in that room.

Finally, we also feel thoroughly let down by the IOPC who concluded that there was insufficient evidence to find that any of the officers had a case to answer for misconduct. We hope in light of the jury conclusion that they review their decision.”

Deborah Coles, Director of INQUEST said: “The jury accepted that the officers suspected Carl had taken something, yet instead of responding to him as a medical emergency, he was left to die on a police station floor.

While state
bodies, such as Kent Police, receive automatic legal representation at inquests from the public purse, families have to go cap in hand to the Legal Aid Agency for support. Carl’s family were denied full funding and were required to pay a significant contribution to ensure the opportunity to interrogate the facts and ensure that mistakes or harmful practices are brought to light.

The inquest function in seeking the truth, as well as exposing wrongful action and unsafe practices, serves a vital public interest in addressing the adequacy of systems for safety and welfare. This is why INQUEST and the families we work alongside are calling on the government to act now and urgently introduce fair public funding for legal representation at inquests.”

The family solicitor Sophie Naftalin made the following comments: “Carl’s death is a tragedy for his family but this jury’s conclusion vindicates many of their concerns about the failures of the officers”.  



For further information, please contact Lucy McKay and Sarah Uncles on [email protected] [email protected]

A photo of Carl is available on request.

INQUEST has been working with the family of Carl Maynard since after his death. The family is represented by INQUEST Lawyers Group members Sophie Naftalin and Anastasia Solopova of Bhatt Murphy Solicitors and Stephen Simblet of Garden Court Chambers.

The other interested person represented at the inquest was Kent Police.

Despite the fact that Kent Police were represented by the public purse, the family has been asked by the legal aid authority to make a financial contribution to their legal representation.

In February INQUEST and bereaved families launched the campaign Now or Never! Legal Aid for Inquests. This campaign is calling for the government to urgently introduce automatic non-means tested legal aid funding to bereaved families, like Carl’s, following a state related death.