9 April 2019

Before Assistant Coroner Elisabeth Bussey-Jones
West Sussex Coroners Court
11 March to 9 April 2019
An inquest into the death of Duncan Tomlin, 32, has today concluded that he died due to cardiorespiratory failure due to both restraint in a prone position and the effects of a combination of drugs, and that his death was contributed to by neglect.

Duncan died on 29 July 2014 in Haywards Heath, Sussex. He became unresponsive after being restrained by Sussex Police and placed into a police van. After over three weeks of evidence, the jury gave a conclusion detailing that:

  • There was no clear continuity of the sharing of information relating to the risk assessment of Duncan’s care as different police officers exchanged positions within the restraint.
  • There was an insufficient sense of urgency to move Duncan onto his side to address the risks of positional asphyxia from prone restraint coupled with the use of handcuffs, limb restraints, the effects of Captor spray and the suspicion that Duncan had taken stimulant drugs. Duncan should have been moved onto his side earlier.
  • Although the police receive training in Positional Asphyxia and the available policies extensively cover it, the efficacy of this training is inadequate.

Duncan is described by his family as being a very creative person who was talented at arts and crafts and enjoyed fishing with his friends.

The inquest heard that at 23.44 on 26 July 2014, two Sussex Police officers were tasked with responding to a call to attend an incident at a residential address, when they arrived they encountered Duncan and his partner, Ann-Marie Botting, in the street. The officers accept they were told by Ms Botting that Duncan was having an epileptic seizure. Duncan is said to have run away. He was subsequently taken to the ground by a Sussex Police officer, using an unrecognized technique, and restrained, assisted by an off-duty Metropolitan Police officer, in the prone position. They put Duncan in handcuffs and captor spray (an incapacitant) was deployed, which is known to have an impact on breathing.

At around midnight, five more officers arrived. At some point, leg restraints were applied. Duncan remained restrained in the prone position for between 8 and 12 minutes, until 00:04 when he was moved into a police van and again restrained in the prone position for just under four minutes. A decision was made to drive Duncan to hospital due to the length of time it would take for an ambulance to arrive. After the journey to hospital had begun the officers gave evidence that they realised that Duncan had stopped breathing, the hand and leg restraints were then removed, and he was taken from the van and CPR was commenced. Expert pathologists told the inquest that the restraint by officers contributed to Duncan’s death.
Evidence was heard that the officers suspected that Duncan was under the influence of stimulant drugs, such as cocaine, and alcohol. They had been told by Duncan’s partner that he may have been having an epileptic seizure. Evidence was also heard that during the restraint Duncan was groaning and shouting incoherently, with mucus “streaming” from his nose and saliva in his mouth. All relevant police witnesses accepted that they owed a duty to keep Duncan safe and to avoid his death. Despite the well-known risk of positional asphyxia (prevented breathing) from prone restraint the officers gave evidence that they did not consider there was a risk of positional asphyxia in this case.

Paul Tomlin, father of Duncan said: "As a family we feel the finding of neglect by the jury is a damning assessment of the police’s behaviour. Coming into the inquest we had real concerns about information sharing, the need to move Duncan onto his side from the prone position, the use of handcuffs, limb restraints, and incapacitant spray, as well as the training that the officers had received in relation to positional asphyxia. Having heard the evidence the jury clearly shared these significant concerns. They have found not only that there were failings, but that there were gross failings.
Throughout the past four and half years we feel Sussex Police and their officers have been arrogant, defensive and evasive. It has been incredibility traumatic to repeatedly have to watch the footage of Duncan in the back of the police van when we consider he clearly needed help. The jury have agreed.

We would like to sincerely thank our barrister Mr Jude Bunting of Doughty Street Chambers and our solicitor Ms Helen Stone of Hickman and Rose for their diligent and tireless efforts in preparing and presenting our case at this inquest; they have both been beyond impressive. 

We thank the coroner for her diligence and humanity. We would also like to thank all the staff in the Coroner’s Court for the kind care and compassionate consideration they have shown us during the last five weeks.

This is not the end of the process; the least we can do is continue to seek clarity and justice for our missing son and brother Duncan.”

Selen Cavcav, Senior Caseworker at INQUEST said“The police are well aware of the dangers of prone restraint and its potential to cause death. Instead of treating Duncan’s condition as a medical emergency they held him face down, brutally restraining him and placing him in a police van where he collapsed. 

For over 3 weeks, Duncan’s family listened to repeated attempts by police lawyers to concentrate on his drug taking to support their narrative that it was his behaviour which led to his own death. The jury conclusion today vindicates them and sends a message to the police that they cannot use unjustified force with impunity. 

This troubling death from police neglect must accelerate much needed change in police leadership, culture and practice.”

Helen Stone, Solicitor at Hickman and Rose, who represented the family said: "The jury's conclusion that Duncan Tomlin died due to neglect is a damning indictment of the police's actions in this case - and the way police treat vulnerable people generally.

Neglect means causing someone's death by a gross failure to provide basic medical attention to someone who obviously needs it - but cannot look after themselves. In this case, the inquest jury clearly held that Sussex police neglected Duncan's urgent needs with the result that he died.

All Britain's police forces have strict rules governing how their officers can restrain vulnerable people; and all officers should receive extensive training on how to abide by these rules.

But the sad reality is when these rules are breached – as they often are - the only way in which those responsible can be held to account is by putting pressure on the authorities through the courts.

Today's decision is a vindication of the Tomlin family's four year battle for accountability against denial and obfuscation from Sussex police and the bodies charged with overseeing police conduct.”



For further information, please contact Lucy McKay and Sarah Uncles on [email protected] [email protected]
INQUEST has been working with the family of Duncan Tomlin since August 2014. The family is represented by INQUEST Lawyers Group members Helen Stone of Hickman and Rose and Jude Bunting of Doughty Street Chambers.
Despite the fact that there are seven other legal teams representing nine other individuals and organisations at this inquest, some through the public purse, the family has been asked by the legal aid authority to make a financial contribution to their legal representation.

In addition to Paul Tomlin and his family, the other Interested Persons being represented at the inquest are:

  • Anne-Marie Botting
  • Chief Constable of Sussex Police
  • Police Sergeant Glasspool
  • Police Constable Jewell
  • Police Constable Jackson
  • Police Constable Watson
  • Former Police Constable Bennett
  • Former Detective Constable Shahbazi
  • South East Coast Ambulance Service

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 Duncan’s, following a state related death. 

A photo is available upon request.
Restraint related deaths

  • The Independent Review into Deaths and Serious Incidents in Police Custody, published in October 2017, recommended that ‘Police practice must recognise that all restraint can cause death’, and made strong recommendations to prevent such deaths. See INQUEST Briefing on Angiolini review, P.3
  • The government’s Deaths in police custody: progress report, one year on from the Angiolini review, did not note any progress on use of force and restraint in policing.
  • In the financial year 2017/18, the Independent Office for Police Conduct reported that seventeen of the people who died in or following police custody or other contact were restrained or had force used against them by the police or others before their deaths.

To reach a neglect conclusion, the jury much be satisfied that there is a gross failure:

  1. To provide or procure basic medical attention;
  2. For someone in a dependent position who cannot provide for himself, in this case due to incarceration;
  3. Whose condition or need is known or should be known to those providing care; and
  4. The failure(s) had a direct and clear causal connection with the death, which means the failure(s) contributed in a more than minimal, negligible or trivial way to the death.