6 June 2019

Before HM Senior Coroner Nadia Persaud
Coroner for the Eastern Area of Greater London
Tuesday 7 May – 6 June 2019

Edir Frederico Da Costa, known as Edson to his friends, was 25 when he died following contact with police.  A jury has today returned the conclusion at the inquest into his death, making a majority ruling of 9:2 that Edir died by ‘misadventure’.

The jury further recorded a narrative of facts which noted, Mr Da Costa died from the consequences of cardio respiratory arrest after his upper airway was obstructed by a plastic bag containing drugs he had placed in his mouth.”

Edir was stopped by Metropolitan Police in East London on 15 June 2017. During this stop, he placed a package (later identified as containing drugs) into his mouth and was restrained. Edir became unconscious and was taken to hospital. He did not regain consciousness and died six days later on 21 June 2017.

The inquest heard that during the ‘stop and search’ of Edir, he was restrained on the ground by four officers. He was held in the ‘prone’ position face down, handcuffed with his arms behind his back, and was hit by two ‘distraction blows’ (one open, one closed handed), two applications of the ‘mandibular angle’ pressure point pain compliance technique and CS spray used at close proximity to Edir’s face, despite police guidance suggesting that generally a one metre limit is appropriate. 

Evidence was heard that during the course of restraint, Edir became unresponsive. Armed Response Vehicle officers arrived on scene and commenced CPR.  At 10.05pm, an officer radioed for an ambulance, but the Metropolitan Police Service call handler initially gave the London Ambulance Service the incorrect address, referring them to “Woodcote” in Surrey. This contributed to delays in the paramedics arriving. When the paramedics arrived at 10.18pm they took over attempts to resuscitate Edir. He was conveyed to Newham Hospital where he died several days later.

Edir was born in Portugal and had lived in London since he was four years old. He was a loving father and partner. He was very close to his family who describe him as generous, loving and resilient. He loved to eat sweets, to dance with friends and family, and had a passion for fixing things. Edir volunteered with “Street League”, a sports coaching company that helps to coach children aged 8 – 11 years in football. He was awarded a Sports Leadership Award for his work with them.

Black men disproportionately die following restraint by police. Edir was one of four black men to die following restraint by police in just five weeks in 2017. The Independent Office for Police Conduct 2017/18 annual statistical report identified the highest number of deaths recorded in or following police custody since 2004, 17 involving the use of force and restraint. 

Legal submissions on whether the coroner should make a report to prevent future deaths will be made at a future hearing.

Ginario Da Costa the father of Edir Da Costa said:To hear the detail of the last moments of Edir’s life has been an extremely traumatic experience for the whole family and is something we will never be able to erase from our minds. It has been particularly difficult to hear about the officers holding Edir in the prone position and spraying CS spray in his face from just a few centimetres away.

It is hugely upsetting to us that the unarmed officers did not identify the risk that he might be choking. We also now understand from the expert evidence that what the lead officer thought were Edir’s yawns were in fact his dying breaths. We find it very worrying that Edir was thought to be breathing normally when he does not appear to have been. The Metropolitan Police then gave the London Ambulance Service the wrong address, leading to a delay in the paramedics arriving. We cannot help but wonder whether Edir would still be here had the police identified the risk of Edir choking earlier and taken steps to help him.

Edir’s passing has left a huge hole in all of our lives. Seeing him with his little boy made me so proud, but now his son will have to grow up without his father. Losing Edir has broken my heart and I have still not come to terms with his death. Edir did not deserve to die in the way that he did and we will forever feel that if things had been done differently his life may have been saved.”

Deborah Coles, Director at INQUEST, said: “Edir is one of a five young black men who died after police restraint within a six-month period. Officers restrained him and failed to recognise that he was choking and unable to breathe.

A hostile environment was created at this inquest through the defensive and combative tactics of police lawyers, who sought to narrow lines of inquiry and divert attention away from the circumstances that resulted in Edir’s death. Such tactics have been criticised in both the Bishop of Liverpool’s post Hillsborough Review and the Angiolini review into deaths and serious incidents in police custody. This unduly adversarial approach must not be tolerated as it fundamentally undermines the ability of an inquest to seek the truth to prevent future deaths.

This case also underscores the importance of bereaved families having proper legal aid in inquests. It is hard to imagine how Edir’s family could have coped with the volume and complexity of the evidence, and the police lawyers’ arguments, without proper representation”.

Susie Labinjoh, Head of Civil Liberties at Hodge & Allen, who represents the family, said:The inquest into Edir’s tragic death has revealed a series of concerns about how the police respond to those who are suspected of placing drugs or other items in their mouths. Officers should be taught not to assume that a person is resisting arrest when there is a risk that they are struggling because their breathing has been restricted. There appear to be deficiencies in the training of police officers with regard to choking risks and identifying when a person’s breathing is abnormal. In addition, there were apparent issues surrounding the need for a safety officer to consider a person’s welfare during a restraint.

There are also serious issues surrounding the ability of Metropolitan Police control room staff to hear information provided and to accurately convey this to the London Ambulance Service. It is clear from the evidence that a great deal needs to be done, both with officers on the street and those in the control room, to ensure tragedies like this do not happen again.”



For further information, photographs and to note your interest, please contact Lucy McKay and Sarah Uncles on 020 7263 1111 or [email protected] [email protected]  

INQUEST has been working with the family of Edir da Costa since shortly after his death. The family are represented by INQUEST Lawyers Group members, Susie Labinjoh, Brid Doherty and Cormac McDonough of Hodge Jones & Allen solicitors, and Henrietta Hill QC and Samuel Jacobs of Doughty Street Chambers.

Other interested persons represented at this inquest are the Metropolitan Police, the five plain clothed officers, London Ambulance Service and the IOPC.

Family run ‘Justice 4 Edson’ campaign pages can be found on Facebook, Twitter or Instagram.

The Independent Office for Police Conduct (IOPC) most recent annual statistics on deaths during or following police contact in England and Wales, published on 25 July 2018 showed:

  • There were 23 deaths in or following police custody, the highest figure recorded in the past 14 years, and an increase of nine since last year.
  • Four people who died in or following police custody were detained under the Mental Health Act.
  • Seventeen of the people who died in or following police custody or other contact, including Edir, were restrained or had force used against them by the police or others before their deaths.
  • 12 of the 23 people who died in or following police custody had mental health concerns.

See the INQUEST media release and our rolling statistics on deaths in or following police contact for further information.

In December 2018, the Home Office published the first national statistics on police use of force (April 2017-March 2018). Black people were overrepresented, as subject in 12% of incidents but representing only 3.3% of the general population. See INQUEST media release for more information.

In 2017, as well as Edir, INQUEST are aware of the following restraint related deaths of black men, three of whom died within four weeks of Edir’s death:

  • 19 July 2017 - Darren Cumberbatch, 32, died in Nuneaton, Warwickshire following restraint by police.
  • 15 July 2017 - Shane Bryant, 29, died in Leicestershire following restraint by members of public and police two days earlier.
  • 22 July 2017 - Rashan Charles, 20, died in Hackney, East London following restraint by police.
  • 24 November 2017 - Nuno Cardoso, 25, died in Oxford following restraint by police.

The following year, on 3 March 2018, Kevin Clarke, 35, black man experiencing mental ill health died in Lewisham, South London, following restraint by police officers.

In October 2017 the landmark Independent review of deaths and serious incidents in police custody by Dame Elish Angiolini QC was published. In December 2018, the Home Office published a report on progress on deaths in police custody.

Angiolini’s review found that police practice must recognise that all restraint can cause death and made a series of recommendations on the use of force and restraint more broadly. She also made recommendations on institutional racism, as well as on intoxicated subjects. The progress report by the Government does not mention any progress on these important recommendations, despite commitments in their original response to the review.

The Bishops review of the experiences of families affected by Hillsborough calls for important changes in the response to state related deaths and includes recommendations on:

  • Cultural change at inquests which would ensure the process is not adversarial, but inquisitorial as intended, upheld by relevant Secretaries of State who should make clear how public bodies should approach inquests.
  • A ‘Charter for Families Bereaved through Public Tragedy’ in which public bodies would commit to placing the public interest above their reputation and approach forms of public scrutiny such as inquiries and inquests with candour.

In February, INQUEST launched a new campaign - Now or Never! Legal Aid for Inquests. We are calling for the introduction of automatic legal aid funding for bereaved families following state related deaths.