9 October 2020

Before Senior Coroner Andrew Harris
Southwark Coroner’s Court
7 September to 9 October
An inquest has today concluded that the death of Kevin Clarke was contributed to by restraint and highlighted serious failures involving Metropolitan Police Officers, the London Ambulance Service, South London and Maudsley NHS Trust (SLaM) and Jigsaw, an assisted housing provider. The jury found that opportunities for earlier, less restricted intervention were missed by SLaM and Jigsaw, and that the use of restraints by police were ‘a high risk option’ which ‘escalated the situation to a medical emergency’.

Kevin Clarke, a 35 year old black man, was experiencing a mental health crisis when he died following restraint by Metropolitan Police officers in Lewisham, South London, on 9 March 2018. During the restraint, which lasted 33 minutes, he told officers 'I can’t breathe' and 'I’m going to die', but they said they did not hear him. Despite this, the jury concluded that it was ‘highly likely’ that at least one officer heard Kevin say ‘I can’t breathe’.

The medical cause of Kevin’s death was Acute Behavioural Disturbance (in a relapse of schizophrenia) leading to exhaustion and cardiac arrest contributed to by restraint struggle and being walked. The jury found the following issues possibly or probably contributed to Kevin’s death:

  • The failure of the ambulance crew to conduct a complete clinical assessment on their arrival, and provide appropriate clinical advice, both of which amounted to a failure to provide basic medical care.
  • Jigsaw’s and SLaM’s crisis management plans did not include critical information to assist with Kevin's wellbeing and relapse management which was inadequate and a serious failure in the quality of care.
  • Inappropriate management of the relapse by the community mental health team.
  • Inappropriate restraint and failures to properly supervise the restraint by police officers.
  • Inadequate risk assessments by the paramedical staff together with the police officers of Kevin’s condition.
  • The inappropriate way in which Kevin was moved from the playing field which impaired his breathing and increased the stress on his body. 

Kevin (known as KC) was diagnosed with paranoid schizophrenia when he was 17 years old. From February 2016 he resided in assisted living for people with complex mental health needs run by Penrose Jigsaw Project. He was under the clinical care of South London and Maudsley NHS Trust (SLaM).
The inquest heard that two days before his death, Kevin had not attended his mandatory medication supervision. When staff next saw him the next day, he appeared unwell and staff become concerned that he may be relapsing. When Jigsaw staff notified the SLaM team, Kevin’s responsible clinician advised that he would likely need to be taken to a place of safety by the police under Section 136 as he deteriorated quickly when he was relapsing. Kevin was considered high risk by SLaM on the day of his death. Despite this, no plans were made by SLaM to manage the Section 136 process and nobody was specifically assigned to see him. The inquest heard evidence that the care plan drawn up by SLaM and in place for Kevin had not been updated to include crisis management advice.
On the day of his death, Kevin had been standing outside in the cold for over four hours before the Jigsaw staff called the police. When the police did eventually arrive to see Kevin, officers assessed that they did not have sufficient grounds to use their Section 136 powers to detain him. These officers had not been aware that a community mental health nurse had spoken to Kevin not long before they arrived, albeit completely by chance, and had assessed that Kevin was relapsing, hallucinating and needed to be taken to a place of safety. The police did not consult any mental health professionals before making their decision not to use their Section 136 powers.
Minutes after these police officers left the scene, the police were called to a report of a large man running through gardens and climbing over fences. When police arrived, Kevin was found lying on the wet muddy field, rolling side to side and mumbling to himself. In total nine officers attended. Evidence was heard at the inquest that the officers had recognised signs of mental ill health and Acute Behavioural Disturbance (ABD**) and were aware of the risks of restraint. Police called an ambulance but did not communicate their concerns about ABD.
After been contained for over ten minutes, as soon as Kevin attempted to get to his knees, although swaying from side to side and visibly unwell, police officers lay hands on him and immediately restrained him. Kevin was handcuffed in the rear stack position, placed in the prone and then semi-prone position and then had leg restraints placed on him. The jury found that the officers' decision to use restraint was inappropriate because it was not based on a balanced assessment of the risks to Kevin, compared to the risks to the public and police. They concluded that Kevin was generally cooperative and responsive up until the point when officers laid hands on him.
When the ambulance crew arrived at the scene around ten minutes after the restraint began, they stood back and did not carry out a proper assessment of Kevin’s health, with the lead paramedic telling the inquest that she felt too scared to get close to him to do so. The paramedics did not bring their medical emergency bag. The LAS were not made aware of and did not recognise signs of ABD.
The police officers and paramedics briefly discussed carrying Kevin to the ambulance using a carry sheet or moving the ambulance to the field, however it was decided by the police to walk Kevin under significant restraint. When Kevin was eventually taken to the ambulance, he bent over at the waist and handcuffed behind his back, with officers at his sides and back. His hoody was pulled over his head and downwards, obscuring his face. Officers and paramedics accepted at the inquest that this inhibited their ability to monitor Kevin’s vital signs. The jury found that the choice of conveyance worsened Kevin’s state of exhaustion, added more strain on his body and led to his cardiac arrest.
During this move, Kevin collapsed twice over a short period. No medical intervention or assessment was offered by the paramedics and the police officers did not conduct a check on his welfare. After the second collapse, his head appeared limp and he was unresponsive. A carry sheet was then used to move Kevin to the ambulance, where at 3.14pm cardiac arrest was reported, and chest compressions initiated. Restraint devices were initially kept on even as paramedics administered emergency treatment. Kevin was pronounced dead at 4.17pm at Lewisham hospital.
Kevin’s death comes in the broader context of a disproportionate number of black men who have died following use of force by police in England and Wales, and the well-known risks of restraint as highlighted in recommendations arising from previous deaths.
Wendy Clarke, Kevin’s mother, said on behalf of the family: “KC was a loving kind caring person who always looked out for others. But those involved in his death saw him as the stereotyped big black violent mentally unwell man. KC was restrained unnecessarily and with disproportionate force. There was a lack of engagement, communication and urgency by all those who owed him a duty of care. Despite the fact that KC can be heard saying ‘I can’t breathe’ and ‘I’m going to die’ they ignored him. So to hear officers say they would not do anything different is shocking. My son lost his life because of a number of missed chances by the mental health team, the accommodation provider, the police and paramedics who all stood by and let KC die.
KC was loved by many and will be missed dearly. In his memory we want to see accountability, and real change, not just in training, but the perception and response to black people by the police and other services. We want mental health services better funded so the first point of response is not just reliant on the police. There must not be another George Floyd, Sean Rigg or Kevin Clarke.”
Anita Sharma, Head of Casework at INQUEST, said: INQUEST has documented a long history of Black people disproportionately dying following use of force and neglect by police, particularly those experiencing mental ill health. This inquest is further evidence of discriminatory treatment which is rooted in racial stereotypes of the violent and dangerous ‘big Black man’, rather than the relevant training or procedures.
There is an urgent need for structural and cultural change in policing, mental health and healthcare services. One which ends the reliance on police to respond to public health issues, and which confronts the reality of institutional racism in our public services.”
Cyrilia Davies Knight, Solicitor at Saunders Law who represented the family, said: “This inquest has highlighted the many failings by all those who were involved in the events that led to Kevin’s death. The jury have found and it is clear from the body worn camera footage shown during this inquest that the officers did not need to restrain Kevin, and when they did, the force used during the restraint was excessive, inhumane and contributed to his death.
This inquest has also highlighted the systemic problems associated with the way in which people with mental ill health are often treated as criminals rather than patients by public bodies in times of crisis. This is all too familiar and needs to change.” 


For further information, please contact Sarah Uncles on 020 7263 1111 or [email protected] 
Interviews with the family, legal team, and INQUEST are available on request. A photo of Kevin is available here.
INQUEST has been working with the family of Kevin Clarke since his death. The family is represented by INQUEST Lawyers Group members Cyrilia Davies Knight and Ben Curtis of Saunders Law and Professor Leslie Thomas QC and Ifeanyi Odogwu of Garden Court Chambers. The INQUEST caseworker is Anita Sharma.
The other interested persons represented at the inquest are the London Ambulance Service, South London and Maudsley NHS Foundation Trust, the Jigsaw Project, the Metropolitan Police Service, nine police officers, and the Independent Office of Police Conduct.
*Section 136 of the Mental Health Act (1983) enables police to detain people who they think have mental ill health requiring ‘care or control’, to be taken to a ‘place of safety’ which could be a home, hospital or police station. 
**Acute Behavioural Disturbance (ABD) is an umbrella term for a set of conditions, which can often be life threatening. ABD is regularly connected to restraint related deaths in custody, particularly where the person is experiencing a mental health crises. Police guidance associates the condition with symptoms including agitation, sweating, and insensitivity to pain. It is understood to be a serious medical emergency.
In October 2017 the landmark Independent review of deaths and serious incidents in police custody by Dame Elish Angiolini QC was published. Commissioned by Theresa May when she was home secretary, the reviews recommendations included tackling discrimination, through recognition of the disproportionate number of deaths of people from Black, Asian and Minority Ethnic groups following restraint and the role of institutional racism, both within IPCC (now the IOPC) investigations and police training.
Black people are subject to 16% of use of force by police, despite comprising 3% of the population (Home Office data on use of force, April 2018 to March 2019). Analysis of available data by INQUEST shows: the proportion of deaths in police custody of people from Black and Minority Ethnic groups where restraint is a feature is over two times greater than in other deaths in custody. More information on race and deaths in custody is available on our website.