28 January 2020

Before HM Assistant Coroner Geraint Williams
Cornwall and the Isles of Scilly Coroner’s Court
13 – 28 January 2020

The inquest into the death of Marc Anthony Cole has concluded with the jury finding he died from excess use of cocaine resulting in paranoid and erratic behaviour, with the use of a Taser by Devon and Cornwall Police having a more than trivial impact on Marc going into cardiac arrest. The medical cause of death included the use of cocaine, an episode of altered behaviour including self-harm, excitement, exertion and restraint including the discharge of a TASER X26 device.
 
Marc died on 23 May 2017. He was experiencing a mental health crisis, precipitated by the death of his father. Following a period of self-harm and after having ingested cocaine, the police attended, and Marc was subject to prolonged use of Taser, for a total of 43 seconds, followed by handcuffing. Marc went into cardiac arrest on entry to the ambulance, at approximately 9.30pm and was sadly pronounced deceased at 11.20pm.
 
Marc’s family and friends described him as a loving, popular young man who was a confidante for many of his friends. Growing up, Marc had excelled at sport but sadly had to cease playing following a car accident when he was a teenager. He was the father to two young boys, and his partner described him as an amazing Dad and partner.
 
Exemplary of Marc’s caring nature and empathy for those around him, he became primary carer for his terminally ill father. The death of Marc’s father in 2016 profoundly affected him, and he would visit his father’s grave every day. Marc’s family told the inquest that he had been showing signs of severe depression, anxiety and delusional thinking in the weeks leading up to his death. They believe Marc was reluctant to come forward for help due to the considerable stigma that still exists around mental ill health in young men.
 
The inquest heard that on the day of his death, Marc had gone to a friend’s house where he had appeared fearful that people ‘were coming to get him’. He had a kitchen knife with him, which his friends describe him holding as though he was trying to defend himself. Marc exited his friend’s property through a first floor window. In entering a neighbour’s garden, he accidentally caught the neighbour with the knife causing a superficial minor injury that was later described as a ‘graze’.
 
Following this, the police were called to respond to a ‘stabbing’. Other neighbours also called the police as Marc was now in the street with the knife. Witnesses described him to the police as wandering and not appearing to threaten anyone. One witness told the inquest that Marc looked like a ‘lost soul’. Marc was seen holding the knife to his neck, and officers described him beginning to self-harm on their arrival. The police immediately shouted at Marc to ‘drop the knife’, following which the Taser was discharged, causing Marc to drop to the floor ‘like a sack of spuds’ in the words of one witness.
 
The inquest heard how the effect of the Taser can cause a person’s muscles to ‘lock up’ through Neuro Muscular Incapacitation, and the police officer involved acknowledged that this may have occurred in Marc’s case as he maintained a firm grip on the knife. In total, Marc was subjected to 43 seconds of near continuous Taser, during which time the knife was knocked from Marc’s hand using a baton. Marc was then handcuffed by at least two officers whilst on the ground. Witnesses described hearing Marc shout for his mum and ask, ‘what have I done?’ appearing confused rather than aggressive or angry. Shortly after, he lost consciousness and paramedics arrived responding to the initial 999 call, and were faced with an unexpected scene.
 
The officer who Tasered Marc admitted during the inquest that he had given inaccurate initial statements to the Independent Office for Police Conduct investigation. He said this was on the advice of the Police Federation solicitors, who encouraged him not to “express uncertainty” and to state he had discharged the Taser only twice. However, during the Inquest, the officer admitted discharging the Taser three consecutive times. Other officers echoed the advice of the Police Federation Solicitors in responding to questions regarding why their first accounts differed from later statements.
 
Dr Soar, a medical expert, told the inquest that there is an issue with research and literature on Taser use and dangers, as the majority of the research is produced by the manufacturers of Taser, Axon. The expert indicated that in his view, bolstered by his clinical experience and the research of bodies such as DOMILL*, while the manufacturers’ position was that Taser is not lethal, it is not a device with zero risk.
 
The jury accepted the evidence of Dr Soar and found that the use of Taser had a more than trivial impact. The jury described the actions of the paramedics as appropriate on the evening in question, in contrast with their conclusion relating to the evidence of the police which they rejected. The family feel that this shows that the use of force in this case was clearly not justified in the circumstances. Marc was Tasered for nearly 43 seconds despite the jury not finding that he had been aggressive or posed a threat.
 
Lisa Renee Cole, Marc’s sister, said: “Marc's tragic death has destroyed our lives and we miss him terribly every single day. We were hopeful that this inquest would finally give us some clarity on the critical minutes leading up to his untimely death. Instead we have been confronted with officers falsifying evidence, closing ranks and deferring to the Police Federation.
 
This is not only an insult to our grieving family but leads to a lack of accountability. While there is no transparency or accountability for loss of life, preventable deaths during police contact will continue, and those with mental ill health will continue to be overrepresented in this marginalised group.
 
The Jury have found that the Taser had a more than trivial impact on Marc’s death. What is needed is an urgent review of police use of Taser, considering the lack of robust training in responding to those experiencing mental ill health or intoxication, and the risks associated with repeated and prolonged exposure to Tasering. It is too late for Marc, but we believe this would save lives.”
 
Nadine Kinder, Marc’s partner, said: “An inquest is meant to be about truth, but the only truth I remain sure of is that two innocent children were robbed of a life with their dad and me.
 
Police walk around every day with people’s lives in their hands, but I now believe they are protected from the moment they put on their uniforms. Admitting giving inaccurate statements and raising more questions than they have answers, they have shown no emotion or sympathy for the family they have destroyed.
 
Next time you call the police, who we are meant to trust to help us in crisis, know that it could be your family, friend or neighbour at the blunt end of this. Something needs to be done within the force to ensure that the police understand the ramifications of Taser use, and the pain that is caused when they close ranks during an inquest.”

Deborah Coles, Director of INQUEST said: At a time when the Home Office are spending £10million on arming more officers with Tasers, this inquest has exposed a disturbing lack of understanding and sufficient training on the dangers.
 
Use of force by police is disproportionately employed against those experiencing mental ill health and intoxication, the very people for whom the risks are highest. The data shows Taser use has already rapidly increased, raising questions about whether it is becoming a first not last resort.
 
To prevent further deaths and protect those in crisis like Marc, we must look beyond policing and instead fund our communities’ health, welfare and specialist services.”
 
Emily Comer of Broudie Jackson Canter Solicitors said: “The circumstances of Marc’s tragic death paint a disturbing picture of police use of Taser, particularly against those in mental health crisis. The inquest heard how the use of Taser played a more than trivial part in Marc’s death, while officers involved in both the incident and in training appeared confused over the possible effects of the weapon.
 
The family have conducted themselves with enormous dignity throughout this lengthy and protracted process, in the face of admissions from the police officers regarding inaccurate statements made at the advice of Police Federation solicitors.”
 
ENDS

NOTES TO EDITORS:

For further information, interview requests and to note your interest, please contact INQUEST Communications Team: 020 7263 1111 or [email protected]; [email protected]

Marc’s mother and sister are represented by INQUEST Lawyers Group members Leanne Devine and Emily Comer of Broudie Jackson Canter and Emma Favata of Garden Court Chambers. Marc’s partner is represented by Clare Richardson of Deighton Pierce Glynn. The family are supported by INQUEST Senior Caseworker Natasha Thompson.
 
Other interested persons represented are Devon and Cornwall Police, represented by barrister Mark Thomas of 5 Essex Chambers; South Western Ambulance Service represented by barrister Nigel Lyons of Browne Jacobson and the Independent Office for Police Misconduct represented by Harry Petty.
 
* DOMILL = Defense Scientific Advisory Council (DSAC) Sub Committee on the Medical implications of Less Lethal Weapons. See the DOMILL statement on the medical implications of use of the Taser X26 and M26 Less-Lethal Systems on children and vunerable adults (amended 27 January 2012)
 
Deaths in Devon and Cornwall Police contact:

• Thomas Orchard, 32, died on 3 October 2012 after coming into contact with police whilst experiencing a mental health crisis. Officers used restraint, including an Emergency Restraint Belt over Thomas’ face, which had a causative role in his death. In 2019, the Office of the Chief Constable for Devon and Cornwall were found guilty of a breach of health and safety law in relation to use of the belt. See media release, 3 May 2019.
• Andrew Pimlott, 32, died on 23 April 2013 from complications of burn injuries, after a police officer deployed a Taser whilst he was covered in petrol. The inquest concluded the Taser likely caused his death. See media release, 2 October 2015.
• Leslie ‘Les’ Douthwaite, 38, died following restraint by police and bouncers on 2 May 2015. Les was intoxicated and was handcuffed and restrained in prone position (face down) by an officer. The inquest found restraint and lack of sufficient monitoring contributed to his death. See media coverage, December 2016.
• Chang Somers, 36, was found dead on 22 August 2012 in a garden in Paignton, Devon after being reported missing by his family. An inquest identified major failings by Devon and Cornwall Police, ambulance and community mental health services. See media release, March 2015.

Inquests into some more recent deaths in contact with Devon and Cornwall Police are awaited.

Tasers and policing

• The Home Secretary recently announced £10million of new funding to equip more police officers with Tasers, which are intended to be a ‘less lethal’ weapon option, despite evidence of the dangers.
• Police use of force statistics published December 2019 show significant increases in the use of Taser in recent years. In 2017/18 the use of Taser was recorded 16,900 times, while in 2018-19 a total of 23,500 uses were recorded, an increase of 39%. (See page 16-17). This included use when the Taser was not discharged. In 2018/2019, Taser was discharged 2,700 times.
• The latest data from Devon and Cornwall Police (October 2019) shows they have 976 Police Officers who are currently trained to use Taser. In the next 12 months they plan to increase the number of trained officers by approximately 200.