Before HM Senior Coroner Heidi J. Connor
Reading Coroner’s Court
Town Hall, Blagrave St, Reading RG1 1QH
15 November – 2 December

Today, an inquest into the death of Neal Saunders, 39, who died following prolonged restraint by Thames Valley police officers found that Neal being transported in a prone position and the lack of monitoring whilst in the ambulance may have more than minimally contributed to his death.

Neal was from Berkshire. A well-loved member of his community who was always willing to help others out, Neal’s father said he was “like a brother to so many people”. He described Neal as a very hard worker, fashionable and a “mummy’s boy”.

On 3 September 2020, Neal was suffering a drug induced psychosis in his family home. He was agitated, paranoid and extremely vulnerable. His father, Ron, acted like any concerned parent and sought help from the emergency services, namely the police at around 23:52 when Neal began to hallucinate that Ron had allowed people into their apartment.

Six Thames Valley police officers attended to Neal during the early hours and the last moments of his life. Each of the police officers knew that Neal was presenting with Acute Behaviour Disturbance (ABD), a set of symptoms arising from a heightened state, which amount to a medical emergency.

Despite this, Neal was restrained in rear stacked handcuffs and limb restraints by four police officers for over an hour. Two paramedics from Polaris Medical attended Neal after he had already been restrained for around 50 minutes.

During this time Neal’s condition had visibly and audibly deteriorated. He struggled against the restraint, and he can be heard in Body Worn Video footage pleading with the officers to “get off”, told them “I can’t breathe”, asked to sit up, and his breathing was audibly laboured.

Neal was then transported to the ambulance at around 01:25 hours on a police carry mat in the prone position (face down). On the Body Worn Footage shown to the jury, a Firearms Officer officer is heard saying "We need him on his back, don't we?". PC Brown responded "Just take him any way you can," Another officer replied: "Face down, head up."

Neal was then further transported in prone position (face down) in a Polaris ambulance to Wexham Park Hospital, whilst still in handcuffs and leg restraints. This is contrary to police and paramedic guidance and training which states prone position should be avoided wherever possible. After 14 minutes in this position, he suffered a heart attack, which led to a cardiac arrest.

Neal suffered a further cardiac arrest at 02:36 hours and was placed on life support at Wexham Park Hospital before his life support machines were switched off at 14:15 hours.

This inquest has raised very serious questions about the police and the attending paramedics’ role in Neal’s death – including the use of restraint and the positioning of Neal face down on an ambulance stretcher whilst he was transported to hospital.

The jury found:

  • It was appropriate that Neal was restrained for the duration of the incident, as there was no safe, practicable alternative, although resistance against restraint contributed to his death;
  • Neal stated that that “he couldn’t even breathe”, medical evidence was that he could breathe throughout although it was “laboured”;
  • Thames Valley Police are trained to avoid prolonged restraint but not trained in how to assess when restraint becomes prolonged;
  • Neal was transported in the prone position on a police carry mat and ambulance for 14 minutes. The positioning of Neal may have more than minimally contributed to his death;
  • The JRCALC guidelines for paramedics indicate that transportation of ABD patients in prone position is dangerous. The paramedic was not aware of the guidelines which state that “use of the prone position should be avoided wherever possible or used for a very short period of time only” – but was aware that the prone position should be avoided generally. Police officers suggested positional options for transport from the flat to the ambulance, but the paramedic decided to transport Neal prone.

The jury concluded that the degree of attention paid to Neal’s positioning in the ambulance was unsatisfactory. Neal’s prone position was not causative of death but may have more than minimally contributed to it.

The jury had heard evidence from pathologist, Dr Fegan-Earl, in the course of the inquest who agreed that struggle against restraint and the restraint itself are the same thing in respect of cause of death because it contributes the upset of clinical levels of the person restrained.

Ron Saunders, Neal’s father: “I called the police for help with Neal. I would never have done this if I had known officers would restrain him for over an hour. I thought they might be able to help calm him down.  I defy anyone to be restrained like Neal was and feel able to breathe properly or calm.

I wish there had been an emergency crisis service with properly trained medical professionals who could have helped Neal to relax in some kind of containment rather than subjecting him to prolonged restraint which clearly caused him a lot of distress.

I live with the guilt every single day that Neal might still be alive if I hadn’t called the police but there was no other emergency service who could have helped us. Neal spent his very last moments in life extremely distressed whilst he was restrained by officers and then face down in an ambulance for over 10 minutes in handcuffs and leg restraints. We have got to find another way of responding to someone in Neal’s condition so that no one is forced to experience this kind of treatment.”

Jodie Anderson, Senior Caseworker at INQUEST, said: “‘I can’t breathe’ have been the dying words of men, women and children under restraint across four decades of INQUEST’s work.

Of concern is the total lack of learning from others who have died following restraint and whilst suffering from Acute Behaviour Disturbance, locally and nationally. The IOPC’s total lack of scrutiny in their investigation only serves to perpetuate the lack of accountability and change.

The only solution if we are to prevent further deaths is to look beyond policing and redirect resources into community, health, welfare and specialist services and end the unsafe reliance on police as emergency first responders.”

Rachel Harger of Bindmans LLP, who represent the family, said: “It is clear that someone in Neal’s condition, who is experiencing hallucinations and paranoia, would resist against restraint, which is precisely why restraint in these circumstances can be lethal. Officers are trained to avoid prolonged restraint of those suffering with ABD and yet Neal struggled against restraint for over an hour, ultimately contributing to his tragic death.

The family hope if nothing else that the tragic circumstances of Neals’ death can facilitate a conversation about who is best placed to respond to someone suffering with ABD, drug induced psychosis or any other mental health crisis.  

It is hoped that serious consideration can be given to establishing an emergency crisis team that can respond to those in crisis which is led by medical professionals rather than police, properly trained in de-escalation and containment.” 



For further information please contact Leila Hagmann on [email protected].

The family is represented by INQUEST Lawyers Group members Rachel Harger of Bindmans LLP and Ifeanyi Odogwu of Matrix Chambers. The INQUEST caseworker is Jodie Anderson.

Other interested persons represented at the inquest are Thames Valley Police, Polaris Medical (employers of the paramedics who attended Neal), South Central Ambulance Service and NHS Digital .

Other Thames Valley police related deaths:

  • Brian Ringrose, 24, died on 2 February 2021 following restraint by Thames Valley police officers. Five officers have been advised that they are under investigation for alleged gross negligence manslaughter and unlawful act manslaughter. One of the officers is also being investigated for alleged common assault. The inquest into his death is awaited. See media coverage.
  • Nuno Cardoso, 25, died following contact with Thames Valley Police in Oxford on 24 November 2017. He was restrained and struck with a baton during an arrest, in which it was suspected he had swallowed a package of drugs. Despite this potentially being a medical emergency, he was taken to the police station and not a nearby hospital. He fell seriously ill in the police van and later died. See media release.
  • Adam Stanmore, 37, died on 13 June 2019 following contact with mental health services and Thames Valley police at a time when he was suicidal. Armed response officers discharged Taser and used force to restrain Adam, removing a knife from him. He told police he was suicidal, but when they handed him over to the care of paramedics they did not inform them and he was able to leave the ambulance and later died by suicide. The inquest was critical of the police, ambulance and mental health services. See media release.
  • William Cameron, 38, died whilst in the care of Thames Valley police officers in Loddon Police Station, Reading on 8 January 2020. A police sergeant and health care professional are currently subject to a criminal investigation in relation to his death. See media coverage.
  • Leroy Junior Medford, 44, died whilst in the care of Thames Valley police officers also in Loddon Police Station, Reading on 2 April 2017. The inquest into his death had a highly critical narrative conclusion, identifying individual and systemic failures. His death related to consumption of drugs, and a lack of awareness and action from police. See media release.
  • Habib “Paps” Ullah, 39, died when he was stopped and searched by police on 3 July 2008 in High Wycombe. In the course of being forcibly restrained, Habib suffered a cardiac arrest. He was taken to hospital but attempts to resuscitate him were unsuccessful. The inquest into his death concluded in 2015 and was highly critical of the use of force by Thames Valley police. See media release.
  • Philmore Mills, 57, was being treated in hospital for lung cancer and pneumonia, when he died after police restraint on 27 December 2011. He was subject to restraint by Thames Valley Police, including being handcuffed and pinned face down for an extended period of time. An inquest concluded that restraint and communication failures contributed to his death. See media coverage.