18 July 2019

Before HM Senior Coroner for Oxfordshire Darren Salter
Oxford Coroner’s Court
8 - 17 July 2019

Nuno Cardoso died following arrest by Thames Valley Police in Oxford on 24 November 2017. The inquest concluded yesterday (17 July) with the jury reaching an uncritical narrative conclusion, despite the troubling evidence heard during the hearing. Nuno was one of five black men to die following use of force by police in the year 2017, the majority of which relate to the police’s response to drug swallowing or consumption.

Nuno, from Kentish Town in London, was 25 years old and in the first year of a law course at Ruskin College in Oxford. His family describe him as a caring, charismatic and outgoing person, the life and soul of their home, who wherever he went would bring laughter.

Nuno was arrested at Ruskin College at approximately 4.50am on 24 November 2017, following reports of an altercation. Restraint and batons were used during the arrest. The inquest heard that Nuno was demonstrating signs of intoxication. In the body worn video recorded of the arrest, which was shown during the inquest, officers can be heard discussing the possibility that Nuno had something in his mouth. At this point Nuno was not properly communicating with the officers. One of the Ruskin College witnesses described Nuno as talking as though he had a mouth full of food. The officers told him that if he did not show them what was in his mouth that they would have to take him to hospital. Officers told the inquest that they ultimately did not believe he had anything in his mouth.

Police guidance at the time was that, if someone was believed or suspected to be packing drugs, they should be taken to hospital. However, Nuno was not taken to the hospital five or six minutes away, but instead was transported in a van to Abingdon Police Station, around 20 minutes away. Officers reported that, on the way to the police station, Nuno appeared to be chewing something, started to sweat and slumped in his seat. Police officers gave some first aid and the ambulance service was called. Nuno was then taken to the John Radcliffe Hospital and died later that day.

The jury reached a narrative conclusion which included that:

  • They accepted the police officers’ evidence that they did not believe that Nuno had swallowed drugs or that he had anything in his mouth.
  • This was not a medical emergency until the situation rapidly changed when Nuno became unwell at approximately 5.20am.
  • Nuno died at 6.23pm from cardiorespiratory arrest caused by the combined drug intoxication caused by alcohol, cocaine and morphine (heroin).

Doroteia dos Santos, Nuno’s mother said: My family and Nuno’s friends have had to endure over a year and a half of waiting since Nuno’s death and six days of evidence in the coroner’s court to find out the truth about how he died. We are extremely disappointed by the jury’s conclusion, which we cannot reconcile with the evidence we heard.

Nuno was the youngest of my children, and the bonds we shared with him as a family have been broken so abruptly. We are thankful that we were blessed by such a beautiful, caring person even if was for just a short time.

Each of the four police officers involved accepted in evidence that they knew of the guidance which said, if someone was believed or suspected to have swallowed or be packing drugs, that they should treat the situation as a medical emergency. Officers also accepted that they had a duty of care to my son.

Yet Nuno never opened his mouth to show the officers whether he had anything inside and he was not taken to the hospital, despite it only being five or six minutes away. Instead, officers set off for Abingdon Police Station, around 20 minutes away, and Nuno collapsed in the back of the van.  My belief is that those officers did not care for my son. Nuno should have been afforded respect and dignity. I do not think he got that on 24 November 2017.”

Please also see the full statement of the family.

Deborah Coles, Director of INQUEST, said: “The police encounter a variety of people, many of whom are vulnerable, unwell or intoxicated. Recent inquests have highlighted failures or delays in police responding to dangerous situations as medical emergencies. Too often this is based on a suspicion of people feigning illness or a problem, particularly those from black and minority ethnic groups.

There is no harm in police taking people to hospital to be checked and receive care. However the cost of overlooking warning signs, especially to families like Nuno’s, is immeasurable. There are clear policies in place to safeguard individuals suspected of consuming or swallowing drugs. The inquest heard that, not only were officers aware of them, but if they had been followed Nuno may have been saved. Police forces nationally need to improve their policies and practices to ensure care, not disbelief, is the default position.”

Ruth Mellor of Saunders Law, who is representing the family, said: “The evidence heard over the course of this inquest has reinforced concerns about the police response to people in their care, as well as the action that they take when things go wrong. The jury saw footage of officers asking Nuno what he had in his mouth, discussing whether he had anything in his mouth, and telling him that they would have to take him to hospital if he did not open his mouth.  Despite this, Nuno was not taken to the hospital that was only five or six minutes away.

It is hugely concerning that officers who gave live evidence in this inquest said that they thought at some point that Nuno was faking – whether that was pretending to have something in his mouth or pretending to become unwell. The risks associated with swallowing or packing drugs are high, and if police officers do not take these situations seriously then families will continue to lose loved ones while they are in the custody of the police.

Before they wrote their initial accounts, the four key officers were told by their sergeant that they could talk amongst themselves, with no guidance as to what they could and could not talk about. Poor post incident management such as this makes it especially difficult for families to have faith in IOPC and Coronial investigations.”


For further information please contact Lucy McKay 020 7263 1111 or [email protected]  

INQUEST caseworker Natasha Thompson has worked alongside Nuno’s family since his death. Nuno’s family are represented by INQUEST Lawyers Group members Ruth Mellor of Saunders Law and Una Morris and Laura Profumo of Garden Court Chambers.

Other Interested persons represented were Thames Valley Police, four of the police officers involved in the incident, and South Central Ambulance Service.

As well as Nuno’s death, INQUEST are aware of the following deaths of black men in 2017:

  • 19 July 2017 - Darren Cumberbatch, 32, died in Nuneaton, Warwickshire following restraint by police. The inquest concluded in June 2019 finding that the police’s restraint contributed to his death, which was a result of multiple organ failure relating to cocaine use in association with restraint and related physical exertion.
  • 15 July 2017 - Shane Bryant, 29, died in Leicestershire following restraint by members of public and police two days earlier. The inquest is awaited.
  • 21 June 2017 – Edson da Costa, 25, died following a stop by police in East London six days prior. The inquest concluded in June 2019 finding his death was by ‘misadventure’. During the stop, Edir placed a package (later identified as containing drugs) into his mouth and was restrained. He became unconscious and was taken to hospital.
  • 22 July 2017 - Rashan Charles, 20, died in Hackney, East London following restraint by police. The inquest concluded in June 2018, finding his death was “accidental”, and that the officer used “justified use of force” but did not take appropriate action for medical emergency. The jury found the officer not follow prescribed police protocol for when someone is not breathing and suspected of swallowing drugs.

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.

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.

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.

Other recent inquests of relevance include:

  • Inquest identifies missed opportunity by Kent Police to seek medical treatment for Carl Maynard after suspected drug swallowing (Media Release, 11 June 2019). The inquest jury found that ‘failing to take Carl directly to hospital’ represented a ‘missed opportunity to increase Carl’s chance of survival’.  Since Carl’s death Kent Police changed their policy shortly to ensure that anyone suspected of swallowing a substance should be taken directly to hospital.
  • The jury at inquest into death of Leroy (Junior) Medford concluded that his death was contributed to by "a clear lack of awareness" of and failure to implement, the Thames Valley Police Drugs Standard Operating Procedure on the part of all officers who dealt with Junior on the evening of his death (Media release, 27 June 2019).
  • Adam Harris - Evidence was heard that between Adam’s arrest and his arrival at the custody suite he was not searched. Whilst held in the van dock Adam began to demonstrate increasingly bizarre and concerning behaviour, but the custody sergeant was not alerted. He later produced a small plastic ‘snap bag’ from his mouth. This was finally recognised by the custody sergeant and the nurse as being a medical emergency, because of the dangers of swallowing packaged drugs, but there was a delay of some six minutes before an ambulance was called. The jury found that the cause of death was cocaine and alcohol toxicity (Media release, 14 June 2019).