22 December 2023

Before HM Senior Coroner Philip Spinney
Exeter and Greater Devon Coroner’s Court
6 November – 21 December 2023

Thomas Orchard, 32, died following police restraint whilst in mental health crisis in October 2012. Eleven years on the inquest has now concluded. The jury found Devon and Cornwall police failures, around the use of a belt designed for limb restraint as a spit guard, may have contributed to his death. 

The jury also highlighted the impact of prolonged restraint, including that the use and manner of use of the belt was not necessary and reasonable, alongside issues with communication.

Thomas was a church caretaker, who his family describe as a “genuine person and a man of integrity” who was deeply insightful. Thomas, while physically healthy, had a long-standing diagnosis of paranoid schizophrenia for which he was receiving effective treatment in the community. 

Up until the week preceding his death Thomas was stable, happy and living in semi-independent accommodation in Exeter. At the end of September 2012, Thomas’ mental health deteriorated. He had stopped taking his medication.

On 2 October, he was assessed by the Home Crisis Team and was found to be experiencing an acute psychotic relapse. It was decided that Thomas should have a formal assessment under the Mental Health Act 1983 with a view to admitting him to hospital. 

The assessment was arranged for the morning of 3 October. Tragically, Thomas left for church that morning but had not returned home when the assessment team arrived.

After attending church Thomas went to Exeter city centre. He was acting irrationally and in a challenging way towards members of the public. Members of the public called 999 calls stating that Thomas appeared unwell or intoxicated. 

At 11.05am, the police arrived. One of the officers immediately took hold of Thomas and restrained him against the side of the police car. Thomas was taken to the ground and further restrained, face down in the prone position, with handcuffs and leg restraints. He was arrested for a minor public order offence.

Thomas was then carried to a police van, face down and in restraints, and taken to Heavitree Road police station. He was transported in full mechanical restraints whilst positioned on the floor of the van in a very small space.  

Thomas was said to have been quiet in the van and on arrival at the custody centre. The lower leg restraint was removed before he was hopped to the door of the custody unit.

Giving evidence at the inquest, officers said that on entering the unit, Thomas went to “kick out”.  He was immediately taken to the floor and the lower leg restraint reapplied. Thomas was again restrained face down in the prone position.

One of the officers then called out “no biting” and, giving evidence, a police officer and a detention officer (civilian staff) said Thomas had gone to bite them. The detention officer applied an Emergency Response Belt (ERB) around Thomas’ face. 

The ERB had been authorised for use by Devon and Cornwall Police as a “spit/bite” guard, despite it being a piece of equipment designed as a limb restraint. 

Prior to the inquest the Chief Constable of Devon and Cornwall Police pleaded guilty to a criminal offence under health and safety legislation in relation to the use of ERB. The Chief Constable admitted that when introducing the ERB for use as a spit/bite guard there had not been adequate consideration or assessment of the ERB’s use for this purpose. 

The Chief Constable also admitted that there had been subsequent failures to identify the risks the ERB posed to breathing and that training on its use as a spit/bite guard was inadequate. These admissions form part of the record of this inquest.

At 11.24am, Thomas was carried in the prone position (face down, which puts further pressure on breathing) and restrained by four officers to a cell.  One of the detention officers was responsible for holding the ERB around Thomas’ head and lifting him. 

In the cell, Thomas was placed face down on a mattress, and officers searched him whilst restrained and with the ERB still in place. The ERB was not removed until 11.29am, when officers left Thomas in the cell having performed a “cell extraction”. 

Thomas was left in the cell in the prone position. The CCTV footage showed him lying motionless. Thomas was “checked” through the cell door and via CCTV. Officers saw no discernible movement from Thomas. Only 11 minutes later, they re-entered Thomas’ cell and found that he had stopped breathing.

A police nurse administered CPR and an ambulance was called. When paramedics attended, there was a return of spontaneous circulation. Thomas was taken by ambulance to the Royal Devon and Exeter Hospital where treatment continued. 

Thomas did not regain consciousness and was pronounced dead on 10 October 2012. Thomas had suffered a cardiac arrest.

The inquest jury concluded that the admissions from Devon and Cornwall police about the inadequate procurement and processes around the use of the ERB as a spit/bite guard possibly contributed to Thomas’ death. 

While the jury found that officers were acting in accordance with trained techniques when they initially used force against Thomas, they also recognised that Thomas was therefore stressed and in a prone position and this possibly contributed to Thomas’ death.

In their narrative conclusion, the jury findings also included the following issues:

  • The ongoing restraint of Thomas whilst being transported in the van was part of a prolonged restraint which possibly contributed to his death.
  • The communication between officers involved with Thomas in the city centre and in custody, that Thomas may have been suffering from a mental illness, was not reasonable.
  • While the initial application of the ERB was reasonable, as officers were acting in line with their training and had not been provided another option to protect against spitting and biting, the application of the ERB possibly contributed to Thomas’ death.
  • The use and manner of use of the ERB when Thomas was carried was not necessary and reasonable, and there was a lack of warning or communication both with Thomas and between officers. This process likely increased his stress and possibly his ability to breathe, which possibly contributed to his death.

Following the conclusion of the inquest, the family of Thomas Orchard said: 

The conclusion of the inquest marks another milestone as we continue to seek justice for our son and brother. We miss Thomas every day and it has been distressing for us to hear how Thomas was killed and how things could and should have been different.

We are pleased that the inquest has thoroughly and carefully examined elements of Thomas, his life and the circumstances of his death. We are clear that Thomas was in mental health crisis. We have been encouraged by the care and support given to Thomas in the years and days up to his death by Caraston Hall, the NHS and its staff.

Their approach was in stark contrast to that of Devon and Cornwall Police.

We feel that Thomas was let down by those involved in his arrest and detention and they missed many opportunities to prevent his death. We have been troubled by the way that the police have sought to defend their reputation rather than taking accountability for their actions.

We therefore tentatively welcome the findings of the inquest today. However, we feel that the jury could have gone further in finding that the actions of the Devon and Cornwall Police and their staff probably contributed toward his death. We remain very distressed that the coroner did not allow the jury to conclude that the use of the ERB around Thomas’ face probably contributed to his death and that the option of unlawful killing was withdrawn from them.

Throughout the last 11 years the people defending the force, their officers and staff have sought to deflect, mislead and overwhelm those seeking to find answers about the manner of his death. Time and again they have tarnished Thomas’ memory in order to avoid the focus being on the behaviour of officers and staff.

We would welcome the receipt of a full and genuine apology from the Force, something which we have never received to date.

Thomas cannot be brought back but we can only hope that some good can come from his death. We heard some encouraging evidence about some very positive changes that have been made since Thomas died and we can only hope that these changes are implemented robustly with appropriate training, supervision and monitoring.

The biggest change we would like to see is for police staff and officers to treat everyone, especially those in mental distress, with kindness and compassion, - a cultural change - such they earn respect as the Police Service and not just the Police Force.”

Anita Sharma, Head of Casework at INQUEST, said: “Thomas’ family have endured 11 years of protracted proceedings including two manslaughter prosecutions, a Health & Safety Act prosecution, and a lengthy inquest. They have throughout been seeking public accountability for his death.

The family’s experience of the processes which followed Thomas’s death, including the inquest, were marred by a defensive and adversarial approach taken by all those involved. However, nothing can distract from the traumatic nature of Thomas’ death, including the use of an emergency response belt as a spit and bite guard that was neither risk assessed nor authorised by the Home Office for this use.

The fact that people in mental health crisis continue to die following police use of force and in disturbing numbers years after Thomas’ death shows a lack of commitment to learning by police forces on a local and national level.”



For further information and interview requests please contact Lucy McKay on [email protected] or 020 7263 1111. A photo of Thomas is available here

The family is represented by INQUEST Lawyers Group members Helen Stone of Hickman and Rose, Fiona Murphy KC and Alison Gerry of Doughty Street Chambers. They are supported by INQUEST’s head of Casework, Anita Sharma.

Other Interested persons represented at the inquest were the Chief Constable for Devon and Cornwall, PS Kingshott, PCs Kennedy, Nagle, Dodd and Conway, Detention Officers Marsden and Tansley. Nurse Janet Zaloumis and Serco, Devon Partnership Trust and the Independent Office for Police Conduct (IOPC),


· 3 October 2012 - Thomas was detained in Exeter City Centre by Devon and Cornwall police officers that morning. Shortly after midday he was taken by ambulance to hospital.

· 10 October 2012 – Thomas Orchard was pronounced death in hospital.

· 7 October 2013 – The Orchard family made a statement one year on from his death, asking why the investigative and legal processes were moving so slowly. It would be a further ten years until the inquest concluded.

· 17 December 2014 - The Crown Prosecution Service (CPS) charged the custody sergeant and two detention officers involved in the restraint of Thomas Orchard with unlawful act manslaughter, gross negligence manslaughter.

· 12 January 2016 - The prosecution of Custody Sergeant Jan Kingshot and Detention Officers Simon Tansley and Michael Marsden, began.

· 21 March 2016 - The jury in the above trial were discharged for legal reasons. The CPS has said it intended to proceed to retrial.

· 31 January 2017 - The retrial commenced. In his evidence to the Court, Home Office pathologist, Dr Delaney, identified that Thomas’ death resulted from a struggle and period of physical restraint including a prolonged period in the prone position and the application of an Emergency Response Belt across the face resulting in asphyxia.

· 14 March 2017 – The custody sergeant and two detention officers were acquitted of manslaughter, despite the concerning evidence heard.

· 15 February 2018 - The Independent Office for Police Conduct (IOPC) directed Devon and Cornwall Police to bring disciplinary action against six of the seven officers involved with the detention and restraint of Thomas. The family welcomed this decision.

· April 2018 - the Crown Prosecution Service announced its decision to prosecute the Office of the Chief Constable of Devon and Cornwall police for an offence under section 3 of the Health and Safety Act, in relation to the use of the Emergency Response Belt (ERB), the piece of equipment used to restrain Thomas. The CPS decided against bringing charges under the Corporate Manslaughter Act.

· 1 August 2018 – After an earlier hearing in July at the Magistrate’s Court, the Heath and Safety Act trial commenced at Bristol Crown Court.

· 19 October 2018 - Office of the Chief Constable for Devon and Cornwall Police today pleaded guilty to breaching Section 3 and Section 33 of the Health and Safety at Work Act 1974, but did not accept that these health and safety failures caused Thomas’ death.

· 18 April 2019 – A judge determined that he could not be sure that the use of an Emergency Response Belt (ERB) wrapped around Thomas Orchard’s head had a causative role in his death.

· 3 May 2019 - The Office of the Chief Constable for Devon and Cornwall Police was sentenced for health and safety breaches. The judge ordered the Office of the Chief Constable to pay a fine of £234,500, as well as costs of £20,515. This was only the second Health and Safety prosecution relating to a death following contact with police, following the Jean Charles de Menezes shooting by the Metropolitan police in 2005.

· 12 July 2019 – A disciplinary panel discontinued the proceedings against four Devon and Cornwall Police officers facing allegations of gross misconduct in relation their interactions with Thomas, due to abuse of process arguments.

· 24 October 2019 - The IOPC have today informed the family of their decision to withdraw directions for gross misconduct proceedings against two Detention Officers. Meaning none of the six police officers or staff would face gross misconduct charges, as originally directed.

·       6 November 2023 – The inquest was originally suspended by Elizabeth Earland, then HM Senior Coroner for Exeter and Greater Devon, to allow for the criminal prosecutions to take place. After this, the Health and Safety trial and the misconduct processes took place, the family made submissions for the inquest to reopen to ensure the systemic issues and key evidence arising from Thomas’ death be fully explored. This inquest finally reopened on 6 November 2023, with 5 weeks of evidence being heard.

·       December 2023  - The inquest concluded, more than 11 years on from Thomas’ death.