14 March 2017

A custody sergeant and two detention officers have been acquitted of manslaughter relating to the death of Thomas Orchard in October 2012.

Custody Sergeant Jan Kingshot and Detention Officers Simon Tansley and Michael Marsden were charged with gross negligence manslaughter after Thomas died of asphyxia following a period of prolonged restraint in their custody. The jury at Bristol Crown Court found them not guilty.

Thomas was a fit and physically healthy 32-year-old who was living independently in supported accommodation at the time of his death. Thomas had a history of mental illness and a diagnosis of schizophrenia. He had been doing well and was working as a church caretaker. However, by the end of September 2012 he was showing signs of a relapse following interruptions to his medication.

On the morning of Wednesday 3 October 2012, Devon and Cornwall police officers attended Exeter City Centre in response to reports of Thomas’ increasingly bizarre and disorientated behaviour. He was dealt with by seven police officers, handcuffed to the rear and restraints applied to his legs and ankles. He was arrested for a public order offence, carried into a police van and taken, not to a hospital, but to Heavitree Road Police Station.      

Upon Thomas' arrival at the police station, in addition to the triple limb restraints applied, an Emergency Response Belt (ERB), made from a tough impermeable webbing fabric, was put around his face. The ERB was still held around his face as he was carried face down to a cell.

After the restraints were removed, he was then left lying unresponsive on a cell floor for a further twelve minutes. By the time officers re-entered his cell, Thomas was in cardiac arrest. He was transferred to hospital and pronounced dead on 10 October 2012.

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.

Thomas’s family said:

“Today we join a growing group of people who have lost loved ones in police custody and have found no sense of justice.

Thomas cannot be brought back but we want his needless death to bring about change. And the change we want most is in the attitude of the police, particularly towards those with mental health vulnerabilities.

The pain of the past four-and-a-half years has diminished us and today is a setback but, on behalf of those vulnerable people and in memory of our Tom, our fight for truth and transparency continues.”

Deborah Coles, director of INQUEST said:

“It is difficult to reconcile this verdict with the disturbing evidence which has emerged during this trial. Thomas’ death is amongst the most horrific that INQUEST has ever seen.

Thomas was in mental health crisis and should have been taken to hospital. Instead, he was bound and gagged with a restraint belt across his face in what must have been a terrifying ordeal.  Those who should have protected a vulnerable man lost sight of him as a human being. Mental ill health affects so many of us and this could have been any one of us.

The fact that the restraint belt, a piece of equipment neither approved or regulated by the Home Office was used begs questions about corporate responsibility that needs urgently addressing.

At a time when police are calling for more equipment, including spit hoods and tasers, we need to question priorities. Surely the first and most urgent need must be to train officers to respond safely and humanely to those in mental health crisis.

We hope that this trial and the immense courage Thomas’ family have shown will lead to urgent change in police culture and practice towards those with mental illness.”

The solicitor for the family, Helen Stone of Hickman and Rose, said:

“Families who have had to fight for justice following a death in police custody first and foremost want to see police staff held to account for their conduct. Too often criminal charges are not brought until an inquest jury reaches critical conclusions about the death; often many years later. Many families have fought very hard to change this culture. The fact that in this case the IPCC investigation led to a referral, and in turn a prosecution, marks a significant and welcome recognition that a criminal jury should decide issues of criminal liability where the evidence meets the CPS test under the Code of Crown Prosecutors.

A joint investigation by the IPCC and the Health and Safety Executive is ongoing which includes investigation of Devon and Cornwall Constabulary for suspected offences of corporate manslaughter and offences under Health and Safety at Work legislation relating to Thomas’ death. We hope that a decision is now made about these potential charges as quickly as possible.”

INQUEST has been working with the family of Thomas Orchard since his death. The family is represented by INQUEST Lawyers Group members Beth Handley and Helen Stone of Hickman Rose solicitors.




For further information or to secure a media interview with the family or INQUEST, please contact Gill Goodby on 0207 263 1111.

• Police Detention Officers are civilians employed by the police. They work in police custody units.

• The last successful prosecution of a police officer for manslaughter was in 1986 over the death of Henry Foley.

• Since 1990 there have been 1,045 deaths in police custody or following police contact and 63 fatal shootings by police officers in England and Wales. Whilst the number of deaths involving the use of force by the police is a small proportion of the total number of deaths in custody, these deaths have often been the most controversial.

• Since 1990, there have been nine unlawful killing verdicts/findings returned by juries at inquests into deaths involving the police and one unlawful killing finding recorded by a public enquiry none of which has yet resulted in a successful prosecution.

• The majority of INQUEST’s police related cases over the past five years have involved the death of vulnerable individuals in some form of mental health crisis. Following an eleven-year low of 11 police deaths in 2013/14, the number of deaths in or following police contact rose sharply to 17 in 2014/15. Eight out of those 17 deaths were of people identified as having mental health concerns; five were restrained. This marks the continuation of a trend in mental health related deaths where in 2012/13 of the 15 people who died in or following police custody, almost half (seven individuals) were identified as having mental health concerns. In 2013/14 of the 11 people who died, four were identified as having mental health concerns.  See IPCC annual statistical report.

• In February 2016 the Home Secretary announced an independent review, conducted by Dame Elish Angiolini QC, into Deaths in Police Custody. Her report is due to be published imminently. INQUEST Director Deborah Coles was special advisor to the review.

 INQUEST’s written submission to the 2014 Home Affairs Select Committee review of policing and mental health.


INQUEST provides specialist advice on deaths in custody or detention or involving state failures in England and Wales. This includes a death in prison, in police custody or following police contact, in immigration detention or psychiatric care. INQUEST's policy and parliamentary work is informed by its casework and we work to ensure that the collective experiences of bereaved people underpin that work. Its overall aim is to secure an investigative process that treats bereaved families with dignity and respect; ensures accountability and disseminates the lessons learned from the investigation process in order to prevent further deaths.

Please refer to INQUEST the organisation in all capital letters in order to distinguish it from the legal hearing.