Thomas’s Inquest

Posted on by MentalHealthCop

The time passed between the death of Thomas Orchard in Exeter in October 2012 and the inquest conclusion just before Christmas 2023 is the longest I’ve known.  In years spent looking at death-after-contact inquests in policing and mental health, +13yrs is the most egregious of all the delays, but then a lot has had to happen.

Thomas died after collapsing under restraint in Exeter Police Station having been arrested for a public order offence in the city.  Investigations took place, by the (then) Independent Police Complaints Commission and the Health & Safety Executive, leading to criminal prosecution of both individual officers involved in the incident for manslaughter and of the Chief Constable of Devon and Cornwall Police for health & safety at work offences.  The jury in the manslaughter trial were dismissed leading to the need for a second trial which acquitted the officers and staff involved and after the Chief Constable pleaded guilty to the H&S offences, there was then a disciplinary process to finalise.

All of this took place before the senior Coroner for Exeter began the seven week inquest process in November 2023 and whilst I’m still far-from-convinced 13yrs is anything like fair on Thomas’s family and they have said as much in their post inquest remarks.  I’ve also noticed over the last two months how little coverage this inquest has received when compared to other death-after-custody incidents which had almost daily updates on the BBC news website and several mid-inquest updates during the evidence on broadcast media.  I can only wonder why this didn’t happen in Thomas’s case, given how similar many of the issues were and how exceptional one aspect was.

NARRATIVE CONCLUSION

The jury has returned a narrative conclusion.  This means they have answered a series of questions from the Coroner to outline certain facts they have determined to be true —

  • Thomas died after suffering a cardiac arrest in police custody and he died at hospital after attempts by paramedics and doctors to treat him failed.
  • Communication with Thomas throughout his arrest, transport and detention in custody was unreasonable.
  • He died following prolonged restraint which possibly contribute to his death.
  • The application of an “Emergency Restraint Belt” (ERB) was reasonable in the first instance but its application possible contributed to Thomas’s death.
  • The manner of the ERB’s use once applied was not necessary or reasonable and there was a lack of communication with Thomas whilst it was applied which possibly affected his ability to breathe and possible contributed to his death.

Evidence was heard at the inquest that Thomas may have stopped taking medication for his mental health problems.  He was assessed by the Crisis Team on 2nd October 2012 and found to be relapsing and acute psychotic – they decided formal assessment by an AMHP and two Doctors should occur and that assessment was arranged for the following morning, 3rd October.  Thomas left his home for church that morning and had not returned when the team arrived for the assessment.  After church, he headed in to the city centre where various 999 calls were made about his behaviour, including statements that he seemed unwell or intoxicated.

Upon arrival of the police, he was immediately restrained and arrested for a minor public order offence (I will assume it was section 5 of the Public Order Act 1986, based on descriptions of behaviour given).

PLACE OF SAFETY

Thomas’s family has said throughout that he was in mental health crisis when the police encountered him and both his sister and brother have commented over the years they believe he should have been removed to a place of safety.  Of all the processes in this case, including the inquest, this is one aspect I have read little about and I admit I do remain curious how the inquest covered this point, if at all.  Thomas was arrested in a public place so if officers had concerns about his mental health it was an option to consider use of s136 of the Mental Health Act.  Of course, it’s not always possible to know what is driving human distress and there are countless arrests for disorderly or disturbed conduct where it’s only later, perhaps once things have calmed to some degree, that someone’s mental health issues come in to focus.

There is something else to note about removal to a Place of Safety.  I wrote about Thomas’s case in 2017 when the second criminal trial cleared the custody sergeant and detention officers of manslaughter.  Within that post I touched upon s136 and removal to a Place of Safety and someone commented on the post —

“I used to be an officer with D&C police and worked for many years in Exeter … I can tell you that any person detained under s136 MHA who is in any way violent (and I mean even in the most minor way) will not be accepted at the designated place of safety. The exclusions also apply to anyone under the influence of drugs or alcohol, and often anyone who has been violent in the past.”

Fortunately for others, but sadly in reflecting on this case, much has changed since 2012 – including the law.  Since 2017, no-one may be removed to police custody whilst detained under s136 MHA unless certain specific criteria are met, including the authorisation of a police inspector.  I’ve written before that I would never be prepared to authorise such a thing because anyone satisfying the other criteria, which some would argue Thomas was, would be at risk from medical implications of restraint and without anyone having an adequate understanding of what may be driving behaviour giving cause for concern.

MEDICAL IMPLICATIONS OF RESTRAINT

Of course, none of that matters at all if someone was arrested for a minor Public Order Act offence – people arrested for offences go to custody and the MHA Regulations about use of police custody as a Place of Safety are legally irrelevant to anyone not detained under the MHA.  Something I’ve said in other inquests where I have been involved and which is borne out my medical guidance published since Thomas’ death, is the medical implications of restraint.

Since these sad events, various medical publications have underscored the need to consider whether prolonged, resistant behaviours may have a medical cause or consequence – or both.  And of course, where this may be true it would remain true regardless of whether you’re arrested for an offence, detained under the MHA or not detained at all.  In effect, they are saying that where there is concern for mental health, drugs or alcohol or suggestion of medical factors in play, prolonged restraint should be considered a medical emergency.

You can get a sense of this across the following documents —

It’s the final document I want to highlight, however and it is a document I mentioned to the senior Coroner for Bedfordshire during the Leon Briggs inquest and which was cited by her in the Preventing Future Deaths report issued subsequently.  Leading up to 2015, the NHS had experienced a number of deaths after restraint in mental health settings and examination had revealed

So in addition to considering any prolonged restraint as having medical implications and being more concerned still where there could be medical causes or complications in the background, it’s also important to monitor people post-restraint.  And by “monitor”, I mean medically monitor – vital signs, inc blood pressure pulse and oxygen, etc..  For several hours after the end of the restraint.  This is not something you can easily do in police custody where someone has been removed there after arrest and it also means the discussion about police custody or Place of Safety (ie, a mental health unit) is also somewhat redundant – some of this stuff might only be possible in A&E so therefore ambulance service involvement may be required, to guide the medical decision-making appropriately at the point of contact.

LEARNING LESSONS

Thomas’ inquest, sadly, tells us again what we (mostly) already knew – that there needs to be proper consideration in each area about things like police training on mental health (inc the medical implications of restraint), place of safety processes, risk assessment, perhaps involving the ambulance service.  It therefore tells us again about the importance of local protocols to set out how all of this works – protocols which we still find to be absent or inadequate in many areas.

Thomas’ family call for cultural change amongst police officers, emphasising the need fror a police service not a police force, when it comes to responding to mental health emergencies and whilst so much has changed since 2012, so much remains unaddressed.  We know HMIC reported in 2018 mental health training remains a concerning factor in policing and they recommended all forces review that by 2019 – I’m unsure whether that took place or what the outcome of those reviews was.  We also know the police service is under-going a radical re-examination of how it approaches mental health related demands and that this is having a cultural impact on attitudes towards mental health demand – it remains to be seen whether that is the right kind of cultural change.

I was profoundly saddened to see how little coverage Thomas’ inquest received and how many of the issues within are matters known about prior to 2012 after other difficult inquests involving families whose lives had been torn apart.  I can only keep chipping away through this blog to highlight the lessons I’ve seen in these sad cases, emphasising the documents above and any Preventing Future Death reports issues by Coroners.

Winner of the President’s Medal,
the Royal College of Psychiatrists.

Winner of the Mind Digital Media Award

 

All opinions expressed are my own – they do not represent the views of any organisation.
(c) Michael Brown, 2024

I try to keep this blog up to date, but inevitably over time, amendments to the law as well as court rulings and other findings from inquests and complaints processes mean it is difficult to ensure all the articles and pages remain current.  Please ensure you check all legal issues in particular and take appropriate professional advice where necessary.

Government legislation website – www.legislation.gov.uk

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Published by MentalHealthCop

Any views expressed here are entirely personal and do not represent those of any organisation.