The sad death of Kevin Clarke in south London is not one I’ve covered too closely on this blog – mainly because processes were ongoing in connection with the events leading to him being declared deceased at Lewisham Hospital in 2018. This death followed a difficult restraint incident after police responded to Mr Clarke in mental health crisis in south London.
The Independent Office for Police Conduct investigated Mr Clarke’s death independently, bringing no criminal changes against the officers involved and recommending no misconduct proceedings against any of them. Following an inquest in 2020 which produced a quite damning list of indictments of both police and mental health services, misconduct was reconsidered and in the last week two officers have faced a gross misconduct hearing in London. They were accused of failing to ensure the wellbeing of a member of public, connected to the claim Mr Clarke had made it clear “I can’t breathe” during his restraint and accused of lying under oath at the inquest, bringing their integrity in to question.
They were cleared today on both aspects of the conduct allegation.
ACCOUNTABILITY
There has been a lot of process here, hasn’t there? – IOPC investigation; inquest proceedings, re-consideration of misconduct by the IOPC, a gross misconduct hearing held by the Metropolitan Police and when it was announced in August 2023 that there would be gross misconduct proceedings against two constables, it was stated a sergeant would also face different police procedures for “gross incompetence” which is a different kind of performance management process.
What we now have from all of this:
A damning inquest outcome for both police and mental health services – a Preventing Future Deaths notice gives the detail on that – an, presumably, a sergeant subject to monitoring for whatever aspect of his performance was deemed unsatisfactory.
And this took almost seven years.
I can fully understand why Mr Clarke’s family – regardless of the rights and wrongs here – feel let down by the processes. In addition to it being yet another story in the national press about excessive police restraint of a black man, in mental health crisis leading to a death which is regularly cited as another excruciating example of the police falling short. Crucially for what Mr Clarke’s family must be trying to wrap their heads around this evening is the panel’s decision that it could not be proved “I can’t breathe” was said, despite the inquest proceedings finding it was said more than once and “highly likely” the police officers heard it.
CONFUSION AND CONTRADICTION
Not withstanding that apparent contradiction which catches the attention, the legal chair of the Misconduct Hearing addressed this point specifically, stating the inquest’s findings were “correct” and “not in dispute”.
“On a couple of occasions, it is possible that the words ‘I can’t breathe’ were said. His speech was so muffled that one couldn’t be confident of this.”
I know this is all about burdens of proof but many must be saying “make it make sense!” The family’s lawyer said after the hearing:
“Sadly, the family had no expectations of justice as they believe this system is clearly not designed to deliver accountability, particularly where there is a death in police custody. This outcome, while devastating for the family, was sadly, in their opinion, inevitable.”
Somewhere in the midst of all this, the point is being lost – the process was never likely to deliver whatever people think they mean by “accountability” because it wasn’t a process: it was a series of inter-connected and unconnected processes working to different “rules”. I knew of this case not long after it happened and have followed it as it worked its way through but in particular, I remember being shocked after the inquest five years ago when some of the body worn video was released to the public. I just couldn’t understand why it moved so quickly from talking to Kevin as he sat on the floor, to forcing him to stand up and walk forward to the ambulance, bent at the waist in circumstances where at the inquest, medical evidence was heard it was likely to have restricted his breathing.
The main point for me, though: he wasn’t in immediate danger – Kevin was sat on the grass, minding his own business. He was in a place where he shouldn’t have been, but not causing a disturbance at the point of arrival. So why move to intrusive restraint so quickly? I never understood that aspect of this.
LEARNING THE LESSONS
There was a BBC Panorama programme in 2020 (no longer available in iPlayer), after the inquest, partly dedicated to Mr Clarke’s case and it involved a senior Metropolitan Police officer, Commander Bas Javid, providing the Met’s response to the findings. It included an apology and a promise to “learn lessons” and “work with national partners” to ensure best practice, etc. … all the standard stuff we expect to hear, post inquest from senior officers. I watched that with some difficulty, I must admit – because looking at the recent history of restraint related, policing and mental health related deaths after police custody or contact, the response to Kevin Clarke was probably supposed to be one of those were the lessons needing to be learned had been learned.
Even if we restrict ourselves just to London, in the years before Mr Clarke’s death we had completed the processes after the deaths of Seni Lewis, Sean Rigg and Roger Sylvester – to name just three – we had seen the publication of the 2013 London-specific report by Lord Adebowale about policing and mental health and we had seen other national incidents and reports saying exactly similar things after the deaths of Leon Briggs, Terry Smith and Kingsley Burrell – to name just three more. In all of these cases we heard the apology, the promise to learn lessons and revise policy and training, etc., but what we didn’t see was much evidence the lessons promised in the earlier cases were reflected in the latter cases.
On a personal note: I spent the years 2010-11 working on helping forces understand the first ever national guidelines on policing and mental health and the particular emphasis was on ensuring police responses which mitigate against the risk of deaths in custody. I then spent 2014-2016 updating those guidelines and developing national training packages on mental health as part of the Crisis Care Concordat work – all in addition to what I had, by then, spent years putting out on this website – and the police asked me to do this: I didn’t ask them if I could.
It was extremely disappointing to read HMIC’s 2018 Picking Up the Pieces report and find no police force had fully delivered that training. Forces were asked in that report to revisit the question of training by August 2019 but I’m not aware of anything public which audits whether they did. I can only add that in the final five years of my service, I wasn’t aware of any force which had and was constantly reminded by acting as an expert witness several times that many forces still did not have proper joint protocols in place with statutory partners – they were often defective but occasionally just entirely absent. I have been known to suggest those two years, 2014-16, were “a near complete waste of my time”, which is probably over-egging it but reflects frustration the service asked me to do something and then ignored what I produced despite them agreeing it’s what they asked for.
And nobody is asking senior officers to account for any of that, are they? – it’s PCs in the Misconduct Hearing and a sergeant on report.
THE PARADOX OF NOW
Yes, we need to talk about and examine the individual actions of some professionals in these events – and not just the police – but I’ve been saying for YEARS now:
If senior officers do not give proper leadership, ensure effective governance, oversight, training and partnerships, we’re just creating conditions within which the lessons we promised to learn, simply won’t be learned because the conditions within which frontline staff are operating mean the correct options don’t always exist, are not known about or people just haven’t been trained – and that’s nothing much frontline PCs and sergeants can do about that. We might also wonder whether the Right Care, Right Person context, which is enthusiastically encouraging a whole lot of “less” on mental health in policing, is going to help create those conditions?
Nothing I’ve seen, read or heard so far suggests it will.
And finally – and regardless of anything else – seven years is a real disgrace, isn’t it? It doesn’t do anyone any favours to take so very long to reach such paradoxical and confused conclusions for anything as sensitive as a death after police contact which undermines the very legitimacy of policing itself.
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, 2025.
I am not a police officer.
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
Mental Health Cop 