Police restraint of mentally ill man contributed to death – inquest jury

The decision by police to use restraints on a mentally ill man “escalated the situation to a medical emergency” and contributed to his death, an inquest jury has found.

Kevin Clarke, a relapsing paranoid schizophrenic, died in police custody at Lewisham Hospital in 2018 following an incident in the Polsted Road area of Catford, south-east London.

An inquest at Southwark Coroner’s Court heard that the 35-year-old told officers “I’m going to die” and “I can’t breathe” as he was put into handcuffs due to his size.

He lost consciousness as he was taken to an ambulance.

Kevin Clarke
Kevin Clarke

Returning a narrative conclusion on Friday after five days of deliberations, an inquest jury found that the decision to use restraints on Mr Clarke, as well as the way he was walked to an ambulance by officers, was “inappropriate”.

It also concluded that it was “highly likely” that at least one officer heard Mr Clarke say “I can’t breathe” on more than one occasion.

A jury foreman said: “The officers’ decision to use restraint was inappropriate because it was not based on a balanced assessment of the risks to Mr Clarke, compared to the risk to the public and the police.

“It appears Mr Clarke was generally co-operative and responsive up until the point when officers laid hands on him.”

The foreman added: “It appears that the officers’ decision to restrain Mr Clarke was unduly influenced by the knowledge that he had been Tasered on a previous occasion.

“They did not sufficiently take into account other facts that were clearly evident.”

The jury found the use of restraints was a “high-risk” option, which “escalated the situation to a medical emergency”.

“The restraint exacerbated Mr Clarke’s agitation, leading him to struggle and causing him to become even more exhausted.

Kevin Clarke
Kevin Clarke

“Failure to properly supervise also meant opportunities to release the restraints were missed. It is therefore likely the restraint, and serious failures of supervision increased the risk of death more than minimally.”

Mr Clarke was moved to the ambulance while being “bent forward, with the back of his head held down by the hood” and his arms held in an “elevated” position, the inquest heard.

The jury said this “impaired his breathing and increased the stress on his body”.

It added: “Failure to remove all restraints at the point where Mr Clarke became unconscious was a further indication that speed was prioritised over his overall clinical needs.”

Mr Clarke had been living at the Jigsaw Project, a residential support service, for about two years up until his death in hospital on March 9 2018.

He had been seen by officers earlier that day, but was not sectioned despite concerns from staff at Jigsaw.

Police were called again later in the day and Mr Clarke was found lying on the ground at the edge of a school playing field.

An ambulance was called after the situation was deemed “a medical emergency”, and Mr Clarke was placed in two sets of handcuffs – linked together due to his size – along with leg restraints.

Pc Lee Pidgeon, who was one of several officers at the scene, told the inquest Mr Clarke had begun to get “a bit fidgety” and the use of handcuffs to restrain him was appropriate as he was showing signs of acute behavioural disorder.

In body-worn camera footage, Mr Clarke could be heard groaning, saying “I can’t breathe” and “I’m going to die”.

When asked by coroner Andrew Harris why Mr Clarke was “ignored” by the officers in attendance, Pc Pidgeon replied: “I cannot answer that, sir, I don’t know.”

The London Ambulance Service (LAS) has already admitted its crew failed to conduct a “complete clinical assessment” of Mr Clarke on arrival.

This amounted to a “failure to provide basic medical care”, which the jury said possibly contributed to his death as there was no “proper understanding of his condition”.

His cause of death was given as “acute behavioural disturbance, in a relapse of schizophrenia, leading to exhaustion and cardiac arrest, contributed to by restraint struggle and being walked”.