Police issue apology to family of a man who died after custody restraint
The jury were asked to decide on a number of questions about whether the police actions were necessary or reasonable and whether they contributed to Orchard's death
Last updated 21st Dec 2023
After 11 years the family of a former church warden - who died after being restrained in custody - have finally got the apology they wanted.
It came after an inquest jury ruled the use - by police - of a type of restraint originating in America may have been a factor in the death of Thomas Orchard.
The 32 year old - who had schizophrenia - was arrested after reports of being aggressive in Exeter back in October 2012.
Thomas became unresponsive and died in hospital after suffering a cardiac arrest a week after a police emergency response belt - which is no longer used - was placed over his face at the now closed Heavitree police station.
The force has already admitted to health and safety failures over the use of the ERB and been fined.
Thomas' mum Alison told Greatest Hits Radio "It is inconceivable to me how anyone thought it was ever appropriate (the Emergency Response Belt or ERB) it stops them seeing. It's going to panic someone like Thomas who was in mental health crisis.
Sister Jo added the 11 year fight to understand what happened has taken a huge toll on the family, adding: "My mum, every time we hear a siren, it fills us with absolute dread'.
Alison said: "I can't think of an area of my life that it hasn't affected. It's affecting me financially, I haven't been able to work at times, it's affected my mental health I've had counselling."
Brother Jack says he felt the portrayal of Thomas over the past 11 years made him sound uncharacteristically aggressive, as he reflected: "I don't think there was ever any attempt to try to ascertain whether or not he was in mental health crisis at the stage (in Exeter city centre) I think that makes it worse."
Mum Alison said since Thomas' death 'there have been some very very good and positive changes'.
"Now there is a place of safety in Exeter and there is more awareness I think - but I don't think we feel confident enough that is going to be applied robustly."
Philip Spinney, the Senior Coroner for Exeter and Greater Devon, reflected on all the evidence heard - before sending the jury out - including Orchard's mental health treatment which was described as 'reasonable and consistent with what other practitioners would have done' at the time.
Mr Spinney reminded jurors of the pen portrait by Thomas' mum Alison who said she missed him 'every day'. She had said he was a child of few words, who often struggled to fit in and had a troubled life - but in later life did find solace in the church.
During the summing up jurors were reminded the curate of Thomas' church in Exeter said she'd witnessed him 'grow as a member of the community' - eventually becoming caretaker and someone who would lead evening prayer.
The inquest was told 'Thomas was doing quite well' until he stopped his medication and while he was always 'withdrawn' he was aware of the importance - and impact - of taking his own medication and the consequences of not. The jury were told he was diagnosed as having schizophrenia.
Support workers said they thought 'Thomas had been the best he'd ever been' and 'his normal self' in the month before he died, before a deterioration in his condition where he was 'unable to give a straight answer' as to whether he'd been taking his medication - and had been 'hearing voices'.
Jurors were told how support workers responded to the change of behaviour, including two daily initial crisis-team meetings with him, but he also appeared 'rational' during some monitoring visits. Many subsequent meetings and discussions took place over concerns about him - including whether he was relapsing into a psychotic state - while looking into the process of restarting his medication.
The jury were reminded about delusional beliefs and signs of psychosis that Orchard had been experiencing, including believing he was a vampire who could not leave his home. Supposed messages from the TV were also heard by him. The jury were reminded of assessments of Orchard, including the belief that he was not an 'imminent risk to himself or others' as he was not expected to head out on the night of Tuesday October 2.
Discussions took place the following morning between support workers, when it emerged Thomas had left his home - and his behaviour that day was described as 'strange', wearing a baseball cap and dark glasses in church. Orchard was asked if he was 'ok' after arriving late for the service, before he raced off afterwards and unusually swore at another senior church member.
On the morning of 3 October 2012, Thomas was detained in Exeter City Centre by Devon and Cornwall police officers and transported to Heavitree Road police station where an Emergency Response Belt, which had been authorised by Devon and Cornwall police as a bite and spit hood, was placed around his face.
Shortly after midday Thomas was taken by ambulance to hospital where he was subsequently pronounced dead on October 10.
The jury were told about the incident in Exeter city centre on the morning on October 3 where an eye-witness felt someone resembling Orchard attack him - who he didn't know - but thought the person 'had been on drugs or had mental health problems'.
Another person said Orchard struck him and was saying 'drop your weapon' and one eye-witness account said Orchard was 'aggressive' and struggling when police tried to put him into a van, screaming 'I will kill you and swearing' with another officer needing to help.
Many eye-witnesses did not report 'concerns' with what they saw of the police response to Orchard's behaviour, with some describing seeing biting and spitting.
One witness said she heard Orchard telling officers 'you are hurting me'. The jury were also reminded that evidence from various police officers said they followed guidance and did not kneel on him to exert pressure in any chest or back area.
The jury were reminded about a 2001 report by Dr Graham Cook which raised concerns that the device (an Emergency Response Belt) could partially obstruct a person's airway - with the risk growing if the person, with a known underlying medical condition, was to forcibly struggle. Further research and reports were also reflected about the use of ERBs, which originated in the US.
The jury were reminded of accounts from different police officers in the city centre, the transport van, and back at the detention centre about their involvement in Orchard's arrest. There were detailed accounts about the decisions made that day on how best to restrain Orchard and look after his welfare.
The jury were told a medical report from a forensic pathologist, which found his death was 'multi-faceted' and likely impacted by Orchard stopping taking his psychotic drugs.
It added that extra struggles as a result of the custody process and prolonged prone position may have been factors - but it was 'difficult to determine'.
The jury were asked to decide on a number of questions about whether the police actions were necessary or reasonable and whether they contributed to Orchard's death. They found the restraint method and use of the prone position may have had an impact - but did not single out any staff member.
In May 2019 the Office of the Chief Constable for Devon and Cornwall Police was fined £234,500 after admitting health and safety breaches following an Independent Office for Police Conduct investigation into the death of Mr Orchard.
In March 2017, a custody sergeant and two staff members from Devon and Cornwall Police were acquitted of Mr Orchard's manslaughter by gross negligence.
What do police say?
Acting Chief Constable Jim Colwell said in a statement: "Over the last 11 years, there have been two criminal trials relating to Thomas’ death and a Health and Safety Act prosecution of Devon & Cornwall Police relating to the procurement of the ERB device.
"The record of inquest reflects that there were failings on the part of Devon & Cornwall Police and those failings were also recognised by the Force in formal admissions within this inquest. For those failings I offer an unreserved apology.
"Since Thomas’ death the Force has implemented a significant amount of learning and improvement, specifically in relation to mental health awareness training for staff, use of force training and ensuring our custody provision offers the required level of care needed by those we come into contact with, particularly the most vulnerable.
"Following a lengthy inquest, in which evidence was heard from members of the public, public agencies, and officers and staff from Devon & Cornwall Police, the jury have delivered their conclusions.
"We accept and respect the conclusions reached by the jury in this inquest. Their conclusions have provided answers to a number of long standing questions.
"The inquest has been an important and long awaited process for Thomas’ family and others. My thoughts are with the family and also a number of colleagues who have had this matter at the forefront of their lives for over 11 years.
"Thomas’ death in 2012 was a tragic event and I want to finish today by reiterating our most sincere and heartfelt condolences to Thomas’ family and friends."