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Police restraints of Kevin Clarke contributed to his death, inquest finds
9 October 2020, 18:14
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.
Mr Clarke, who was a paranoid schizophrenic, died in police custody at Lewisham Hospital in March 2018, following an incident in Polsted Road, south-east London.
Southwark Coroner's Court heard that officers handcuffing Mr Clarke “ignored” pleas from the 35-year-old.
In body camera footage he could be heard groaning, saying "I can't breathe" and "I'm going to die".
Returning a narrative conclusion on Friday, jurors said: "It is highly likely that at least one officer heard Mr Clarke say 'I can't breathe', on one of the occasions he repeated it.
"Despite this, no action was taken other than one officer saying 'you've got to breathe, you've got to breathe, breathe, deep breaths'.
"Failure to remove restraints at this point was contrary to guidance and training."
The inquest jury concluded the use of restraints "probably more than minimally or trivially" contributed to his death.
Mr Clarke was living at the Jigsaw Project, a residential support service, for about two years prior to his death on March 9 2018.
Police and an ambulance were called after he was found lying on the ground at the edge of a school playing field, having previously been spoken to by officers earlier in the day.
PC Lee Pidgeon, who attended the scene with several other officers, said Mr Clarke was placed in two sets of handcuffs and a pair of leg restraints, as he was showing signs of acute behavioural disorder.
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 jury said: "It appears Mr Clarke was generally co-operative and responsive up until the point when officers laid hands on him."
The London Ambulance Service have previously admitted its crew failed to conduct a "complete clinical assessment" of Mr Clarke, which the jury said amounted to a "failure to provide basic medical care".
Speaking outside the coroner's court following the decision, Mr Clarke's sister, Tellecia Strachen said: "My brother lost his life because of a number of missed chances by the mental health team, accommodation providers, the police, and the paramedics.
"There must not be another George Floyd, Sean Riggs, or Kevin Clarke. Those involved in his death saw him as the stereotype big, black, violent, mentally unwell man.”
She added: "In his memory we want to see accountability and real change, not just in training but the perception and response to black people by the police and other services.”
The jury foreman said: "The jury would like to express their sincere condolences to Kevin's family and friends.
"We've come to learn a lot about Kevin in the previous weeks and it was clear that he was well loved."