Physical intervention is always a last resort. On our Challenging behaviour training courses and our Physical intervention training sessions we always stress this. We also always draw attention to the fact that every time a physical intervention or physical restraint technique is applied the amount of force employed must always be the minimum, for the minimum amount of time. There are serious consequences for getting this judgement wrong as recent events have shown.
Last week a police officer and three civilian detention officers were cleared by a jury at Bristol crown court of the manslaughter of paranoid schizophrenic Thomas Orchard, who collapsed and died in custody during the application of physical and mechanical restraints. Thomas Orchard suffered a cardiac arrest and brain damage after an emergency response belt was held across his face.
During the trial the court were played audio clips from Orchard’s cell. Mark Heywood QC, who was prosecuting the case said: “You don’t hear a constant stream of threats and aggression. Those sporadic, occasional shouts are consistent to short expressions. They are things such as ‘get off’ or ‘let go’.” The court heard that Mr Orchard shouted “Let go” or “Get off” a total of seven times. Mark Heywood went on to say that the belt (which was typically used for securing a prisoners legs) was held across Orchard’s face for five minutes and two seconds, with the net result being his breathing was restricted and custody officers were unable to observe his condition.
Mr Orchard died in hospital seven days later. The court heard had he was experiencing a mental health crisis on the day he was arrested for a public order offence in Exeter city centre. He had not taken his medication for a week and had told a mental health professional he believed he was a vampire. A pathologist concluded that he died from severe hypoxic-ischemic brain damage, caused by a prolonged cardio-respiratory arrest “following a violent struggle and period of physical restraint”. Sgt Jan Kingshott, and civilian detention officers Simon Tansley and Michael Marsden, had denied manslaughter, and were acquitted after arguing that the force used was proportional and lawful. A number of jurors wept as the verdicts of not guilty were delivered.
On the day of his arrest Mr Orchard was dealt with by seven police officers. He was manually restrained and then secured with handcuffs and retaining straps around his legs before being transported by police van to Heavitree Road custody unit. It was here that Sgt Kingshott, Mr Tansley and Mr Marsden were on duty. None of the defendants recognised that Mr Orchard was mentally ill and did not check how long he had been physically restrained for so far. By this time it was in fact a total of 18 minutes. Mr Orchard appeared to attempt to bite an officer as he was taken through the door into the holding area of the custody suite. Mr Tansley called for an ‘Emergency Restraint Belt’ (ERB) and wrapped it around Mr Orchard's face using it in effect as a spit-guard. A ERB is a restraint device made of ‘tough cloth’, consisting of a long rectangular body of fabric with webbing handles at each end. It has Velcro fastenings that pass through a metal 'D' ring on the other end. It enables a subject to be wrapped securely and then lifted or controlled by using the looped handles. Devon and Cornwall Police had authorised the US-made restraint device for use across the face to prevent spitting or biting. A risk assessment of the belt by the force did not identify or make reference to any risks to detainees when it was used around the face and head.
Mr Orchard’s family expressed deep concern at how he was treated. His mother Alison said, “I’m completely certain that, had it been picked up as a mental health crisis and taken to a place where that was understood, he would be alive..” His sister, Jo said, “Tom was really, really let down. It was clearly a medical crisis, not a criminal one.” She added, 'He would have been so scared. He was acting the way he was because he was scared. I think for someone going through a mental health crisis having something placed over your face would be very scary. If you factor in the adrenaline and how it affects your breathing, I can imagine it being horribly scary for Thomas….'
Thomas Orchard's Last Week (Timeline Source: The Mail)
- September 28 2012 - Mr Orchard tells staff at the supported housing residence where he lives that he is hearing voices. He is visited by a mental health crisis team.
- September 29 - Mr Orchard is seen again by the crisis team.
- October 1 - Staff at the housing association notice that Mr Orchard appears to be relapsing.
- October 2 - 10am - Mr Orchard is seen by a community health practitioner and the crisis team.
- 7.45pm - The crisis team visit Mr Orchard again at his home.
- October 3, 2012
- 9.30am to 10am - Mr Orchard sees the manager of the supported housing property and promises to be back for 11am for an appointment with the mental health team.
- 10.40am - Mr Orchard tells the curate at St Thomas's Church to "f*** off" and leaves.
- 11am - Mr Orchard is in Exeter city centre shouting and threatening members of the public, who believe he is mentally ill.
- 11.05am - Police arrive in Sidwell Street and arrest Mr Orchard on suspicion of a public order offence. He is handcuffed and restraints are placed above his knees and ankles.
- 11.09am - Mr Orchard is lifted and carried by four police officers to the van. He appears to make a biting movement towards Pc Alexander Kennedy.
- 11.13am - The police van leaves Sidwell Street for Heavitree Road police station.
- 11.18am - The van arrives at the police station.
- 11.21am - The lower leg restraints are removed but Mr Orchard is still restrained by his hands and above his knees.
- 11.22am - Mr Orchard is moved into the custody suite. He is able to 'bunny hop' into the police station with the help of Detention Officer Simon Tansley and two Pcs.
- 11.23am - His head appears to lunge towards the officers and he is lowered to the floor in the prone position. He is held there for 32 seconds by Tansley and two Pcs. The lower leg restraint is applied above the ankles. Tansley asks a colleague for the Emergency Restraint Belt. He places the belt around Mr Orchard's face. Mr Orchard is lifted in the prone position.
- 11.24am - Mr Orchard is carried 20 metres to cell M6, a journey that takes 28 seconds through three doorways. He is placed faced down on a mattress in the cell. He is searched as officers physically hold him. He shouts out.
- 11.25am - Detention Officer Michael Marsden takes over the hold of the ERB from Tansley.
- 11.26am - The lower leg restraints are removed. Mr Orchard shouts for the final time.
- 11.27am - The upper leg restraints are removed and Mr Orchard's legs are placed in a figure of four hold by a Pc. The handcuffs are removed and Mr Orchard is placed in a wrist lock and held down. Mr Orchard begins to violently struggle.
- 11.28am - All restraints have been removed and the officers release their grip. Mr Orchard has been restrained in the cell for four minutes and 39 seconds. The ERB has been around his face for five minutes. Mr Orchard is left alone in the cell.
- 11.33am - Marsden approaches the cell door and remains there for three minutes looking through the hatch.
- 11.39am - Marsden returns to outside the cell door with another detention officer and remains there for 34 seconds.
- 11.40am - There is a conversation between Marsden and Kingshott.
- 11.41am - They and others, including the custody nurse, enter Mr Orchard's cell and resuscitation commences.
- 11.42am - An ambulance is called.
- 11.47am - Paramedics arrive and take over resuscitation.
- 12.08pm - Mr Orchard is transported to the Royal Devon and Exeter Hospital.
- 12.12pm - The ambulance arrives at the hospital.
- 1.35pm - Mr Orchard is admitted to the intensive care unit.
- October 10. 6.05pm - Mr Orchard is declared dead.
SecuriCares Risk Manager Lee Hollins, “I wasn’t in the custody suite on the day, and I didn’t participate in this particular restraint so I can’t comment on the decision making process that the defendants went through. But I can comment on the general process. There are three fundamental questions you have to ask and answer when an individual’s behaviour is physically challenging. Firstly: ‘is the use of some form of force absolutely necessary’?, then; ‘if so how much’? before finally ‘Now that I have implemented the least restrictive strategy am I actively managing any and all foreseeable risks’?
“The first question calls into question the nature of the behaviour and the respondents understanding of it. In a custody suite staff are probably facing a stream of unknown individuals day and night; some drunk, others under the influence of drugs. Some angry others actively hostile towards the Police. Some may even have long histories of violence towards them. It’s perhaps easy to see how the objective can become control, and control as quickly as possible…”
“What we need to do is contrast this with the health or social care setting where staff know the person, where they understand their moods and behaviour. Where they constantly review their wants and needs, their likes and dislikes along with their triggers and the interventions that work. It’s in this context that we can minimise or ideally prevent restraint. In those rare instances when it is used the specific nature of it should allow for it to be regulated at all times and risks managed… This is where good training is essential”
SecuriCare offer a range of courses designed to enable support workers, carers and foster families to best respond to any ‘Challenging Behaviour’ that may occur. All programmes are finalised after full training needs analysis and delivered by experienced frontline practitioners. Click to see our ‘Preventing & Managing Challenging Behaviour’ Course which includes ‘Positive Behaviour Management’ techniques designed to minimise the need for any kind of restrictive intervention. Check out our ‘Physical Intervention’ courses and our online ‘Restraint Risks’ course. You can also take a look at our person centred Behaviour Planning Service.