What happened
Kevin Clarke, 35, was diagnosed with paranoid schizophrenia at 17 and from February 2016 lived at the Jigsaw Project, a residential support service in Lewisham, under the care of South London and Maudsley NHS Foundation Trust.
On 9 March 2018 he stood outside in the cold for more than four hours before Jigsaw staff called police. Officers decided they had insufficient grounds to detain him under section 136, not knowing that a mental health nurse had just assessed him as relapsing and needing a place of safety. Minutes later police were called to a man running through gardens and climbing fences, and found him on a muddy school playing field in Catford, rolling and mumbling. Nine officers attended.
He was contained for more than ten minutes, cooperative throughout. When he tried to get to his knees, officers laid hands on him. He was handcuffed in the rear stack position with two sets, placed prone and then semi-prone, and leg restraints were applied. The restraint lasted 33 minutes. Body-worn video recorded him saying “I can’t breathe” and “I’m going to die”.
The outcome
An inquest before Senior Coroner Andrew Harris at Southwark Coroner’s Court ran from 7 September to 9 October 2020. The jury returned a narrative verdict of acute behavioural disturbance leading to exhaustion and cardiac arrest, contributed to by the restraint struggle and by being walked.
It found the restraint “probably more than minimally or trivially” contributed, that it was not appropriate, and that it was not based on a balanced risk assessment. It found nine failures, and that it was “highly likely” at least one officer heard him. Misconduct hearings followed, with Met proceedings reported during 2023.
What went wrong
The words were spoken, recorded, and the only response on the footage was an officer telling him to breathe. The restraints were not removed, which the jury found contrary to guidance and training.
A hooded top was pulled over his head, head down and torso bent forward, so nobody could monitor him. Officers and paramedics accepted this. The ambulance crew stood back, did not bring their medical emergency bag and did not assess him; the lead paramedic said she felt too scared to get close. He was walked rather than carried, though a carry sheet had been discussed. He collapsed twice before anyone acted.
What it teaches
A person’s own account of their airway is a clinical observation, not agitation to be managed. Once someone says they cannot breathe, the restraint comes off and the assessment starts. Anything else converts a mental health crisis into a medical emergency.
The second lesson is ownership. Police and ambulance staff were both at that field and neither assessed him. A joint plan needs someone named as responsible for the medical decision, and the person with the handcuffs is not it.
Questions for the room
- He was cooperative for ten minutes before officers laid hands on him. What changed?
- You hear “I can’t breathe” on your body-worn video. What do you do in the next thirty seconds?
- Neither agency assessed him. What would a joint plan have needed to say, and who would own it?
Evidence and limits
Confidence: confirmed. The INQUEST press release, a Guardian report and an archived BBC report were all read and agree on the verdict and the sequence.
The record has no exact date field. The date of 9 March 2018 and the 33-minute duration come from the sources named above, not from the record. Proceedings concluded on 9 October 2020.
Clarke is named because open reporting names him and he is the case. No officer is named, and none was convicted of an offence.
Dynamis trains staff in [physical interventions](/training-solutions/physical-interventions) for mental health and care settings.
Sources
- INQUEST, 9 October 2020
- The Guardian, 9 October 2020
- BBC News (archive clipping), September 2020 · `01_source_text/crazee-restrainee/Kevin-Clarke-Man-who-died-in-custody-said-I-can-t-breathe-BBC-News.txt`
Reviewed 20 October 2026.