What happened
Dennis Stevens was 29 and a prisoner at HMP Dartmoor in Princetown, Devon. On 18 October 1995 prison officers restrained him on the landing. They held him prone, face down, for “some twenty minutes or more”. They then placed him in a rigid body belt, and he was found dead in that belt 24 hours later.
The inquest heard undisputed medical evidence that he would not have died but for the physical restraint in the prone face-down position, followed by the belt.
The outcome
The inquest ran to 61 witnesses. It was adjourned on 14 November 1997, when the coroner accepted an invitation from the Prison Service to withdraw the verdict of unlawful killing from the jury.
The family challenged that decision and lost, first in the Divisional Court on 20 November 1997 and then in the Court of Appeal on 10 December 1997. On 19 December 1997 the jury, directed that it could choose between accidental death and an open verdict, returned accidental death.
In 2001 the damages claim was settled in Palmer v Home Office for £50,000, according to the claimant solicitors’ case list. No criminal or disciplinary finding against any officer is recorded.
What went wrong
The mechanism was not one event but two. The first was the pressure of the hold on the ground, kept up for twenty minutes or more. The second was a day of immobilisation that continued long after any struggle had ended.
The inquest jury heard what INQUEST described as “ample evidence of fact to conclude that the restraint was unlawful and dangerous and/or grossly negligent”. It was then directed not to consider unlawful killing. Whatever the legal merit of that direction, the operational point stands: the restraint was not reviewed as a clinical risk at any point between the landing and the cell, and nothing in the material held shows a clinical review of the day that followed.
What it teaches
Restraint does not end when the person stops fighting. It ends when the restraint is removed. A body belt converts a twenty-minute incident into a twenty-four-hour exposure, and someone has to own that period: checks, position, airway, and a time limit that is enforced rather than noted.
Twenty minutes is long enough for a prone hold to become a decision that nobody is making. A day is long enough for a belt to become part of the furniture. Both need a named person who returns, looks, and writes it down.
Questions for the room
- He was held prone for some twenty minutes, then belted for a day. Which of those periods would your records show as monitored, and by whom?
- You are the officer who applies the belt. What do you write down, what do you ask for, and when do you go back?
- A coroner withdraws unlawful killing at the request of the employer. Who is expected to safeguard the evidence in a restraint death, and what does that mean for your notes?
Evidence and limits
Confidence: probable. The inquest conclusion, the dates, the mechanism and the challenge to the coroner’s direction are documented by INQUEST. The £50,000 settlement rests on the claimant solicitors’ case list alone, and no other source held confirms it.
The verdict was accidental death. The coroner’s decision to withdraw unlawful killing means the jury never ruled on whether the restraint was lawful, and the description of the medical evidence as undisputed is INQUEST’s reporting of the inquest, not a transcript.
Our vulnerable and volatile persons training covers de-escalation, restraint monitoring, and who owns a person’s care once the hold ends.
Sources
- INQUEST, Dennis Stevens inquest conclusion · 19 December 1997
- Bhatt Murphy solicitors, Our notable custodial death cases (Palmer v Home Office, 2001)
Reviewed 20 October 2026.