What happened
Malcolm Cash, 29, died outside his home in Wellingborough, Northamptonshire, in July 2002, shortly after he was arrested following reports of a disturbance.
Shortly before the arrest he had taken a large number of sleeping pills and cut himself. A friend had called the emergency services after he threatened to hang himself.
His girlfriend told the inquest that police handcuffed him while he was pinned on the ground, officers kneeling on his back as he lay face down. “He was struggling a bit but he wasn’t fighting them off.” She shouted at them not to kneel on him, because he had previously suffered broken ribs and pressure could puncture his lungs.
He was taken to Kettering General Hospital after breathing difficulties and losing consciousness at the point of arrest, and died there.
The outcome
A 2005 inquest returned a verdict of accidental death. The High Court quashed that inquest and ordered a fresh one, R (Cash) v HM Coroner for the County of Northamptonshire [2007] EWHC 1354 (Admin), on 8 June 2007.
The fresh inquest sat at Rushden & Diamonds FC and ended on 25 April 2008. The jury returned accidental death again, on a cause of myocardial insufficiency under arrest, with chloral hydrate and alcohol contributing. It found the arrest and the takedown justified.
The standing conclusion is an accidental death attached to a restraint the jury did not criticise. Only the second inquest stands.
What went wrong
What the record holds is a witness account, not a finding. A man face down with officers kneeling on his back, still handcuffed when he was sat up. His face went “a funny colour, like blue”, he was gasping, and she described the colour spreading from his lips across his whole face.
She had already told them about his ribs.
No source reached here carries the officers’ account or expert evidence on the mechanism.
What it teaches
A face changing colour is a clinical sign reported by a layperson at the scene. It outranks the plan.
Colour change and gasping are an emergency that overrides the restraint decision, and they are not resistance to be waited out. A bystander who knows the person’s medical history carries risk information that arrives too late to be checked.
Accidental death here came from a jury that also found the arrest and the takedown justified. That verdict is a finding about cause, not a finding that the restraint was safe.
Questions for the room
- A bystander is shouting that the person’s face has changed colour. What do you do with that information in the next ten seconds?
- You are holding a handcuffed man face down and he is struggling without fighting. What is the difference, and how would you know which you are dealing with?
- His girlfriend had shouted at officers about previous broken ribs. Where should that information have been, and who should have had it before the arrest?
Evidence and limits
Confidence: probable.
One source is filed, and it is thin: an undated BBC News archive clipping, which cannot be tied to either the 2005 or the 2008 inquest. The witness account is carried through the vault record and the précis.
The two disagree on the outcome. The précis says the fresh inquest’s conclusion could not be traced in any published source reached for that pass. The record says it ended on 25 April 2008 with accidental death, citing BBC reporting of that date. This page follows the record on status.
The 2005 verdict was quashed and is not used as the standing conclusion. No officer is named.
Our [physical intervention training](/training-solutions/physical-interventions) covers position, duration and the point at which a hold has to end.
Sources
- BBC News, 25 April 2008
- BBC News (archive clipping), undated · `01_source_text/pos-asphyxia-dropbox/deaths-in-2008.txt`
- BAILII, R (Cash) v HM Coroner for the County of Northamptonshire [2007] EWHC 1354 (Admin), 8 June 2007
Reviewed 20 October 2026.