What happened
On 3 October 2012 Thomas Orchard, 32, a church caretaker with paranoid schizophrenia, was detained by Devon and Cornwall police officers in Exeter city centre. He was in a mental health crisis and had been abusive to members of the public.
Seven officers restrained his arms and legs. At Heavitree Road police station an Emergency Restraint Belt was placed around his face because of concerns that he would spit and bite. The force had authorised the device as a bite and spit hood.
He was found unconscious in his cell and taken by ambulance to hospital shortly after midday. He was pronounced dead on 10 October 2012, seven days later.
The outcome
There was an independent investigation by the Independent Police Complaints Commission. A custody sergeant and two detention officers were charged with gross negligence manslaughter and acquitted in 2017.
The inquest had been suspended by the senior coroner, Elizabeth Earland, to allow the criminal proceedings. The family asked for it to resume, and the senior coroner, Philip Spinney, agreed in May 2022. It sat from 6 November 2023 and concluded on 21 December 2023.
The jury found that the use and manner of the emergency response belt may have contributed to the death, and that prolonged restraint and being held prone led to a cardiac arrest. The Office of the Chief Constable later pleaded guilty to breaches of the Health and Safety at Work Act.
What went wrong
The belt was authorised for one purpose and used for another: a spit hood wrapped round a man’s face in a cell. The custody sergeant had never been told that a webbing belt should not be wrapped round the face.
That is a training gap with a name and a date on it. A device on the authorised list is not authorised for every use someone can think of, and nobody in the chain knew where the line was.
Underneath sits the restraint itself. Seven officers held his arms and legs, the prone position was maintained, and the man in the cell was seriously mentally ill. The jury drew the line from the prolonged prone hold to the cardiac arrest.
What it teaches
Before kit is used, someone has to say what it is for and what it must never do, and the person who authorises it and the person who uses it have to be told the same thing. Authorisation travels badly.
The second lesson is position and duration: a prone hold kept on by several officers, which the jury named as the finding.
The third is the eleven years between the death and the inquest. Nothing anyone learned in that time reached the staff who needed it.
Questions for the room
- You are the custody sergeant and someone hands you a webbing belt for a detainee who is spitting. What do you do next?
- Seven officers restrained him and he was found unconscious in a cell. Who was responsible for looking in on him, and how would anyone have known?
- The belt was on the authorised list. What does that tell you about how a device gets approved?
Evidence and limits
Confidence: confirmed, on the vault record and the case précis, which agree on the sequence from the inquest conclusion and INQUEST’s case background.
The ITV News West Country report of the conclusion did not load when the case was researched, so the terms of the jury’s finding here rest on the vault record and not on the press report itself. The record gives no date for the force’s guilty plea, so none is stated.
No member of staff is named; the three charged were acquitted.
Our physical interventions training covers equipment limits and the prone position, including when a hold has to end.
Sources
Reviewed 20 October 2026.