What happened
Nuno Cardoso, 25, from Kentish Town in London, was in his first year of law at Ruskin College, Oxford. At about 4.50 in the morning on 24 November 2017 he was arrested at the college after reports of an altercation. Restraint and batons were used; the inquest heard he showed signs of intoxication.
Body-worn video records officers discussing whether he had something in his mouth. He was not communicating properly, and one college witness said he spoke as though his mouth was full. Officers told him that if he did not show them what was in his mouth they would have to take him to hospital. They later said they did not believe he had anything there.
He was not taken to the hospital five or six minutes away. He was driven to Abingdon police station, around 20 minutes away.
The outcome
On the way, officers reported that he appeared to be chewing something, began to sweat and slumped in his seat. They gave some first aid and called the ambulance service. He was taken to the John Radcliffe Hospital and died later that day, at 6.23 in the evening, from a cardiorespiratory arrest caused by alcohol, cocaine and morphine, or heroin.
Police guidance at the time was that a person suspected of packing drugs should be taken to hospital. All four officers accepted in evidence that they knew it and had a duty of care to him.
The inquest concluded on 17 July 2019 with a narrative conclusion. The jury accepted their account of what they believed and found no medical emergency until 5.20, by which time he was sweating and slumped in the van. His family said they were concerned at the conclusion.
What went wrong
The suspicion was spoken aloud and then dropped. The mouth was discussed on the footage, and the officers themselves told him that hospital was the alternative. They then decided there was nothing there and drove him 20 minutes to a police station, past a hospital five or six minutes away.
What the case turns on is what the duty of care required when a man would not open his mouth. All four officers knew the guidance. The open question is whether it meant keep asking, take him somewhere his mouth could be examined properly, or treat his silence as an answer.
What it teaches
This case will not sit still, and a trainer should not force it to. The jury did not criticise the officers. The missed hospital and the mouth point the other way. Teach it as a live dispute about what a suspicion of drug packing requires, and let the room find where the duty of care bit.
The second lesson is post-incident management. The sergeant allowed the officers to talk before their accounts were written, and an account written after that conversation is evidence of the conversation too.
Questions for the room
- All four officers knew the guidance and the duty of care. What does that duty require when a man will not open his mouth?
- You are the officer in the van and he starts to chew and sweat. What is the nearest hospital, and what is your next radio call?
Evidence and limits
Confidence: probable. Both documents read are INQUEST publications, the release on this inquest of 18 July 2019 and a later release summarising the case. The two-publisher test is not met, so a second independent publisher is needed before this page is cited as settled fact.
The record calls the conclusion uncritical of the force used, and the family’s disagreement is part of the record. The page carries both, and does not present the jury’s finding as the only reading.
Dynamis trains staff in [restraint reduction](/training-solutions/restraint-reduction-rrn) for services where a person in crisis stops cooperating.
Sources
Reviewed 20 October 2026.