What happened
On 28 May 2018 Joshua Ball, 26, was seen near the Dog and Partridge pub on Turnhurst Road in Packmoor, Stoke-on-Trent, stopping cars and trying to get into them. Several callers reported someone possibly in a mental health crisis. When an officer apprehended him, both ended on the floor.
He was screaming, not making sense, and trying to get up. One officer had a knee on him and told him to stay down. A spit guard was applied.
He was carried on a stretcher to the ambulance with straps at the legs, a harness at the shoulder and a strap on the upper chest. His blood oxygen level was 85 per cent. He kicked at an officer.
The crew stopped twice on the way to Royal Stoke University Hospital: once because he was spitting and kicking, and once at Basford Bank to give a sedative. He had a seizure. He was declared critically unwell on arrival, had three cardiac arrests resuscitated in theatre and several more, and died.
The outcome
A five-week jury inquest before assistant coroner Sukhdev Garcha ended on 31 March 2023. The jury found the death unlawful, and gave the medical cause as serotonin syndrome, acute cocaine intoxication and small bowel injury.
The IOPC investigated the police contact and found no case to answer for the officers involved. Staffordshire Police state that the jury found the officers’ actions were not a contributory factor. No criminal or disciplinary proceedings against police officers or ambulance staff are recorded.
What went wrong
The material held does not include the jury’s reasoning, so what follows is the sequence rather than the finding.
A man in an excited, confused state after cocaine was restrained on the ground, with a knee on him and a spit hood on. He was then strapped to a stretcher and kept strapped in a moving ambulance while he kicked and spat. His saturation was 85 per cent. The crew accounts differ on whether the hood was pulled down for the oxygen mask or removed. Sedation came at the second stop. The seizure was the first unambiguous sign of a medical emergency.
What it teaches
Transport restraint has to be re-justified as the patient’s condition changes, not once at the point of application. A person fighting straps in an ambulance is usually not being non-compliant. They are hypoxic, hyperthermic or toxidromic, and the struggle itself is the danger.
Saturation, position and level of consciousness decide whether a restraint is still proportionate. All three were available here, and all three were abnormal.
Questions for the room
- He was restrained on the ground, then on the stretcher. At which point should the crew have stopped and reassessed?
- You are the technician with a saturation of 85 per cent, a spit hood and a kicking patient. What do you do in the next two minutes?
- The crew stopped twice before sedation. Who was making the clinical decisions on that journey?
Evidence and limits
Confidence: confirmed. The Staffordshire Police statement, the BBC’s report of the opening evidence and the Stoke Sentinel’s report of the ambulance evidence were all read. The two press reports cover the hearing, not the verdict, so the finding that the death was unlawful rests on the police statement and on the record.
Ball is named because open reporting names him. No member of staff is named, and no finding is made about any individual. Proceedings concluded on 31 March 2023.
His clothing and injuries at the scene are not described; they are not part of the finding.
Our vulnerable and volatile persons training covers acute behavioural disturbance, positional risk, and restraint that continues during transport.
Sources
Reviewed 20 October 2026.