What happened
On 3 September 2020 Neal Saunders, 39, a roofer from Slough, was at his father’s flat in Langley, Berkshire, in a drug-induced psychosis. His father called 999 at 23:52.
It took six Thames Valley Police officers to restrain him because of his extreme strength. He was handcuffed in the rear stack position, straps were placed round his ankles and knees, and an officer sat on him using a baton to press down on his legs. Four officers restrained him for 58 minutes.
Body-worn video recorded him saying “I can’t breathe”, pleading with officers to get off and asking to sit up. Two paramedics attended after around 50 minutes.
At about 01:25 he was carried to the ambulance face down on a police carry mat, against their training. On the footage one officer asks “We need him on his back, don’t we?” and another replies “Just take him any way you can”. He was transported prone to Wexham Park Hospital, still handcuffed and leg-restrained, against guidance. After 14 minutes in that position he had a heart attack and a cardiac arrest. A second arrest followed at 02:36, life support was switched off at 14:15, and he died the following day.
The outcome
An inquest at Reading Coroner’s Court before HM Senior Coroner Heidi J. Connor ran from 15 November to 2 December 2022. The jury found unanimously that restraining him for the duration was appropriate, because there was no safe, practicable alternative. It found his resistance contributed to his death.
It found the prone position not causative of death but possibly contributing more than minimally, and the attention paid to his positioning unsatisfactory. The coroner recorded multi-organ failure after a second cardiac arrest in hospital, with cocaine use and his earlier heart attack among further factors.
The IOPC found the officers’ actions proportionate. No prosecution followed.
What went wrong
The force was found justified and the man still died. What the inquest criticised was the aftermath: a man carried and driven face down for 14 minutes, against guidance the paramedic knew only in outline and a concern officers raised but did not press.
The jury also found officers were trained to avoid prolonged restraint but not to assess when it had become prolonged. Nobody there held the clock. The coroner said there was ample time to check the guidance and nobody did.
What it teaches
A restraint can be lawful, appropriate and still kill. The verdict says both at once, and training that uses this case has to hold both.
The risk sat in the margins: how he was carried, which way up he travelled, who watched the chest wall, who counted the minutes. Justification is settled at the start. Safety has to be re-decided all the way to the hospital doors.
Questions for the room
- Four officers held him for 58 minutes. Who timed it, and what would they have done at minute thirty?
- You are the paramedic deciding how to load him. What do you choose, and why?
- The jury found officers are trained to avoid prolonged restraint but not to recognise it. What would that training look like in one sentence?
Evidence and limits
Confidence: confirmed. INQUEST’s release and an archived BBC report are independent and agree on the 58 minutes, the baton, the prone transport and the jury’s findings.
The record gives 3 September 2020 as the case date; the BBC says he died the following day, so this page gives no date of death. The record calls the 999 call a report of an assault; the précis says his father called, so the page states only that his father called.
No officer is named and no finding is made against any individual.
Our [vulnerable and volatile persons training](/training-solutions/vulnerable-volatile-persons) covers acute behavioural disturbance, positional risk and the handover to ambulance crews.
Sources
- INQUEST, 2 December 2022
- BBC News (archive) · `01_source_text/crazee-restrainee/Neal-Saunders-died-after-appropriate-police-restraint-jury-finds-BBC-News.txt`
Reviewed 20 October 2026.