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The way police detained a paranoid schizophrenic “probably more than minimally” contributed to his death in custody, an investigative jury said.
Kevin Clarke, 35, died in March 2018 amid a mental health crisis.
The investigating jury members found the manner in which the police officers detained him was inappropriate.
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They said: “It is very likely that at least one officer heard Mr. Clarke say ‘I cannot breathe’, on one of the occasions when he repeated it.
“Despite this, no action was taken other than an officer saying ‘you have to breathe, you have to breathe, breathe, breathe deeply.’
“Not removing the restraints at this point was contrary to orientation and training.”
They added: “It appears that the officers’ decision to immobilize Mr. Clarke was unduly influenced by the knowledge that he had been attacked with Tase on a previous occasion; they did not take sufficient account of other facts that were clearly evident.”
Before the conclusion of the investigation, Sky News spoke with Kevin’s mother, Wendy, and her sister, Tellecia.
To them, he was always smiling and incredibly caring, and they can’t believe he’s not here anymore.
He told officers: ‘I’m going to die’ while they handcuffed him
The month-long investigation at the Southwark Forensic Court heard from Metropolitan Police officers present on the day, the London Ambulance Service, as well as an independent expert consultant physician and consultant psychiatrist.
Kevin’s mother sat in court every day.
Speaking to Sky News, she says reliving her son’s last minutes during the investigation has been nerve-wracking: “I’ve asked myself a lot of questions. If they had handled the situation a little better, KC would have been alive today.
“I really can’t accept it. I have collapsed many times. What happened left me with panic attacks, I have had so many since then.
“It has been devastating. It has had a terrible effect on the whole family. I think about him every day.”
Kevin’s support workers had first raised concerns for his safety on the afternoon of March 9. He had been wandering in the cold for hours.
Officers spoke with him about the concerns of his support staff. In police body-borne camera footage, Kevin tells them that he is “just chilling out” and that he is wearing three sweaters to keep him warm.
The two officers left him alone and at that moment it was decided that they were not going to section him.
Kevin as a child
Later, the police were called again, this time to a park where Kevin was found lying on the muddy ground.
A couple of officers approached him and checked his well-being: “Are you okay? What’s your name? Have you been drinking?”
They encouraged him to relax. An officer helped loosen his jacket when he said he was “too hot.” He also obeys when officers reach for his phone and bus pass.
Several officers surrounded Kevin as he swayed side to side on the ground. However, when he stood up, officers gathered around him and then restrained him with two sets of handcuffs and leg restraints.
PC Lee Pidgeon, who says he acknowledged Kevin was in a mental health crisis, said in the investigation that he seemed “a little fidgety” and that the use of handcuffs to restrain him was appropriate as he showed signs of an acute behavioral disorder.
The officers involved said they had followed the correct police training procedures.
In providing evidence, PC John Buckingham said that leg restraints were used to protect Kevin and anyone around him and that in that situation they would automatically request such restraints.
Weighing 19 1/2, it is believed that his height may have intimidated the police, who were concerned about his strength.
Kevin had a history of being violent when responding to help. In 2016, his forensic psychologist described him as a “gentle giant” when he was well.
Kevin was diagnosed with paranoid schizophrenia at age 17
But when he was ill, Senior Coroner Andrew Harris said he became difficult and uncooperative, he also had a habit of resisting treatment.
Kevin can be heard groaning and groaning in the footage while immobilized. PC Pevvy said in the investigation that they felt reducing the situation was not an option.
Another officer in the footage, PC Dannielle Barnes, can be heard explaining to paramedics who found them in the field that he had gone from “silent to aggressive.”
In the same roll of footage, Kevin is heard saying “I can’t breathe” and “I’m going to die.”
During the investigation, many of the officers agreed, reflecting and reviewing the incident on camera, that they could hear distress in Kevin’s voice, but said it was difficult to understand what he was saying specifically.
When asked by the coroner why the officers “ignored” Kevin, PC Pidgeon said, “I can’t answer that sir, I don’t know.”
Kevin lost consciousness when he was taken to the ambulance and later died in the hospital.
He had been living in subsidized housing for two years. The investigation heard that since he was 17, Kevin had been living with paranoia and schizophrenia.
His family was never afraid of him, as he was never aggressive or threatening towards them.
Speaking to Sky News, his mother, Wendy, says that whenever his health deteriorated, she always looked after him: “When he had a crisis, we would go to the hospital to visit him and make sure he got through.
“When he was going through one of his episodes, he was very, very quiet. But he was very active, going to the gym, exercising and swimming. He had good days and bad days.
“It was difficult for him because he wanted to live a ‘normal’ life, but he did his best to get through it every time.”
A tribute to Kevin’s life is captured in a mural painted in front of Lewisham Police Station in South London.
It was the brainchild of former police officer Adam Pugh and he followed the mural with the blessing of the family.
