The inquest found that Kevin Clarke died of acute behavioural disturbance, leading to exhaustion and cardiac arrest contributed to by restraint, struggle and being walked.
The jury said the restraint more than minimally or negligibly contributed towards his death and the restraints should have been removed sooner. There was a lack of supervision of officers at the scene.
At approximately 2pm on 9 March 2018 police attended the supported living accommodation in Catford where Mr Clarke lived after staff reported Mr Clarke was pacing up and down on the street outside, that he was on the verge of a relapse, and to ask police to attend and get him to come back inside. Two officers spoke to Mr Clarke. They assessed there was no basis for exercising powers under section 136 of the Mental Health Act 1983, explained this to the staff and left.
At around 2.20pm officers were called to reports of Mr Clarke climbing over fences in back gardens. Two officers attended and found Mr Clarke lying on the ground in a nearby field. They called the London Ambulance Service. A further seven officers arrived to assist. Whilst waiting for the ambulance, Mr Clarke started to become agitated and officers restrained him. Mr Clarke was moved to the ambulance when it arrived where he suffered a cardiac arrest. He died soon after arriving at Lewisham University Hospital.
Commander Bas Javid, Frontline Policing, said: “Firstly our thoughts and sympathies are of course with Mr Clarke’s family and friends at this very difficult time. His death was a tragedy and on behalf of the Metropolitan Police Service, I apologise for the failings as identified by the jury.
“The officers who attended that day found themselves in a very difficult situation dealing with a man undergoing a mental health crisis who clearly needed urgent medical care. They made a rapid assessment and within 90 seconds had called for an ambulance.
“The Metropolitan Police Service is a learning organisation and we always strive to learn and improve. We continually review our policies in line with national guidance around restraint as well as how we assist those in mental health crisis.
“The jury has made several observations about how those officers dealt with Mr Clarke. Now we need to carefully consider those observations. We will work with colleagues nationally to consider our training and guidance to officers in dealing with these kinds of fast paced and challenging incidents. We will also in due course examine any further comments and reports by the coroner.”