AN inquest jury ruled on Thursday evening, December 21, that police failings may have contributed to the death of a 32 year-old suffering a mental health crisis.
And the jury said the use of an emergency restraint belt may have also contributed to his death in his cell.
Schizophrenic Thomas Orchard died following police restraint in October 2012.
He was arrested in Exeter city centre and taken by police van to the nearby Heavitree Road police station.
There, an emergency restraint belt (ERB) which was used by the police as a bite and spit guard, was placed around his face.
Shortly after midday church caretaker Thomas - who had a history of mental illness - was found unconscious in his cell and was rushed to the nearby Royal Devon and Exeter Hospital where he was declared dead a week later.
After an 11-year wait, and a seven-week-long inquest, a jury returned with their conclusions on the case.
The jury said the ERB fitted around his face in the holding cell was “necessary and reasonable” and said officers had no other options to stop him biting or spitting.
But the ten-strong jury said the use of the ERB and the manner of its use was not reasonable or necessary and said this would have increased Thomas' stress levels and his ability to breathe and may have contributed to his death.
Thomas died from complications of a prolonged cardiac arrest and hypoxic brain injury due to “the effect of prolonged restraint - prone restraint position”.
The inquest jury said that one of more failures admitted by Devon and Cornwall Police caused or contributed to his death.
Those failures included not adequately assessing the use of the ERB as a spit or bite guard as separate from a limb constraint; and the risk of the ERB impacting on the breathing of an individual when used as a spit or bite guard.
And the force also admitted training failures on the use of the ERB around the face and whether it could be safely applied to the face when the individual was being restrained on the ground in the prone position.
During the course of the inquest, held at County Hall in Exeter, they were shown CCTV footage of Thomas' arrest and how he was carried in a prone position in the cell area at the now closed police station in Exeter city.
In 2017 custody sergeant Jan Kingshott and civilian detention officers Simon Tansley and Michael Marsden were acquitted by a jury of manslaughter by gross negligence.
But later the Office of the Chief Constable of Devon and Cornwall Police admitted breaches under the Health and Safety at Work Act.
But a judge in that later case ruled the court could not be sure that the ERB contributed to Thomas' death.
After the inquest, the family of Thomas Orchard said the CCTV of him being arrested and carried into the police custody centre is the “only thing that is realistic and consistent”.
His mother Alison, older sister Jo and younger brother Jack said there has been “no honest or truthful account” of how Thomas died after he was taken into police custody in 2010.
Jack said:"Thomas has never had a voice in the last 11 years.
"CCTV of Thomas at the police station is the only thing that is realistic and consistent. The CCTV is what we are clinging to."
The Orchard family said the police exaggerated Thomas' actions “to justify their behaviour”.
Sister Jo said putting the ERB around someone's head is “terrifying” especially when they are going through a mental health crisis.
They said they were frustrated that the coroner ruled the jury could not come to an unlawful killing conclusion or that the ERB played a probable role in his death.
Jack said: "He should not have been arrested. He should have been taken to a place of safety.
“He was vulnerable and very, very unwell.
“There was no attempt to talk to Thomas before they arrested him and pinned him to a car and pinned him to the floor."
Mum Alison said: "He was a very quiet and gentle person and the police have tried to demonise him, portraying him as angry, violent and hostile.
"We have not had the truth, we have not been able to get justice."
Sister Jo said: "In the custody centre there were seven officers on him. Thomas was restrained by his legs, the ERB was on him, he was prone and they said he was still resisting - he was already dead."
Devon and Cornwall Police apologised on Thursday, December 21, for failings in connection with the death of Thomas Orchard.
Acting Chief Constable Jim Colwell said: "The record of inquest reflects that there were failings on the part of Devon and Cornwall Police and those failings were also recognised by the force in formal admissions within the inquest.
"For those failings I offer an unreserved apology.
"Thomas' death in 2012 was a tragic event and I want to finish today by reiterating our most sincere and heartfelt condolence to Thomas' family."
He said improvements have been made specifically in relation to mental health awareness training for staff.