Police failures may have caused or contributed to the death of a church caretaker who died after being restrained in police custody more than a decade ago, an inquest jury has found.

Thomas Orchard, 32, suffered a cardiac arrest after being held down, handcuffed and placed in restraints with an emergency response belt (ERB) wrapped around his face.

Mr Orchard died in hospital seven days after being arrested and brought to Devon and Cornwall Police’s Heavitree Road custody unit in Exeter, Devon, in October 2012.

An inquest, lasting seven weeks at County Hall in Exeter, has heard that Mr Orchard, who had paranoid schizophrenia, was experiencing a mental health crisis at the time.

He was arrested in Exeter city centre at 11am on October 3 after being abusive to members of the public.

Seven police officers dealt with Mr Orchard, who was handcuffed and restrained around his legs before being driven to the custody suite.

The jury described how, after arriving at the custody suite, the ERB belt was placed around his head “without prior warning or explanation” after a “perceived attempt to bite”.

They said: “At about 11.24am, Thomas was carried into the cell and placed face-down on a mattress. In the cell, Thomas was searched while restrained, including the ERB being held about his face.

“During the search, Thomas was rolled onto each side and was in the prone position in between.”

The ERB and restraints were then removed, and Mr Orchard was left alone in the locked cell where he appeared to lay motionless for 12 minutes before custody staff re-entered and commenced CPR.

Mr Orchard was taken to the Royal Devon and Exeter Hospital, where he died at 6.33pm on October 10.

Devon and Cornwall Police made a series of admissions to the inquest, including that the ERB had not been adequately considered or assessed for use as a spit or bite guard.

The force admitted the procurement process did not adequately consider and assess available medical evidence on the use of the ERB around the face, including any risk that could compromise an individual’s ability to breathe.

It said that between 2002 and October 2012, there was a failure to identify the risk of the ERB impacting breathing when used as a spit or bite guard and this was not included in any form of risk assessment.

Training on the use of the ERB around the face was “inadequate” as it was not consistent on whether it should be used about the face, in which circumstances and whether it could be used in the prone position, the force admitted.

The inquest jury was asked: “Is it possible (more than speculative) that any one or more of these admitted failures caused or contributed to Thomas’ death?”

The jury foreman replied: “Yes”.

He confirmed that the jury thought it was “necessary and reasonable” to restrain Mr Orchard in Exeter city centre, noting that the arresting officer did not have PPE (personal protective equipment).

They also thought it “necessary and reasonable” for the officers to use force on Mr Orchard as he was on the ground in the city centre and to carry him into the police van.

The jury added: “However, we also recognise that Thomas is stressed and in a prone position and this as a possibility contributed to Thomas’ death.”

It said the manner in which Mr Orchard was placed in the police van and left unsupervised within it for nine minutes was not “reasonable”.

When asked if it was possible this caused or contributed to Mr Orchard’s death, the jury replied: “Yes.”

“While Thomas’ position in the van is unknown, he remains in full restraint. This is part of a prolonged restraint, so possibly contributing to Thomas’ death,” they said.

The jury ruled the initial decision to apply the ERB around Mr Orchard’s face while in the holding cell area was “necessary and reasonable”.

It added: “It is possible that it caused or contributed to Thomas’ death.”

When asked whether the use of the ERB as Mr Orchard was carried from the holding cell area to cell M6 was “necessary and reasonable”, the jury replied “No”.

The jury said it was possible this caused or contributed to Mr Orchard’s death.

“This process is likely to have increased Thomas’ stress levels and (his) ability to breathe could possibly be adversely affected, possibly contributing to Thomas’ death,” the foreman told the court.”

When asked whether the use of the ERB was “necessary and reasonable” when within the cell, the jury replied: “No.”

Losing Thomas in this way must be very difficult to bear,

It answered “yes” to whether it was possible this caused or contributed to Mr Orchard’s death, adding that it may have adversely affected the ability of officers to monitor his ability to breathe.

However, the jury found the use of force within the cell, other than the ERB, necessary and reasonable.

It also said the checks on Mr Orchard carried out by police staff once he had been left in his cell were “reasonable”.

Following the inquest, Philip Spinney, senior coroner for Exeter and Greater Devon, spoke to Mr Orchard’s family, who were in court for the seven-week hearing.

“Losing Thomas in this way must be very difficult to bear,” the coroner said.

“Please accept my wide condolences.”

The record of inquest reflects that there were failings on the part of Devon & Cornwall Police and those failings were also recognised by the Force in formal admissions within this inquest. For those failings I offer an unreserved apology

Acting Chief Constable Jim Colwell, of Devon and Cornwall Police, said: “The record of inquest reflects that there were failings on the part of Devon & Cornwall Police and those failings were also recognised by the Force in formal admissions within this inquest.

“For those failings, I offer an unreserved apology.”

He later added: “We accept and respect the conclusions reached by the jury in this inquest.”

Sgt Jan Kingshott and civilian detention officers Simon Tansley and Michael Marsden were acquitted of manslaughter by gross negligence following a trial in 2017.

Later, the office of the chief constable of Devon and Cornwall Police pleaded guilty to breaches under the Health and Safety at Work Act.

In the health and safety case, a judge ruled they could not be sure that the ERB was a contributory factor in Mr Orchard’s death.