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Inquest touching upon the death of Thomas Orchard


Dates of case

Nicholas Moss KC and Harriet Gilchrist were instructed as Counsel to the Inquest in a 7 week Inquest into the death of Thomas Orchard before the Senior Coroner for Exeter and Greater Devon Philip Spinney.

The inquest heard evidence from 87 witnesses including members of the public, police officers and staff, the mental health care team and experts and considered events between 28 September 2012 and 10 October 2012. The inquest involved consideration of a number of issues, including the cause of death, restraint and use of force including the use of an Emergency Response Belt during the restraint at the Custody Centre.

Having heard the evidence, the jury returned a detailed questionnaire and provided a narrative conclusion on their factual findings. On central issues the jury concluded:

  • that it was possible that the failures admitted by the Police Force contributed to death;
  • that the initial intervention and use of force in the City Centre was necessary and reasonable;
  • that the positioning and supervision of Thomas Orchard in the police van was not reasonable and possibly caused or contributed to death;
  • that the communication between the police officers involved in the City Centre and Custody Sergeant about his potential vulnerabilities was not reasonable. However, the jury concluded that this did not probably or possibly contribute to death;
  • that the initial decision to apply the ERB as a bite guard was necessary and reasonable;
  • the use of the ERB in the carry at the Custody Centre and in the police cell was not necessary and reasonable and possibly caused or contributed to death;
  • other use of force within the police cell was necessary and reasonable; and
  • checks conducted by police staff once officers had left the cell were reasonable.

The Interested Persons and representatives were as follows:

Family: Fiona Murphy KC and Alison Gerry

Police Force: Alison Hewitt (previously Jason Beer KC) and Amy Clarke

Detention Officers: Christopher Rees KC

Custody Sergeant: Ramin Pakrooh

Response Officers: Susannah Stevens and Thomas Coke-Smyth

Custody HCP: Barnabas Branston

NHS Trust: Luke Berry

Prior to the Inquest the Detention Officers and Custody Sergeant were acquitted of gross negligence manslaughter following criminal trial (2017) and the Police Force was prosecuted for and pleaded guilty on a basis to health and safety offences (2019).



Related Barristers

Public Law

Nicholas Moss KC

Call 1995 | Silk 2021

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Public Law
Health & Safety
Professional Discipline
Environmental Law

Harriet Gilchrist

Call 2016

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