An inquest has found failures by police in their use of an emergency restraint belt put over the face of a church caretaker may have caused or contributed to his death.
Thomas Orchard, 32, who suffered from paranoid schizophrenia, died in October 2012, a week after being arrested for causing a public disorder in Exeter city centre.
He was restrained by seven officers and taken to a police station where a heavy webbed guard, designed to stop him spitting or biting, was put over his head.
Once inside a cell, the belt was removed – but it was 12 minutes later before officers realised he was unresponsive and began CPR.
He died of cardiac arrest in hospital a week later.
A jury-led inquest at Exeter County Hall, which lasted seven weeks, has found failures by Devon and Cornwall Police did cause or contribute to his death.
The jury also found the use and manner of the emergency response belt (ERB) as Thomas was carried to his cell, and inside the cell, was not necessary and reasonable.
In 2017, a custody sergeant and two detention officers were cleared of manslaughter following a six-week trial.
Police were later fined more than £230,000 in a health and safety case, but a judge ruled they could not be sure the ERB was a contributory factor in Mr Orchard’s death.
Thomas Orchard’s family said it had been a “torturous” 11-year wait for answers.
“It’s made us as much victims as Tom really, in some ways,” said his sister Jo Orchard.
“Eleven years, it’s affected everything; our work, our families, everything. And it’s really made us disillusioned with the system – particularly the police force.
“Whenever we hear a siren it fills us with absolute dread.
“There is no way we want to go to the police when we need help – it’s affected us all.”
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Devon and Cornwall’s acting chief constable, Jim Colwell, offered an “unreserved apology” and called it a “tragic event”.
“We accept and respect the conclusions reached by the jury in this inquest. Their conclusions have provided answers to a number of long-standing questions,” he said.
Mr Colwell admitted there had been failings and said the force’s thoughts remained with Mr Orchard’s friends and family, as well as “a number of colleagues”.