Inquest into the death of Kevin Clarke concludes

The four-week inquest into the death of Kevin Andre Clarke concluded on 9 October 2020, with the Jury making strong criticisms of 1) Kevin’s residential support service (Jigsaw Project), 2) the Community mental health team from South London and Maudsley NHS Trust (SLaM), 3) the London Ambulance Service (LAS), 4) the Commissioner of the Metropolitan Police and 5) the individual police officers involved.  

The facts

Kevin Andre Clarke was 35-year-old black man who died after being restrained by police in Lewisham, South London, on 9 March 2018. Kevin had suffered from paranoid schizophrenia since the age of 17 and at the time of his death was experiencing a mental health episode.

On the day of his death, the Jigsaw Project staff called the police as Kevin had been standing outside in the cold for four and a half hours. Staff at the Jigsaw Project and SLaM believed Kevin was relapsing. When the police arrived however, they decided not to exercise their powers under Section 136 of the Mental Health Act 1983 to detain Kevin and take him to a place of safety.

Under five minutes after the first set of police officers left Kevin, the police were called by a member of the public who had seen someone running through gardens and climbing over fences. When the new set of police officers arrived at the scene, Kevin was lying in discomfort on the playing fields of St Dunstan’s College.

For thirteen minutes, police officers stood around Kevin as he rolled around on the grass in discomfort, clearly suffering from a mental health episode. As Kevin got to his knees, officers immediately lay hands of him and put him in handcuffs (in the rear stack position). Kevin had shown no signs of aggression or violence towards the officers. Kevin was restrained on the ground for fourteen minutes while handcuffed and then with leg restraints. During this period of restraint, officers exerted disproportionate force on Kevin whilst he said “I can’t breathe”.

After fourteen minutes, Kevin was brought to his feet and, despite his exhausted state, was walked by the police out of the field and to the ambulance bent over in a multi-officer arm lock with his hands elevated behind his back. The police kept knee restraints on Kevin and his hood was pulled over his head as he was walked. Kevin was unsteady on his feet for the duration of the walk and collapsed twice before being placed on a carry sheet provided by the LAS and carried to the ambulance. The handcuffs where only removed after he had gone into cardiac arrest whilst he was receiving CPR in the ambulance. The handcuffs had been on Kevin in total for thirty-three minutes. Kevin was pronounced dead by a Doctor shortly after arriving at Lewisham Hospital. The entire sequence of events was captured on body worn camera footage, which was played extensively during the inquest.


The jury’s conclusion found on the balance of probabilities, that the following matters contributed to Kevin’s death:

  1. The ambulance crew’s failure to provide basic medical care:

(i)     Failure to conduct a complete clinical assessment on their arrival; and

(ii)    failure to provide appropriate clinical advice on conveyancing Kevin to the police

Both of these failures were accepted by the LAS

  1. The inadequacy of the Crisis Relapse Management Plan.
  2. The management of the relapse by the community health team on 9th
  3. The officers’ restraint and its supervision on the playing fields.
  4. The inadequacy of any dynamic risk assessments carried out by the paramedical staff together with the police officers of Mr Clarke.
  5. The way that Mr Clarke was moved from the playing fields inappropriate.
  6. The management of Mr Clarke’s relapse by Jigsaw was inappropriate.

Wendy Clarke, Kevin's mother, said on behalf of the family:

“KC was a loving kind caring person who always looked out for others. But those involved in his death saw him as the stereotyped big black violent mentally unwell man. KC was restrained unnecessarily and with disproportionate force. There was a lack of engagement, communication and urgency by all those who owed him a duty of care. Despite the fact that KC can be heard saying ‘I can’t breathe’ and ‘I’m going to die’ they ignored him. So to hear officers say they would not do anything different is shocking. My son lost his life because of a number of missed chances by the mental health team, the accommodation provider, the police and paramedics who all stood by and let KC die.

KC was loved by many and will be missed dearly. In his memory we want to see accountability, and real change, not just in training, but the perception and response to black people by the police and other services. We want mental health services better funded so the first point of response is not just reliant on the police. There must not be another George Floyd, Sean Rigg or Kevin Clarke.”

Cyrilia Davies Knight, lead solicitor acting for the family, said:

“The highly critical Jury findings has highlighted the many failings by all those who were involved in the events that led to Kevin’s death. The Jury have found and it is clear from the body worn camera footage shown during this inquest that the officers did not need to restrain Kevin, and when they did, the force used during the restraint was excessive, inhumane and contributed to his death.

This inquest has also highlighted the systemic problems associated with the way in which mentally unwell people are often treated as criminals rather than patients by public bodies in times of crisis. This is all too familiar and needs to change.”

Saunders Law's Cyrilia Davies Knight and Ben Curtis represented the family of Kevin Andre Clarke. Counsel representing the family were Professor Leslie Thomas QC and Ifeanyi Odogwu (both of Garden Court Chambers).


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