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An inquest jury has said three policemen were responsible for errors which contributed to the death of mental health patient Colin Holt.
After a 12-day hearing, the panel found that the officers had failed to comply with their duty of care for Mr Holt after entering his flat in Goudhurst Road, Twydall, without a warrant.
At one point, a constable said father of two Mr Holt was “out cold” as he was handcuffed in his living room. Another claimed he was “pretending to be unconscious”.
But although Mr Holt, who had earlier that day absconded from a mental health ward at Medway Maritime Hospital, was dying in front of them, neither first aid nor medical assistance was administered,
After the jury had delivered its narrative verdict, the Independent Police Complaints Commission said it would be reviewing the findings.
The panel of eight women and one man, who have been sitting at the Archbishop’s Palace in Maidstone, found Mr Holt died from asphyxia due to restraint in August 2010.
They concluded that for the most part he had been held in a position which compromised his breath, even after his hands were handcuffed behind his back.
The jury felt that Mr Holt was not properly supervised by the first officers at the scene, PC Nicholas Reeves and PC Maurice Leigh, who had gone to his home with the intention of tasking him back to the hospital where days before he had been detained under the Mental Health Act.
A third officer, PC Neil Bowdery, took sole control of Mr Holt when he was in “an impaired state of declining consciousness”
PC Leigh and PC Bowdery were both charged with misconduct in public office following the incident and were cleared at a trial at Maidstone Crown Court in 2013.
Before the jury retired to consider its verdict, assistant coroner Allison Summers told them: “You are focusing on a short period time and, no doubt, fast-moving situation”.
Miss Summers noted that some of the officers’ evidence regarding the positioning of Mr Holt’s body and his actions and behaviour was “at odds”.
She said while the officers were aware of positional asphyxia, which occurs when a person’s position prevents him breathing while being detained, they did not feel adequately trained.
This was disputed by a an expert, who said officers had been taught within the national guidelines.
She reminded the jury that with the struggle, a smashed fish tank, flooded floor and search for the fuse box at the same time there would have been “a period of chaos in that flat”.
When PC David Brett arrived as part of the back-up team, he noticed Mr Holt’s lack of colour, he appeared lifeless and there was vomit around his mouth.
It was then that he swore and asked his colleagues in the room: “Who was checking him?”
Now the Independent Police Complaints Commission (IPCC), has said it will review the findings of the jury who heard how Mr Holt died after he was restrained by PC Maurice Leigh and PC Neil Bowdery.
The IPCC originally investigated Kent Police’s actions leading up to Mr Holt's death in 2010.
The matter was referred to the Crown Prosecution Service and PCs Leigh and Bowdery stood trial for offences of misconduct in public office.
Both were acquitted at Maidstone Crown Court in May 2013.
Chief Superintendent Steve Corbishley of Kent Police said: "This was a tragic case for all concerned and Kent Police would like to offer its deepest sympathies to Colin Holt’s family and friends.
"Any death following police contact is extremely sad and it has been a distressing time for everyone involved since the incident in August 2010.
"We acknowledge the verdict of the jury at the inquest and will review and consider the findings. However, a formal disciplinary process will take place in due course.
"Kent Police officers deal with challenging situations on a daily basis, often facing a number of different issues and in this case they responded to a difficult set of circumstances."