Duncan Tomlin

1. 1. positional asphyxia with multiple risk factors

   “The current and earlier training plans, manuals and policies examined as part of the evidence in this inquest make clear references to risks associated with: (a) positional asphyxia; (b) handcuffs and limb restraints; (c) incapacitant spray; (d) acute behavioural disorder or symptoms thereof; (e) lack of oxygen due to physical exertion; (f) drug/alcohol intoxication; and (g) seizures.”

2. 2. delayed risk assessment after restraint

   “A further concern relates to how officers are trained to prioritise options available to them and the timing of decisions in circumstances similar to those in this inquest.”

3. 3. inadequate monitoring of breathing during restraint

   “The training plans, manuals and policies considered in evidence in this inquest refer to monitoring in different ways, depending on the circumstance.”

4. 4. delayed CPR initiation

   “The evidence relating to current training and training at the time of the death concerned in this inquest indicates that CPR should commence when a person is not breathing normally (described as in 2-3 breaths in 10 seconds for an adult and 3-5 in 10 seconds for small children) or if breathing is distressed (snoring, rasping) known as agonal breathing.”

5. 5. inadequate seizure recognition

   “The training material which has been provided to me on behalf of Sussex Police covers many aspects of epilepsy and seizure that were explored during the inquest.”

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