SAR Thomas

The Safeguarding Adults Review for Thomas was completed and agreed by the TDSAP Board in late September 2021.

The publication of the SAR was delayed to await the outcome of the inquest into Thomas’s death.

Progress on embedding the SAR recommendations into operational practice continued in advance of publication. The TDSAP Board signed off all SAR recommendations as complete, in early 2025.

Following contact with the Orchard family, the TDSAP Board agreed to publish the SAR in December 2025.

Read SAR Thomas.

Thomas Orchard’s family statement on the publication of the SAR

We miss Thomas so much, especially at this time of year, and we find it so hard to come to terms with a feeling that we have not achieved justice for him.

We constantly ask ourselves if, in the process of vigorously defending their actions over the past thirteen years, the agencies involved in Thomas’ care and in treatment that he received at the end of his life, have failed to fully recognise exactly what went so catastrophically wrong, such that changing their practice or mindset as a result becomes impossible. We were also deeply disappointed that the coroner decided against publishing a prevention of future deaths report following his inquest.

We therefore welcome this SAR and its recommendations and thank those who have worked so hard to produce it.

Having viewed the CCTV footage – literally – hundreds of times, we remain convinced the improper and catastrophic use of the Emergency Response belt (ERB) around Thomas’ face (for approximately five minutes) caused his death and we are particularly pleased to see tighter policies, risk assessments and reviews for the use of spit guards. Any device that is used to cover a person’s face and may interfere with their ability to breathe, and others’ ability to monitor them, must be carefully and rigorously scrutinized.

We consider that heavy and prolonged restraint undoubtedly contributed to Thomas’ death. One expert witness at Thomas’ inquest asserted that his level of consciousness was probably starting to fall whilst he was being transported in a police van, unobserved, on the floor and unable to use the seats because he was restrained. We are therefore pleased that this SAR recommends appropriate police vans to transport restrained detainees with CCTV available to frequently and thoroughly monitor their condition.

Thomas’ death was caused by a catalogue of failures and better communication at multiple critical points could have saved his life: communication between officers; between officers and control; between officers and custody staff; and, crucially, between the police and mental health services. This would have identified him as a person in a mental health crisis requiring medical assistance and not as a criminal who needed heavy and prolonged restraint. We are therefore delighted that this SAR recommends increased communication and information sharing between agencies, including the development of multi agency risk management meetings for people with complex needs.

The report highlights, however, how IT changes on a national scale would be required to allow full access to each system and, whilst this document has been produced by the Torbay and Devon Safeguarding Adults Partnership, we hope that it receives the national attention it deserves…. and that Thomas’ life deserves.

We can never bring Thomas back. But we can honour his memory by ensuring that the lessons from his death lead to meaningful, lasting change. We therefore ask that these recommendations are not simply words on paper, but are implemented with urgency and sincerity and that their effectiveness is thoroughly monitored. We hope that these measures ensure that other vulnerable individuals in crisis receive the care and dignity they need and deserve.

Is there anything wrong with this page?