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“I can’t breathe.” Those were the three words repeatedly shouted by Stanwell father Terry Smith as he was restrained on the floor of a cell at Staines police station.

On the evening of November 12 2013, the father of two had been detained under the Mental Health Act after he began acting in an agitated and paranoid manner at his family’s home in Stanwell.

Rather than being taken to hospital as his family believed he would be, Terry was taken into custody where he was restrained by up to six police officers using handcuffs, leg restraints and a spit hood.

During this time, he screamed and shouted at least 13 times that he couldn’t breathe, at one point pleading with officers that he “can’t take the pain no more”.

Less than a day later, Terry Smith died due to a cardiac arrest in hospital and his devastated family were left wondering what could have been done to avoid his senseless death.

Following 13 weeks of evidence heard during an inquest, a jury returned a damning verdict last month that Surrey Police seriously failed in its duty of care to Terry Smith.

They also found that “prolonged and excessive” restraint contributed to his death.

The main cause of death however was given as amphetamine-induced “excited delirium”, a condition which can cause extraordinary strength and aggression in those affected and is often the result of mental illness or protracted use of stimulants.

It’s a condition that can lead to cardiac arrest or asphyxia (especially after a struggle) and therefore classifies as a medical emergency.

Jurors were told during the inquest that if Terry had been taken to hospital by 11.45pm that evening, then he may have had a chance of survival.

However, several decisions meant police officers failed to recognise and treat Terry’s condition as the urgent medical emergency it was.

(Image: INQUEST)

9.30pm

On that night back in November 2013, Terry Smith was at his family’s home in Douglas Road, Stanwell, where he began behaving in an agitated and alarming manner.

Terry’s father, Leslie Smith, was suddenly woken by his daughter telling him that Terry was "acting all strange" and "frightening" her.

In particular Terry was hallucinating, shouting “they’re going to kill me” and at one point dived at a window as if he were trying to escape from the room.

As Leslie called for an ambulance, Terry ran out of the house onto a grassy verge where he was seen pacing up and down while looking towards the sky and shouting.

Speaking to Surrey Live, Leslie said they called for an ambulance because they thought he needed medical attention.

“In our minds he needed help. You can see he needed help - that’s what I thought he was going to get,” he said.

(Image: Alexander Brock)

10.09pm

Two paramedics arrived at Douglas Road shortly after Leslie Smith’s 999 call. However, they decided not to approach Terry and requested police attendance instead.

One of the first officers on the scene, PC Louise Merry, described the moment in which she and her partner approached Terry.

"We saw Mr Smith pacing around in the middle of a grassy communal area," she told the inquest back in February.

"We felt it was urgent to see if he was OK. It was a cold night and he was just in his boxer shorts," she added.

The two officers then chased Terry to a first-floor landing in a nearby flat where they detained him under section 136 of the Mental Health Act and restrained him on the floor using handcuffs and a spit hood.

Due to Terry’s extreme strength and continuous struggling, a response sergeant, David Richardson, and six additional police officers were called to the scene to assist with the restraint.

At this point, after being asked to look in Terry's room for any drugs he may have taken, his father handed "a bag of white substance" to one of the paramedics, the inquest heard.

10.39pm

With Terry now under control on the landing, Sgt Richardson decided he should be taken to a police station rather than the hospital - despite telling officers that he might have been suffering from excited delirium.

The inquest heard that in discussing this decision with the Surrey Police force control room, he said: “Well my view is, I think he’s been drinking alcohol as well as whatever drugs he’s taken.

“He’s not going to be suitable for [section] 136 under those circumstances, I think he’s going to have to go into custody. It’s the only place I think that’s suitable to deal with [him]”.

As Terry was taken away in the back of a police van, his family back in Douglas Road tried to put the night’s events behind them.

“I honestly believed they were going to take him to the hospital. I didn’t take it on board they were taking him to the police station at all,” Leslie said. “We tried to get on with our lives.”

(Image: Terry Habgood)

10.59pm

More than an hour after his family had called for an ambulance, Terry was taken to Staines police station where he was restrained by up to six officers in a cell.

Sgt Richardson did not tell the custody sergeant Andrew Jamieson that he suspected Terry was suffering excited delirium.

Sgt Jamieson also failed to assess Terry’s condition before authorising his detention in the cell, the inquest was told.

As a result, an ambulance was not called and Terry’s chances of getting medical help in time slipped further away.

11.27pm

As his condition grew worse, Terry was visited by the police station’s forensic medical examiner, Dr Abdi Aziz Ali, who said he needed to be taken to hospital but did not emphasise it was an emergency.

Dr Ali later explained to the inquest that he did not explicitly state it was a medical emergency and assumed the officers present would know.

(Image: Alexander Brock)

11.33pm

As officers applied a body cuff (which took a further 25 minutes), Terry began screaming and shouting that he could not breathe and pleaded with officers that he was in pain.

A number of officers present in the cell, just inches from Terry as he shouted repeatedly that he couldn’t breathe, would say at the inquest that they had no concerns he might be having breathing difficulties.

12.13am

More than an hour after he arrived at the police station, Terry was placed, still under restraint, back in the police van - where he stopped breathing and went into cardiac arrest.

An ambulance was called and Terry was taken to St. Peter’s Hospital.

Back at Douglas Road, Terry’s family had attempted to go to sleep but were woken by police officers at around 2.30am, who told them they should go to the hospital immediately.

“At 2.30 in the morning our lives fell apart because of the knock on the door,” Leslie said.

Terry Smith was pronounced dead at St Peter's Hospital at around 9pm on November 13 2013.

(Image: Darren Pepe)

'The impact has been terrible'

Leslie Smith said his son’s death devastated the family, including his two sons who were aged 13 and three at the time of his death.

“The impact has been terrible. His two boys have suffered, the oldest one has suffered quite a lot,” Leslie said.

“We’ve all suffered but we’re trying to get on with our lives. We’re going to keep on fighting for Terry until we get actual closure.”

Leslie added the family felt some justice had been done after the jury found that police seriously failed Terry.

“The verdict was the right verdict. We’ve waited a long time for it. You can see in the CCTV that they never helped Terry at all,” he said.

“It’s been a long time. The last five months have been the worst because going to court every day brings it all back."