It has taken his Belvedere family 863 days to unravel the events of less than an hour which led to the death of Andrew Jordan. Last Friday, the most comprehensive examination of the circumstances of his death his inquest came to an end after 14 days.

AN INQUEST has found mentally-ill man Andrew Jordan need never have died if certain actions had been taken on the day of his death.

Mr Jordan, 28, died when his heart and breathing stopped because he had been kept restrained on his stomach, which prevented him from getting enough oxygen into his body.

This was the unanimous finding of the jury at an inquest into his death held at Erith Town Hall, Bexley Road, Erith.

Police restrained Mr Jordan at his home in Sycamore Mews, St John's Road, Erith, on October 7, 2003, during attempts to get him to the Woodville Unit at Queen Mary's Hospital, Sidcup, for a mental health assessment.

After handcuffing him because he had bitten one police officer, the officers kept him forcibly restrained, kneeling on the floor with his chest on the sofa, for about 10 minutes.

The jury of 11 decided: "Had Mr Jordan been brought into an upright kneeling position at this time, it is probable he would still be alive."

When police tried to stand him up, Mr Jordan had gone limp. He was carried out of the house and put, stomach down, on a canvas stretcher and carried to a waiting ambulance where he was put on a trolley bed, again stomach down, with his hands cuffed behind his back.

The jury decided police had warned the ambulance crew about the dangers of positional asphyxiation, which occurs when a heavy person with a "beer belly" is kept stomach down for a period of time, and which can restrict their breathing.

But Mr Jordan remained stomach down. The cuffs were removed by three police officers who travelled in the back of the ambulance after it had set off, but before it was forced to stop for the first time to check on Mr Jordan's deteriorating condition.

He was strapped onto the trolley bed and as he was put into the ambulance, Mr Jordan appeared to have a fit.

Again, the jury said: "In all probability, if Mr Jordan's position had been changed and oxygen administered, his chance of survival would have greatly increased."

It decided Mr Jordan had died during the ambulance's second stop on the flyover over the A2 in Bourne Road, Bexley, at 1.43pm, although he was only officially declared dead at Queen Mary's Hospital at 2.15pm the same day.

The jury also decided contributory factors in Mr Jordan's death were the lack of communication about his condition between the services involved; attendant medical staff had not been trained about the dangers of positional asphyxiation and "Mr Jordan died in part because asphyxia caused by prolonged restraint was not subsequently treated".

WHAT EXACTLY IS A NARRATIVE VERDICT?

SOMETIMES, instead of recording a straightforward "short form" verdict, such as accidental death or natural causes, a coroner may ask a jury to return a narrative verdict, particularly in complicated cases where there are conflicts of fact.

A narrative verdict, introduced in 2004, is a factual record of how, and in what circumstances, the death occurred.

It may include facts such as where the death took place, the cause or causes of the death, any defects in the system which may have contributed to the death and any other relevant factors.

The verdict does not allow anyone to attribute criminal or civil liability to any named individual.

As he will in the case of Mr Jordan, following the verdict, the coroner has the power to write a report, detailing action he feels should be taken to prevent similar deaths happening in the future.