A coroner has criticised Cheshire Police after “serious deficiencies” were exposed by an inquest into the death of a former cage fighter who died in police custody after being pepper-sprayed by officers.
Jacob Michael, 25, died last August by misadventure as a result of "cocaine induced excited delirium", the inquest jury found.
But the jury at Warrington Coroner's Court also ruled that "ineffective" police training, procedural failures, failures to carry out a "timely assessment" and a lack of communication may also have contributed to the death.
The coroner Mr Rheinberg said he was concerned that this was the second death within a short period of time where Cheshire police officers had failed to recognise that an arrested individual was in urgent need of medical attention because of drugs or alcohol.
Mr Rheinberg said the Chief Constable should appoint a consultant in emergency medicine to conduct a review of practices and procedures in relation to the arrest, transportation and subsequent detention of members of the public.
Cheshire Police said lessons had been learned and that several improvements had already been put into action.
But Mr Michael's mother, Ann Michael, who wept in court on hearing the jury's verdict, said: "I'm very disappointed, but we didn't have much faith in getting a good result."
"We believe that, if the police had not stormed into Jacob's bedroom, he would still be alive.
Instead he died on the floor of Runcorn Custody Suite while handcuffed face down and with police officers treading on his legs. The evidence and the verdict revealed shocking ineptitude and complacency both of police officers and staff, individually and organisationally. I hope that Cheshire Police will start to learn the lessons that may prevent similar deaths in the future."
The inquest was told that Mr Michael called 999 in a distressed and agitated state on 22 August last year because he believed somebody had pulled a gun on him.
He then locked himself in his bedroom in Widnes, in Cheshire, but was restrained by police officers after a struggle. The officers said Mr Michael threatened them with a hammer, which led them to incapacitate him with pepper spray.
Mr Michael was arrested for alleged affray and taken by police van to a custody suite with his hands cuffed and his legs in restraints.
CCTV footage from the police van and custody office was shown to the jury in which Mr Michael can be heard repeatedly saying "please" and "sorry".
The footage shows Mr Michael face down in the cell with his hands cuffed and his legs restrained - moments before police realised he was unwell. Two police officers are seen with their feet on his leg.
The four-week inquest heard that Mr Michael was a cocaine user who would occasionally "binge" on the drug, and had taken it on the weekend prior to his death. He had previously been warned by doctors about the adverse effects of cocaine on his heart.
Deputy Chief Constable Helen King expressed "sincere sorrow" that Mr Michael had died in their care.
She added: "We are fully committed to ensuring we very carefully consider the findings we have just heard and we will diligently put in place those further steps that will help safeguard all who are dealt with by the police."
Deborah Coles, co-director of campaign group INQUEST, said: "This was a shocking death. Yet again, another inquest into a death following use of force has found failures at an individual and senior management level, and those responsible must be held to account."