Sean Rigg died at Brixton police station on 21 August 2008. His untimely death exposed once again the disproportionate dangers faced by black men and people with mental health problems in police custody. His family's fight for the justice revealed familiar obstacles to the truth: the police and the Independent Police Complaints Commission.
Sean Rigg was a body conscious, fit man, with no physical health problems. His first psychotic breakdown was precipitated by his one and only experiment with LSD aged 20; he paid for that with his mental health.
The inquest heard he was a well-liked man, charming, intelligent and generous, a talented rapper and musician, but would become paranoid, deluded and aggressive when psychotic.
His breakdowns were rapid and usually precipitated by stopping the medication which he loathed. Most ended up with Sean being admitted to a psychiatric hospital under section, often with the help of police. He would recover quickly, but was a revolving door patient for two decades.
Sean, 40, always carried his passport in case he became ill, so authorities knew to contact his next-of-kin, older sister Marcia Rigg. She got him back from Paris, Sweden, and the Philippines over the years, and was an "integral" part of his care team.
At the time of his death, he was living pretty independently at Fairmount Road hostel in Brixton, which supported people with a forensic mental health history - those who committed crimes when acutely unwell.
His care was the responsibility of South London and Maudsley NHS Foundation Trust, one the country's leading mental health centres, and Sean liked and respected his forensic psychiatrist consultant Professor Tom Fahey. Professor Fahey was on holiday as Sean's mental health took a rapid nose dive: he was drinking his own urine, practising karate moves, mistrustful of staff he usually liked - a classic relapse. No-one called his family. He last had medication two months before his death, when he had accepted a half dose of a slow-release anti-psychotic.
Despite Sean's relapse, the team did not arrange a mental health act assessment, nor did anyone go and see him in the week before his death. These were, according to the coroner's psychiatric expert, Professor Bob Peckitt, "serious failings" in basic medical care. The crisis plans in place for a man with Sean's forensic history were inadequate.
Professor Peckitt said Sean should have been sectioned before the day of his death, as it was entirely predictable from his history that he would otherwise end up disturbed and arrested by police.
Half of all those who die during or following police contact have known mental illness; police staff receive only basic training about mental health. Mental health services are overstretched.
The jury found that Slam's failure to carry out a mental health act assessment from the 11 to 21 August "more than minimally contributed to his death".
Failed by the hospital team, the hostel tried the police.
An incredible phone call between Angela Woods, the hostel manager, and a 999 call handler was played in court. It was the fifth desperate call requesting emergency police help with Sean - a black-belt in karate who was acutely psychotic, aggressive and posed an immediate danger to public safety.
Ms Woods' demanded an explanation, but the call handler was adamant that Sean was not a police priority - he knew this because he had a psychology degree - and told her to speak with her MP if she was unhappy.
The jury found the call handlers' response mounted to "unacceptable failures to act appropriately".
Ms Woods told The Independent: "I've carried that phone call around for four years; at last the world knows that we tried to get him help."
The information given to the call handlers should have triggered an immediate police response, according to guidelines explained by Inspector Stephen Hughes. A basic intelligence check in the control room would have alerted police to Sean's history of violence when unwell. What's more it was "blindingly obvious" that he was unwell, argued Mr Thomas, and so they should have taken him to A&E. This could have saved his life. There were multiple "missed opportunities" to gather and relay important information about Sean that was readily available, the jury found.
They did not. Instead he was eventually arrested for assaulting a police officer, public disorder and theft of a passport - which was his own.
Sean left the hostel after damaging property and physically threatening staff with martial arts. His bizarre behaviour and half-naked state caught the eye of a passer-by, Liam Jung, who abandoned his car and followed Sean after seeing him randomly karate chop a stranger to the ground. He said it was obvious Sean was mentally unwell.
Eventually, four police constables gave chase after Sean, who jumped over a fence into a housing Estate. The two least experienced but fittest men, PC Mark Harratt and PC Matthew Forward, both trainees, reached him first. Sean, who was acutely paranoid, breathless and disturbed by this point, assaulted PC Forward, and they ended up rumbling on the floor until he was handcuffed.
The officers gave contradictory accounts about the restraint, and critically how long Sean was leant on in a prone, face down position, known to all the officers to be potentially fatal, especially for acutely psychotic and agitated people, from their training.
The inquest heard from several witnesses who saw PC Glasson leaning on Sean's upper back, perhaps with his knee or elbow, including one woman who took two digital photographs which proved the restraint lasted at least four minutes, rather than the 30 to 60 seconds the officers said. He denied using excessive force. The jury found that "unsuitable" force for "unnecessarily" long (eight minutes) which more than minimally contributed to his death.
The officers claimed Mr Rigg was escorted to the van and sat down on the caged back seat but then slumped down into the foot well, where he used his legs to violently 'spin himself around'.
The jury were taken to Brixton police station to see an identical van - the foot well is short and narrow; Sean was 5ft 9inches tall. They concluded that he was in a V position in the van and his mental and physical health deteriorated throughout the journey. He was "extremely unwell and not fully conscious" when taken out of the van.
The officers all denied seeing any physical injuries on Mr Rigg, yet the jury saw photographs of several fresh abrasions on his face and a large bruise on his right shoulder blade area - where he had been restrained by PC Glasson.
The family believe the abrasions came from putting Sean face down, handcuffed in the foot well of the van, with his feet bent backwards in order to fit in, which could have restricted his ability to breath and contributed to asphyxia, but this was not accepted by the jury. A contemporaneous IPCC note, only revealed during evidence, listed the facial injuries recorded by officers on the night.
PC Glasson said they decided to blue-light it back to the station as Sean needed "medical and mental advice", yet no-one radioed ahead to see if a doctor was available. He was kept outside in the van for 10minutes, with officers apparently 'monitoring' him through a Perspex screen. PC Glasson is captured at the custody desk saying: "I hope he hasn't got anything, I've got his blood on me" and "he's faking it". The officer couldn't explain this because he couldn't remember.
Sean was eventually 'carried' by two officers to the caged area, placed on the concrete floor, topless, slumped, handcuffed and unresponsive. He urinated himself; still no-one called an ambulance or got him a blanket. His body was moved only to get him out of people's way, said PC Harratt. "There was an absence of appropriate care and urgency off response by the police which more than minimally contributed to Sean's death," the jury found.
During this period police log show that PC Andrew Birks made two radio calls in order to claim officers had responded to earlier 999 calls by visiting the hostel. He couldn't recall doing this.
The FME was eventually asked to see Sean after around 25minutes, and told the court that at this his heart was still beating and body warm. Ten minutes later his heart had stopped and he was cold to touch, said Dr Nandasena Amarasekera. Life support was commenced by the police as the elderly doctor was physically incapable of doing CPR.
The CPR had implications even if it was futile at the point it was given. It meant that it was impossible for medical experts to conclude whether the visible changes to Sean's brain were down to the restraint or the CPR.
This was part of the pathological evidence considered by the coroner when directing the jury towards a narrative verdict. The coroner decided that there was insufficient evidence to meet the criminal standard for a connection between the restraint or positional asphyxia and Sean's death which could be safely left to the jury to conclude beyond reasonable doubt. So an unlawful killing verdict was withheld.
The neglect verdict was also withheld. That has two stages: a failure to provide medical care, and had it been given, that it would have made a difference to the person's life. The decision to reject that verdict was contested by the Rigg family's legal team.
So more than half an hour after the van 'blue lighted' back to the station apparently in search of medical advice, two 999 calls were made requesting an ambulance, the first at 8.19 was not deemed urgent from the information provided, the second 10 minutes later reported a cardiac arrest. By this time it was too late to save Sean's life, said experts. The jury said he was fully unconscious by 8.11 and dead at 8.24 - before the CPR was started.
Sean did not utter a single word from the moment the police apprehended him to his death; he was just 'gurgling' or 'grunting'. He was still in one handcuff when the paramedics arrived, in case he was violent said the police, even though his heart was not beating. This was "unnecessary and inappropriate" said the jury.
The jury was faced with multiple contradictions in the evidence given by the police officers -contradicted by each other, their own earlier accounts and 'hard' evidence such as CCTV footage, photographs, police logs, telephone calls and radio transcripts.
This made for compelling viewing as they were interrogated by the Rigg family's barrister, Leslie Thomas QC for several hours each, accused of serious failing of duty, lying, a cover-up and misleading the jury - who asked intelligent and searching questions throughout, demonstrating a fantastic grasp of the key issues and refusal to accept the discrepancies.
For example custody Sergeant Paul White spent a morning tell the court about his initial risk assessment of Rigg in the police van, including how he was sitting in the van, his demeanour, that he had looked him in the eyes and wasn't worried about his welfare.
Yet CCTV footage showed that he never went near the van, never mind carry out a risk assessment. He was also heard telling the police doctor that Sean was "feigning unconsciousness", thus "misleading" the doctor about the seriousness of the situation.
Sean Rigg is the only person to die in Sergeant White's custody during his long career, yet he was unable to recall the events or conversations of that night.
CCTV footage showed that PC Andrew Combden and PC John Rees, eventually did attend the hostel around 8.12pm - when Sean was already "half conscious" on the station floor.
Yet in their witness statements to the IPCC some six months later, both got the time and details of the conversation with hostel staff wrong. They were unable to explain why they made exactly the same errors to the jury. They were accused of deliberately misleading the court as part of a rouse to cover-up the police's inadequate response to the earlier 999 calls, at the behest of PC Birks.
The failure by police to respond to the 999 calls in a timely fashion was also "unacceptable and inappropriate".
The jurors wanted to see PC Combden's notebook as the CCTV footage showed him making a note. He couldn't find it. The CCTV was crucial here, yet the IPCC told the family that the footage was "corrupted" and unusable. They didn't believe them and eventually obtained it, intact, from the council.
At 2.30am on 22 August there was a debrief meeting, involving the arresting officers and representatives from the IPCC, who took notes, the Met's Department of Professional Standards, the Police Federation and a senior borough officer. This meeting, where the officers gave their initial thoughts and accounts of the incident, only came to light after PC Harratt mentioned it during his evidence. Why was it hidden from the family? Why was PC Glasson advised by the Federation not to make a statement?
At the very same time police officers turned up at Marcia Rigg's house to tell her that he'd suddenly collapsed and died. "I was shocked. He was a physically fit and healthy young man." They were promised more information but never heard from the police again. The fight for justice began then and continues tomorrow.