Sean Rigg, a black belt in karate and 40-year-old musician, was being held in the back of a police van at Brixton police station in south London when he died of cardiac arrest on August 21 2008.
An inquest jury found officers used “unsuitable” force after arresting Mr Rigg for attacking passers-by and police officers in Balham, south London.
Reading the jury’s narrative verdict at Inner London South Coroner’s Court, coroner Andrew Harris said yesterday: “The level of force used on Sean Rigg whilst he was restrained in the prone position at the Weir estate was unsuitable. In addition, there was an absence of leadership. This led to a failure to take appropriate control of the situation.
The jury found police restrained Mr Rigg in the “prone position” for eight minutes, a length of time that “more than minimally” contributed to his death.
They also concluded officers had failed to identify Mr Rigg was a “vulnerable person” at the point of arrest, despite there having been a number of dispatches which identified him by name as having had mental health issues.
Reading the verdict, Dr Harris said: “Sean Rigg’s health continued to decline during the journey in the cage of a police van back to the police station.
“Sean Rigg’s mental health was already, and continued to be, very poor. As Sean Rigg was brought into the cage at Brixton police station he was extremely unwell and was not fully concious. It was reasonable to expect the police to recognise there was cause for concern regarding Sean’s mental and physical health.”
South London and Maudsley NHS Trust was also criticised for failing to deal with him adequately before his death. It also failed to ensure Mr Rigg took his medication even though he was displaying “clear relapse indicators”.
The mental health hostel in Fairmount Road, Brixton, where Mr Rigg was living was praised for the care it provided, but it had failed to plan for a crisis and should have done more to communicate with his family and clinical team.
Mr Rigg was described by his family as “boisterous, funny and talented” but had a 20-year history of mental illness. In the hours leading up to his arrest he had destroyed a gazebo in the garden of the Fairmount Road hostel.
The inquest heard he had a history of problems with the law, both in the UK and abroad and by the time police were called frightened staff had locked themselves in an office. Mr Rigg left the hostel and became involved in several altercations before being arrested.