Restraint 'contributed to death'
Prolonged restraint and a failure to provide basic medical attention contributed to the death of a student who was detained under mental health laws, an inquest jury has ruled.
A six-week inquest into the death of Kingsley Burrell also found that a covering placed over the 29-year-old's face should have been removed by ambulance workers, hospital staff and police.
Mr Burrell, from Birmingham, died at the city's Queen Elizabeth Hospital in March 2011, four days after he was detained following a disturbance.
The inquest heard Mr Burrell was detained under the Mental Health Act after dialling 999 to say that armed gang members had "put a machine gun" to his head.
But CCTV footage showed that no-one had threatened him and he was taken to a mental health unit after becoming very agitated.
In an extensive narrative verdict, the jury found Mr Burrell died of brain damage due to cardio-respiratory arrest.
The panel of four women and six men further ruled that police did not act reasonably in using force during parts of Mr Burrell's detention and treatment.
The jury's written conclusion also recorded that "restraint and Kingsley Burrell's struggle against restraint whilst demonstrating an acute behavioural disturbance" more than minimally contributed to his death.
Before being applauded by members of Mr Burrell's family at Birmingham Coroner's Court, the jury concluded its findings by saying there had been a "gross failure to provide or procure" basic medical attention in response to an obvious need.
The inquest heard that a covering was placed over Mr Burrell's face during a journey from an accident and emergency department to a mental health unit, as well as inside a "seclusion room".
After the verdict was returned following three days of deliberation, Birmingham Coroner Louise Hunt said she would write to the relevant authorities to ensure national lessons were learned from what had occurred.
Ms Hunt said: "We heard quite a lot of evidence about changes that have been made and the only consolation that any family members have is that lessons can be learned.
"I am satisfied that lessons have been learned locally. Significant work has been done but I am not so sure about nationally."
West Midlands Police has confirmed four serving officers were subject to an Independent Police Complaints Commission investigation which recommended disciplinary proceedings.
The four officers have not been suspended and will face a hearing in June.
Commenting on the inquest, Assistant Chief Constable Garry Forsyth said: "We do not underestimate the impact Kingsley Burrell's death in March 2011, and the subsequent investigation, has had on both his family and the wider community.
"This week, myself and the commander of Birmingham West and Central Local Policing Unit, met with family members and friends of Mr Burrell to listen to their concerns and extend our condolences for the death of Kingsley .
"Crucial lessons have been learned from this tragic case and how the force manages people who are detained with mental and physical health needs."
West Midlands Police launched a street triage scheme in 2013, working alongside psychiatric nurses and paramedics, to provide on-the-spot assessments of people thought to be experiencing mental health problems.