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15 May 2015, 19:49 | Updated: 30 March 2016, 13:50
A coroner's court has decided Birmingham dad Kingsley Burrell was neglected after being detained by police.
Prolonged restraint and a failure to provide basic medical attention are said to have contributed to his death from a cardiac arrest four days after being held under the mental health act.
A six-week inquest 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 Winson Green, died in March 2011 at the city's Queen Elizabeth Hospital.
The hearing into how it happened heard he'd originally called 999 saying an armed gang had "put a machine gun" to his head.
No evidence of that was found on CCTV and he was taken to a mental health unit after then becoming very agitated.
In an extensive narrative verdict, the jury found Mr Burrell died of brain damage due to cardio-respiratory arrest.
They went onto decide police did not act reasonably in using force during parts of Mr Burrell's detention and treatment.
The jury concluded a ``gross failure to provide or procure'' basic medical attention in response to an obvious need had occurred.
Mr Burrell's family applauded those words and Birmingham Coroner Louise Hunt revealed she'd be writing to relevant authorities to ensure lessons were learnt across the country from what happened.
She 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.
They have not been suspended but will face a hearing in June.
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.''
The force say one example of this is their street triage scheme, which sees officers paired up in specialist teams with mental health nurses and paramedics, to answer calls involving people who might have mental health issues.