The use of face-down restraint on a former school teacher contributed to his death but officers behaved reasonably and appropriately, the police watchdog has said.
The Independent Office for Police Conduct said the “struggle” against physical restraint and use of incapacitant PAVA spray contributed to the death of Meirion James at a Welsh police station.
Its findings were published after a jury determined the 53-year-old’s death was caused by “positional asphyxia due to restraint following acute behavioural disturbance, and obesity”.
But although jurors determined that police were justified in using restraint on Mr James, they found he had spent an “excessive length of time” in a prone position.
Following the inquest’s conclusion on Thursday the police watchdog has published its investigation including a number of recommendations to the Dyfed-Powys Police to improve its handling of detainees with mental health problems.
The IOPC found two officers had “a case to answer for misconduct” in connection with not opening a custody record and not arranging a Mental Health Act assessment and who were subsequently given “management action” by the force.
But it said the actions of officers and staff in using restraint and PAVA spray when Mr James rushed out of a cell did not merit any disciplinary proceedings.
The report said: “Mr James did have contact with a number of police officers and police staff involved in the attempted restraint on 31 January 2015 in Haverfordwest Police Station.
“I have found that the actions of the police officers and police staff were appropriate and reasonable giving the dynamic nature of the incident.
“However, the struggle against physical restraint after exposure to PAVA did, to some extent, contribute to his complex multi-factorial death.”
Mr James, who was from Crymych in Pembrokeshire and suffered from bipolar disorder, was taken to Haverfordwest Police Station in the early hours of the morning after calling the police to say he had assaulted his mother.
The previous day he had been detained under the Mental Health Act by police after he crashed his car into another driver and displayed unusual behaviour, the inquest heard.
The jury were shown footage of Mr James charging at police from inside his cell and struggling with them before other officers were called to help hold him down.
The inquest at Haverfordwest County Hall heard Mr James became unresponsive following the restraint and use of PAVA spray by police officers.
He was given CPR but was pronounced dead at hospital at 11.27am on January 31 2015.
The IOPC said a custody record should have been drawn up for Mr James’s detention and a Mental Health Act 1983 assessment carried out.
It said a custody record created when Mr James was detained at Aberystwyth police station would have made important information about his condition available to officers at Haverfordwest the next day.
IOPC Director for Wales Catrin Evans said: “I send my condolences to the family and friends of Mr James, along with everyone affected by his sad death.
“Based on the evidence gathered during our independent investigation into police contact, we found the actions of officers and staff in using restraint and PAVA spray when Mr James rushed out of a cell did not merit any disciplinary proceedings.
“It cannot be known whether a full mental health assessment by doctors and an approved professional would have altered the tragic outcome.”
The IOPC has recommended Dyfed-Powys Police review its Mental Health Act protocols between the force and partners including local authorities and health services.
It also recommends the force reviews its work with healthcare professionals to ensure suitable expertise is available for the mental health needs of detainees.
The IOPC also recommended Dyfed-Powys Police reminds its officers of the process and their responsibilities when detaining someone under the act, the need to open a custody record and the need to handover relevant information.
It said Dyfed-Powys Police accepted its findings and learning from the investigation.