Kevin Clarke was heard moaning in police body-worn camera footage while he was being handcuffed.
The way in which police restrained a paranoid schizophrenic “probably more than minimally” contributed to his death in custody, an inquest jury has said.
Kevin Clarke, 35, died in March 2018 in the midst of a mental health crisis.
Jurors in the inquest found the way that police officers restrained him was inappropriate.
They said: “It is highly likely that at least one officer heard Mr Clarke say ‘I can’t breathe’, on one of the occasions he repeated it.
“Despite this, no action was taken other than one officer saying ‘you’ve got to breathe, you’ve got to breathe, breathe, deep breaths’.
“Failure to remove restraints at this point was contrary to guidance and training.”
They added: “It appears that the officers’ decision to restrain Mr Clarke was unduly influenced by the knowledge that he had been Tasered on a previous occasion – they did not sufficiently take into account other facts that were clearly evident.”
Speaking outside Southwark Coroner’s Court after the verdict had been delivered, Mr Clarke’s sister, Tellecia Strachen, said her brother lost his life because of “a number of missed chances by the mental health team, accommodation providers, the police, and the paramedics”.
She added: “There must not be another George Floyd, Sean Riggs, or Kevin Clarke.”
Ms Strachen said: “KC was restrained unnecessarily and disproportionately. There was a lack of engagement, communication and urgency by all those who owed him a duty of care.
“In his memory we want to see accountability and real change, not just in training but the perception and response to black people by the police and other services.
“We want mental health services that are funded so the first point of response is not just reliant on the police.”
Ms Strachen said her brother was “loved by many and will be missed daily”.
Deborah Coles, from the charity INQUEST, said the jury’s conclusion should be a “wake-up call”.
Commander Bas Javid, from the Metropolitan Police, said Mr Clarke’s death was “a tragedy and on behalf of the Metropolitan Police Service, I apologise for the failings as identified by the jury”.
He added: “The officers who attended that day found themselves in a very difficult situation dealing with a man undergoing a mental health crisis who clearly needed urgent medical care. They made a rapid assessment and within 90 seconds had called for an ambulance.
“The jury has made several observations about how those officers dealt with Mr Clarke. Now we need to carefully consider those observations. We will also in due course examine any further comments and reports by the coroner.”
The month-long inquest heard from Metropolitan Police officers present on the day, the London Ambulance Service, as well as an independent expert consultant physician and consultant psychiatrist.
Kevin’s mother, Wendy Clarke, sat in court every day.
Speaking to Sky News, she said that reliving her son’s last minutes during the inquest had been distressing: “I’ve asked myself a lot of questions. If they’d handled the situation a bit better, KC would’ve been alive today.
“I really can’t come to terms with it. I’ve broken down so many times. What happened left me with panic attacks – I’ve had so many since.
“It’s been devastating. It’s had a terrible effect on the whole family. I think about him every day.”
Kevin’s support workers had first expressed concern for his safety on the afternoon of 9 March. He had been wandering around in the cold for hours.
Officers talked to him about the concerns of his support staff. On the police’s body-worn camera footage, Kevin tells them he’s “just chilling” and is wearing three jumpers to keep him warm.
The two officers leave him be and it was decided at that point they weren’t going to section him.
Later, police were called again, this time to a park where Kevin was found lying on the muddy ground.
A couple of officers approached him and checked on his welfare: “Are you alright? What’s your name? Have you been drinking?”
They encouraged him to relax. One officer helped loosen his jacket when he said he was “too hot”. He also obliges when officers reach for his phone and bus pass.
Multiple officers surrounded Kevin as he lay rocking side to side on the ground. As he went to stand, however, the officers gathered around him. They then restrained him using two sets of handcuffs and leg restraints.
PC Lee Pidgeon, who says he recognised Kevin was in a mental health crisis, told the inquest he seemed “a bit fidgety” and the use of handcuffs to restrain him was appropriate as he was showing signs of acute behavioural disorder.
The officers involved said they had followed correct police training procedures.
Giving evidence, PC John Buckingham said leg restraints were used to protect Kevin and anyone around him and in that situation, they would automatically request such restraints.
At 19-and-a-half stone, it is thought his stature may have intimidated police, who were concerned about his strength.
Kevin had a history of being violent when responding to help. In 2016 his forensic psychologist described him as a “gentle giant” when he was well.
But when unwell, Senior Coroner Andrew Harris said he became uncooperative and difficult. He also had a habit of resisting treatment.
Kevin can be heard groaning and moaning in the footage while restrained. PC Pevvy told the inquest that they felt de-escalating the situation wasn’t an option.
Another officer in the footage, PC Dannielle Barnes, can be heard explaining to paramedics who met them on the field that he had gone from “quiet to aggressive”.
On the same reel of footage, Kevin is then heard saying “I can’t breathe” and “I’m going to die”.
During the inquest many of the officers agreed – upon reflection and in reviewing the incident on camera – that they could hear distress in Kevin’s voice, but said it was hard to make out what he was saying specifically.
When asked by the coroner why Kevin was “ignored” by the officers there, PC Pidgeon said: “I cannot answer that, sir, I don’t know.”
Kevin lost consciousness as he was taken to the ambulance and later died in hospital.
He had been living in supported accommodation for two years. The inquest heard that since he was 17, Kevin had been living with paranoia and schizophrenia.
His family never feared him as he was never aggressive or threatening towards them.
Speaking to Sky News, his mother Wendy said every time his health deteriorated she would always care for him: “When he had a breakdown we’d go to the hospital to visit him and make sure he pulled through.
“When he was going through one of his episodes he’d go very, very quiet. But he’d keep himself very active, going to the gym, exercising and swimming. He had good days and bad days.
“It was difficult for him because he wanted to live a ‘normal’ life but he did his best to get through it each time.”
A tribute to Kevin’s life is captured in a mural painted opposite Lewisham police station in south London.
It was former police officer Adam Pugh’s idea and he pursued the mural with the family’s blessing.