A former cage fighter who died after he was pepper sprayed by police died as a result of misadventure and "cocaine induced excited delirium", an inquest jury found today.
Police failures may have also contributed to the death, the jury found.
Jacob Michael, 25, was arrested for alleged affray in Widnes, Cheshire, and taken by police van to a custody suite with his hands cuffed and his legs in restraints.
Footage taken from the police van and the custody office was shown to an inquest jury in which Mr Michael, who was known as Jake, can be heard repeatedly saying "please" and "sorry".
His breathing appeared heavy and laboured and he later died in his police cell while still in restraints.
The four-week inquest heard that Mr Michael was a cocaine user who would occasionally "binge" on the drug and he had been taking it on the weekend prior to his arrest.
Mr Michael had also been warned by doctors about the adverse effects cocaine could have on his heart, the inquest heard.
Today an inquest jury of eight women and one man at Warrington Coroner's Court, sitting at Daresbury Park Hotel, reached its verdict of death by misadventure after more than two days of deliberations.
Reading their narrative verdict, Nicholas Rheinberg, the Coroner for Cheshire, said: "Partying and his heart's susceptibility to cocaine probably contributed to the death."
The "fear, flight and fight" response caused during the arrest "may have also contributed to the death", the jury found.
The jury also found that "ineffective" police training, procedural failures, failures to carry out a "timely assessment" and a lack of communication may have also contributed to the death.
The CCTV footage shows Mr Michael face down in the cell with his hands cuffed and his legs restrained - moments before police realised he was unwell.
Two police officers can be seen with their feet on Mr Michael's leg.
The footage also shows desperate attempts by police officers and a nurse to save Mr Michael's life and resuscitate him while he is lying prone on the cell floor.
The inquest was told that Mr Michael called police on August 22 last year after he believed somebody had pulled a gun on him.
He then locked himself in his bedroom in Lacey Street, Widnes, and was restrained by police officers after a struggle.
Police officers said Mr Michael threatened them with a hammer, which led them to incapacitate him with pepper spray.
There was a struggle and Mr Michael then ran downstairs into the street, pursued by the two officers.
Police batons were used and he was restrained and loaded into the police van, the jury was told.
He died less than 45 minutes after he made the 999 call, the inquest was told.
Mr Rheinberg said he would write to the Cheshire chief constable to point out matters where action should be taken to prevent similar deaths.
:: Written material should be given out to officers undergoing training to support classroom-delivered instruction;
:: There appeared to be "no procedure" to ensure officers had "understood and retained important information";
:: The inquest revealed serious gaps in the knowledge of operational officers and custody support personnel in relation to policies which might be regarded as key to their particular roles he would ask the chief constable to consider how that particular deficiency might be remedied.
The coroner said he would draw the chief constable's attention to the fact that "this is now the second death in a relatively short period of time where an individual arrested by Cheshire Police has not been recognised as being in urgent need of medical attention by reason of alcohol or drugs" and has died in custody from the effects of alcohol.
He would ask him to consider whether the time has come to appoint a suitably qualified individual, preferably a consultant in emergency medicine, to conduct a joint review, together with a senior police officer, of practices and procedures in relation to the arrest, transportation and subsequent detention of members of the public.
He added: "I will point out that this inquest and the inquest into the death of Tony Davies disclosed serious deficiencies in relation to assessment of detainees at the point of arrest and during transportation and ask him to consider the adoption of a simple form of risk assessment...
"I will point out that had such a risk assessment been carried out in the case of Jacob Michael, then either it would have been appreciated at the point of arrest that he required urgent medical attention or alternatively a custody sergeant would have recognised this fact, were the procedure changed."
He said a system "akin to hospital triage" should be adopted to enable custody sergeants to make informed decisions.
The coroner also said the inquest revealed a "gulf" between written police and actual practice in relation to detainees who had been pepper-sprayed.
The coroner said he "drew immense comfort" from the fact that a senior officer gave evidence to the effect that lessons had been learned.
A spokeswoman for Cheshire Police said: "As with all deaths following police contact, Cheshire Constabulary immediately referred the matter to the Independent Police Complaints Commission for investigation.
"Its formal report has not yet been published.
"Throughout the investigation, Cheshire Police and Police Authority were not allowed to comment publicly on the case.
"However, the Constabulary has already acted on information from the IPCC findings to review its processes, procedures and training, and has introduced a number of improvements."
She said the new systems include:
:: Training for officers and detention officers has been reviewed to improve learning around the condition of excited delirium.
:: Aide memoire has been issued to all officers for inclusion in their pocket notebooks regarding excited delirium.
:: Redesign of transport vans to improve the ability of drivers and escorting officers to monitor detainees during transportation
:: An ongoing roll-out of the issue of "long" handcuff keys to assist in the speedy removal of handcuffs.
Speaking after the inquest Christine Michael, who wept in court on hearing the jury's verdict, said she still blamed the arresting police officers for her son's death.
Standing next to her daughter Miranda Michael who wore a T-shirt with a picture of Jacob on it, she said: "I'm very disappointed but we didn't have much faith in getting a good result."
She said: "He should have been left in his room. He dialled 999, he hadn't done anything wrong. He should have been left alone for us to deal with. It was an abandoned phone call, they should have just left, and left Jacob, and he'd be alive today."
In a statement delivered through the family solicitor, Kate Maynard, Mrs Michael added: "We believe that if the police had not stormed into Jacob's bedroom then he would still be alive. Instead he died on the floor of Runcorn custody suite while handcuffed, face down and with police officers treading on his legs.
"The jury found that the police officers and staff that dealt with Jacob were ineffectively trained, they failed to follow force procedures, they failed to perform a timely medical assessment leading to a delayed call for medical assistance and there was a lack of communication.
"The jury also said that Jacob's fear, fight or flight response may have contributed to his death. This refers in part to the violent arrest and restraint that experts in evidence said could have been avoided.
"We hope that Cheshire Police learns lessons from these harsh criticisms so that other families don't have to go through what we have done."