A review of the way police dealt with Sean Rigg, who died while he was being held at Brixton police station, was set up by the IPCC to re-examine its own investigation into Mr Rigg's death.
The report found:
The review recommends that the IPCC reconsider the conduct of the police officers involved in the apprehension, restraint and detention of Mr Rigg, in relation to possible breaches of their duty of care, with a view to determining whether to bring misconduct proceedings.
The four officers did not check the name on the 'stolen' passport with police records that would have flagged Mr Rigg's mental health needs and could have alerted them to the fact that the person they were dealing with was actually Mr Rigg.
He was well-known to the police through repeated past contact with the police and mental health services.