A jury has found "serious errors, omissions and a gross failure to provide basic medical attention" contributed to the death of a man in Northumbria Police custody.
Mark Needham died at Forth Banks police station on July 23 2015 after suffering four seizures in his cell - six hours after he was arrested for being drunk and disorderly, in Benwell.
Following a three-week inquest into his death a jury concluded the 52-year-old's cause of death was epilepsy and head injuries sustained by falls.
They ruled that a number of "errors and omissions" contributed to his death, including failure to make a medical assessment, or to immediately start CPR when an emergency was declared.
Following the hearing, the Independent Office for Police Conduct said that "the actions of some of the officers and staff involved fell well below the standard expected" and confirmed that disciplinary action had been taken against six officers.
The inquest previously heard that Mr Needham, who had a history of alcohol addiction, homelessness, pancreatitis and alcohol withdrawal seizures, was taken to the station at around 9am after he was seen "exposed" with his pants around his ankles in Newcastle's West End.
Jurors heard from detention officer Brian Hirst, who admitted the welfare checks he carried out on Mr Needham were not compliant with the code of practice for dealing with detainees.
And custody nurse Lynne Hetherington told the hearing that rather than going to see Mr Needham as soon as she was made aware of his medical conditions, she said she "would give him an hour or so to calm down".
She went to Mr Needham's cell for the first time more than three hours later before spending "seconds" with him and deciding he was "fit to be detained".
The jury's narrative conclusion said: "In the assessment by the custody sergeants there were errors and omissions which included an inappropriately completed risk assessment and unsuitable level of care plan given the known medical history.
"Further errors were made in the welfare checks undertaken by the detention officers, which included a failure to perform sufficient rousal checks.
"Further flags were inappropriately acted upon including vomiting, snoring, and the need to put Mr Needham into the recovery position."
They also said "serious errors and omissions" were made by Ms Hetherington.
The conclusion said: "No assessment was done at all when first made aware of Mr Needham’s admission and medical history. A further error was made in not seeing him for an extended period of time. When a cell check was carried out it was wholly unsuitable and lacking as a medical assessment.
"The omission of an initial assessment, the error in performing an unsuitable assessment in the cell and failure to initiate CPR immediately once a medical emergency had been declared was a gross failure to provide basic medical attention constituting neglect."
Senior coroner Karen Dilks warned Northumbria Police she would issue a Regulation 28 report to prevent future deaths, which will set out her concerns and request that action should be taken.
Ms Dilks said officers were at risk of becoming "desensitised" due to the high number of detainees under the influence of alcohol, and suggested "something as simple as a sign saying 'is this person ill or are they drunk'".
The coroner warned that evidence from the inquest would be passed on to the Nursing and Midwifery Council.
Following the inquest the IOPC said its investigation, completed in May 2017, found evidence to indicate gross misconduct and misconduct in the actions of a number of police officers and staff who came into contact with Mr Needham that day.
A police independent disciplinary panel found:
• Gross misconduct proven for a detention officer who received a final written warning.
• Gross misconduct proven for two detention officers who each received a written warning.
• Misconduct proven for two detention officers; one received a written warning and the other a verbal warning.
• The case against the sergeant was found not proven.
In May 2019, a gross misconduct hearing – led by a police independent disciplinary panel – for another sergeant, Claire Hunter, took place regarding her actions during Mr Needham’s detention. One allegation of gross misconduct – concerning a lack of urgency in ensuring Mr Needham’s safety – was proven, and she received a written warning.
In June 2019 a gross misconduct hearing – led by a police independent disciplinary panel – for a third sergeant took place regarding his actions during Mr Needham’s detention. The case against him was found not proven.
David Ford, IOPC interim regional director, said: “Our investigation, the subsequent independent misconduct hearings, and the inquest proceedings gave a clear insight as to what happened that day. The actions of some of the officers and staff involved fell well below the standard expected.
“While the vast majority of police officers and staff uphold the highest professional standards, in this case, more could and should have been done.”
Father-of-three Mr Needham, described by his sister Heather Richardson as "sensitive, kind and funny", had moved to Newcastle from King's Lynn "for a fresh start" just one month before his death.
A statement from the family said: ""It has been a traumatic four-and- a-half years since we first heard Mark had died alone in tragic circumstances in custody at Forth Banks police station, Newcastle.
"We are grateful for the acknowledgement that there were failings in his care in custody by police and detention officers along with neglect by the medical qualified staff.
"As a family we sincerely hope that lessons will be learnt in relation to the way vulnerable people are dealt with in a custody situation. Not only for the sake of other vulnerable people and their families but also for those who ultimately have to live with the knowledge that their failings may have contributed to someone's death."