Sean Rigg was a fit and healthy 40-year old, a successful musician and producer who suffered from bouts of paranoid schizophrenia.

As such, he was well known to the Brixton police, who had been involved in getting him hospitalized on several occasions over a 20-year period. Yet within an hour of the Metropolitan Police responding to calls to deal with a serious relapse in his mental health on August 21, 2008, Sean was dead inside Brixton Police Station. He had been caged at the back of the station on a concrete floor, with no medical attention until it was too late.

Last week, the findings of an inquest into Sean Rigg’s death listed many failings by the police and the mental health authorities.

It found that police failure to respond to five emergency calls for help from hostel staff was “unacceptable and inappropriate”. “Poor communication” between the police when they did respond with regards to Sean’s mental health history meant critical information was not passed on.

The jury found that the “level of force used on Sean Rigg whilst he was restrained in the prone position” on his arrest was “unsuitable.” His physical condition deteriorated during the restraint as his brain was being deprived of oxygen, the jury found, and his condition worsened during his journey to the police station.

Sean was “extremely unwell and not fully conscious” by the time he was “carried” into the cage. Partial positional asphyxia from the police restraint was recorded as one of the causes of death.

The decision to leave Sean in handcuffs while he was unconscious and CCTV footage showing him being “stood up” by officers when he was in this state were also described as “unacceptable and inappropriate”. The failure to provide Sean with appropriate care at every stage, and the lack of urgency in their response to the deterioration in his condition more than minimally contributed towards his death, the inquest found.

The jury said it was “questionable” whether police guidelines were sufficient or had been followed.

Sean’s is one of a number of deaths of vulnerable people in police custody. His case brings to light the near impossible odds faced by those seeking to establish the truth about such deaths and to hold police to account, despite determined efforts by friends and loved ones.

Since 1990, 1,433 people have died in custody or after contact with the police in England and Wales. Yet there has not been a single successful criminal prosecution of the perpetrators. Chief Executive of the Independent Police Complaints Commission Jane Furniss says that its function is to secure and maintain public confidence in the system of complaining against the police. But the IPCC has never acted against the police over deaths in custody in its eight-year history.

Sean’s care was the responsibility of South London and Maudsley NHS Foundation Trust (SLAM). When the staff at the hostel where Sean was living rang SLAM to ask for someone to come out, they were told no one was available and that they should ring the police instead.

The police told staff that it was not a police matter and if they had any complaints about that they should contact their member of parliament.

After several 999 calls, a member of staff tried to reason with the police on the urgency of the situation. “Sean Rigg is out on the street and is a threat to the public... You want me to send paramedics to a man who is psychotic… a black belt in karate who is throwing karate punches... I don’t think you have a handle on the situation... This guy is actively psychotic and is going to hurt somebody... This is absolutely ridiculous…”

It was about three hours and five 999 calls later when the police arrived. Sean was by that time out in the street, naked to the waist and acting very strangely. He had assaulted at least one member of the public with karate moves.

Four police officers chased Sean into a housing estate, where he climbed a tree. One of the officers pulled Sean down and he fell to the ground. Without waiting for him to regain composure, the officers then pinned him down. At the inquest, officers gave contradictory accounts about their use of restraint, including how long Sean was leant on in a prone, face down position—one known to all the officers from their training to be potentially fatal, especially for agitated people.

The inquest heard from several witnesses who saw PC Glasson leaning on Sean’s upper back, either with his knee or his elbow. A female witness took two digital photographs which were used by the jury to prove that restraint lasted at least four minutes, rather than the 30 to 60 seconds claimed by the police. The jury found that “unsuitable” force for an “unnecessarily” long time (around eight minutes) had more than minimally contributed to Sean’s death.

The police then bundled Sean into the back of a police van and drove back to the police station at speeds of up to 73 miles per hour. Yet in court the officers claimed that there was nothing wrong with Sean during the journey. On arrival, Sean was kept in the van for 10 minutes without supervision. He was then carried into the police station, unconscious, limp and lifeless.

PC Glasson is captured on CCTV at the custody desk saying, “I hope he hasn’t got anything, I’ve got his blood on me,” and “He’s faking it”. The officer said at the inquest that he could not explain his words because he could not remember saying them.

Custody Sergeant Paul White told the court in detail about his initial risk assessment of Sean Rigg in the police van, saying he had no reason to be worried about his welfare. Yet CCTV footage showed that White did not go near the van and was in no position to carry out a risk assessment. PC White is also recorded on the CCTV telling the police doctor that Sean was “feigning unconsciousness.” The doctor was given false information at the very time that Sean required urgent medical attention.

Members of the Rigg family were initially told by police that Sean had simply “collapsed” while in Brixton police station without any prior indications of ill health.

The cover-up was then taken up by the IPCC, who put out a public statement declaring that Sean had attacked the arresting officers, in spite of there being no evidence to back up their claim. The IPCC later retracted its statement.

Crucial CCTV footage from within the police station was kept from the family’s lawyer. Police claimed that two of the cameras were out of operation. The IPCC told the family that some of the CCTV footage was “corrupted” and unusable. It later transpired that it was not—the jury obtained it from the council fully intact.

The Metropolitan Police Service claims that the four arresting officers—PC Mark Harratt, PC Richard Glasson, PC Andrew Birks, and PC Mathew Forward—who restrained Sean for eight minutes face down with “unsuitable” force are no longer on operational duties. They have not been publicly disciplined for their part in his death.

The IPCC announced on August 2 that it would carry out an “independent investigation” into the evidence of PC White and review its own investigation into the incident, which was described by the Rigg Family as “inadequate and obstructive”.

The Rigg family have called for criminal prosecutions of those responsible for Sean’s death. Marcia Rigg, Sean’s older sister, said, “This is absolutely ridiculous and unacceptable. I have no faith in the IPCC whatsoever.”