An inquest heard that a fit and healthy man died as a result of “serious failures” by police officers who restrained him face down for more than an hour.
A jury saw harrowing video of handcuffed Krystian Kilkowski, 32, telling officers that he thought he was going to die as they placed leg restraints on him.
Campaigners said his death was similar to that of George Floyd, who was killed by a police officer in the United States in 2020 after being restrained face down for nine minutes.
The inquest, which concluded yesterday, concluded that serious failures by the officers who restrained him, as well as delays in paramedics reaching him, contributed to his death.
Footage shown at the inquest at County Hall in Norwich showed officers repeatedly pushing his head to the ground.
Krystian, who had taken drugs and was behaving erratically, was shown to be visibly frightened for his safety and says he thinks he is going to die.
He is then put into two leg restraints as well as other unspecified methods of restraint.
Norfolk Coroner’s Court concluded that Krystian died ‘a drug-related death following amphetamine intoxication leading to acute behavioural disturbance.’
This was exacerbated by ‘a period of physical activity’ and ‘further complicated by serious failures in the methods of restraint’ used by five police officers.
Assistant Coroner Joanna Thompson also discovered that “operational failures in the emergency services resulted in Krystian not receiving timely critical care.”
Krystian, a fit and healthy Polish man who had lived in England for nine years, died shortly after midnight on August 10, 2020, on his 32nd birthday.
Krystian was found behaving strangely after having taken drugs when Norfolk police arrived at his home address.
They then detained him in accordance with Section 136 of the Mental Health Act of 1983.
Krystian was not told why he was being detained or why he was restrained so severely.
The inquest heard how he struggled against the restraints and bit his own arms and tongue.
The pathologist described the tongue injury as the worst she had ever seen.
The police waited for an ambulance, however miscommunications between the police and ambulance service caused significant delays.
By the time the ambulance arrived, the paramedic said Krystian was beyond his level of expertise and required emergency critical care.
He was blue, bleeding and barely conscious.
The restraints continued for a further 20 minutes before he was put into the ambulance and collapsed.
According to the pathologist, the amphetamines he had taken earlier in the evening were not a fatal dose.
Krystian died hours later in hospital from multi-organ failure.
His family describe him as a very passionate and hard-working man who was always happy and smiling, liked by all who met him with many friends.
The jury concluded there was ‘a serious failure to keep Krystian safe’ which ‘contributed to his rapid physical deterioration during the restraint.’
They noted the police’s ‘approach lacked leadership’ and their ‘decision-making was inadequate’.
Jodie Anderson, Caseworker at INQUEST Lawyers Group, who supported Kyrstian’s family, said: ‘Krystian’s death is another shocking example of the lethal consequences of police officers dealing with people in mental health crises.
‘Krystian was in distress and needed care, not brutality. The failure to treat his rapidly deteriorating condition as a medical emergency meant that he was deprived of any chance of survival.
‘We call for a widespread structural and cultural change in the way that those in acute mental health crisis are treated on the streets.
‘A failure to acknowledge this growing problem will result in further unnecessary deaths following disproportionate use of force at the hands of police forces.’
‘Officers at the scene and the Force Control Room made every effort to get Mr Kilkowski the help he needed,’ said Deputy Chief Constable Simon Megicks of Norfolk Constabulary.
‘The jury determined that the East of England Ambulance Service’s operational failure resulted in a significant delay in critical care.’
‘Due to the delay in medical care arriving at the scene, he was restrained for a prolonged period of time while displaying “agitation and extreme strength”.
‘We will, of course be considering carefully the jury’s detailed findings to explore whether there are any opportunities for learning.’