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24 June 2014, 19:15 | Updated: 24 June 2014, 19:18
Police have apologised to the family of a man who died of a heart attack in cells in Birmingham.
An inquest jury sitting in Birmingham ruled that officers from West Midlands Police failed to carry out an adequate risk prior to the death of Lloyd Butler.
Mr Butler, from Sheldon, died in August 2010 after being placed in a cell at Stechford police station, prompting an inquiry by the Independent Police Complaints Commission (IPCC).
An inquest jury today found that the 39-year-old, who had been drinking, should not have been detained in custody but should have instead been taken to hospital, where he would have been more likely to survive.
In a statement issued after the hearing, Assistant Chief Constable Gary Cann said: "The jury at Birmingham Coroner's Court have found that officers failed to carry out an adequate risk assessment when arresting Mr Butler, placing him in custody instead of taking him to hospital.
"They also found that once in custody, proper checks were not adequately carried out and visits were not maintained on schedule.
"We do not underestimate the impact the death of Lloyd Butler has had on his family and friends and the force extends its sincere condolences.
"On behalf of the force, I would like to take this opportunity to apologise to Lloyd Butler's family.''
An IPCC report released at the conclusion of the inquest said two officers and a member of civilian staff were found to have a case to answer for gross misconduct.
An ``alarming'' number of mistakes and unacceptable behaviour by officers on duty in the custody suite, including failures in an observation plan, were highlighted by the IPCC report.
The watchdog's inquiry also found that a police constable surfed the internet and made personal calls rather than monitoring CCTV footage of Mr Butler's cell.
Meanwhile, improper entries were made in the custody record alleging that officers were checking more often and more thoroughly than actually occurred.
IPCC Associate Commissioner Guido Liguori said: "My thoughts are with Lloyd Butler's family and friends for their tragic loss.
"The indifferent treatment of Mr Butler by officers and staff of West Midlands Police showed a disregard for both the stated procedures of detention and also for human decency.''
A misconduct hearing was held in January 2013, leading to two members of police staff receiving written warnings and a third being given further training.
Lloyd's mother, Janet Butler, said in a statement issued by her legal representative: "This inquest was extremely difficult to sit through as we heard and saw some of the awful behaviour that Lloyd was subjected to whilst he was supposed to be in the care of police in custody.
"We are both relieved at finding out more about what happened that day, but angry and sad to learn that more could and should have been done to prevent his death.''