Officers used handcuffs and leg restraints on Terry Smith, 33, after failing to recognise he suffered from excited delirium

A jury has found that Surrey police seriously failed in its duty of care to a 33-year-old labourer who was handcuffed, placed in leg restraints and had a spit hood placed over his head in the hours before he died.

Terry Smith, a father of two from Stanwell in Surrey, told police he could not breathe on at least 13 occasions. He was restrained by police for more than two hours.

The jury condemned Surrey police and in a narrative verdict found “a serious failure of duty of care” and a failure to recognise that Smith suffered from the condition excited delirium. They also found that he was subjected to “prolonged and excessive restraint” and that neglect was a contributory factor in his death. It said that police needed more training in identifying excited delirium and that Smith should have been treated as a medical emergency and taken to hospital more swiftly.

The inquest, which began on 12 February, is thought to be the longest individual inquest to have been held in the UK.

Smith was restrained by police on the evening of 12 November 2013 after his family called an ambulance because he was unwell. Family members said he was hallucinating and feared that someone wanted to kill him. They said he was not behaving aggressively.

PC Louise Merry, one of the first officers on the scene, said Smith was aggressive and a danger to himself and other people.

After being restrained on the ground outside his parents’ home by several police officers using handcuffs, leg restraints and a spit hood, he was taken to Staines police station, where restraint by five or six officers continued. He was then placed in a police van, where he stopped breathing and went into cardiac arrest. He was taken to hospital and pronounced dead the following evening.

More than 50 witnesses, including many police officers, gave evidence.

The jury heard expert evidence that excited delirium could be treated effectively by administering a sedative and that Smith’s life could have been saved if he had been taken to A&E before 11.30pm that night.

The forensic medical examiner at the police station did not ask for the spit hood to be removed from Smith even though the inquest heard evidence that these hoods can impede breathing. He said Smith should have been taken to hospital as he had a deep cut on his foot and was suffering from a suspected drug overdose.

A post-mortem report in February 2015 found that, although amphetamine was found in Smith’s blood, it was not at a level that constituted an overdose. Causes of death were amphetamine-induced excited delirium with the association of restraint, cardiac collapse and multiple hypoxic organ failure.

The family’s solicitor, Nia Williams of Saunders Law, condemned “a catalogue of failures” that led to Smith’s death.

Deborah Coles, director of the charity Inquest, said Smith should have been dealt with by the ambulance service rather than the police. She said: “The cruel and frightening ordeal inflicted on Terry while he was already in distress reaffirms what has been made clear in recent reviews as well as in police guidance: medical emergencies should not be treated as a criminal justice issue.”

Jeremy Burton, assistant chief constable of Surrey police, said: “We deeply regret it when anyone comes to any harm during the course of police contact.

“There were lessons to be learned for the force following Mr Smith’s death and, I recognise that certain things could have been done differently.

“Mr Smith’s death was almost five years ago and I want to reassure people that we have seen vast changes since then, both in Surrey and nationally, in the way that people detained under the Mental Health Act are dealt with. We have also seen improvements ... regarding our understanding of excited delirium, or acute behavioural disturbance, and the training provided to officers and staff in recognising and dealing with this issue as a medical emergency.”

Burton added: “We will continue to ensure our policies and procedures are continually revised and refreshed to reflect national directive and best practice to safeguard the welfare of those within our care.”