Staffordshire Police criticised over Darren Lyons' cell death
Some custody processes were not followed by Staffordshire Police when they dealt with a man who subsequently collapsed in a cell and died.
Darren Lyons, 43, was arrested in 2014 after carers at his Kidsgrove home became worried about his behaviour.
Recording a narrative verdict, an inquest jury criticised checks on him and the service from healthcare staff, the police watchdog said.
Three officers with the Staffordshire force were disciplined for misconduct.
The Independent Police Complaints Commission (IPCC) said Mr Lyons had died from a combination of medical conditions, including heart disease.
He had a prolonged history of drug and alcohol misuse.
Mr Lyons was arrested by armed officers on 12 January after allegedly making threats to shoot or stab visitors to the property.
Later that day he was found unresponsive in his cell at the custody facility in Etruria, Stoke-on-Trent, and taken to hospital where he died three days later, the watchdog said.
'Complex medical needs'
The IPCC said it had looked at the police response to calls about Mr Lyons, his care in custody and police interaction with family members.
One custody sergeant failed to properly assess and manage the health risk to Mr Lyons and the second failed to conduct an appropriate risk assessment after accepting a handover without making his own checks, the IPCC said.
A third officer, working in custody detention, was disciplined for misconduct over their cell checks and accuracy of record-keeping.
Assistant Chief Constable Emma Barnett acknowledged there were procedural shortcomings and apologised to the family.
"His medical needs were complex and after several weeks of evidence, it is by no means clear from the expert medical evidence whether his tragic death could have been avoided," she said.
Improvements have been made since his death, she added.