LONDON (AP) — London police officers' decision to handcuff a mentally ill Black man even as he told them “I can't breathe" was inappropriate and contributed to his death in 2018, a coroner's jury found Friday.

Police told the inquest that they found Kevin Clarke, 35, lying on the ground at the edge of a school playing field and decided to handcuff him when he became “fidgety" and began displaying signs of “acute behavioral disorder." He lost consciousness as he was taken to an ambulance and was transported to a local hospital where he died.

“Those involved in his death saw him as the stereotype big, Black, violent, mentally unwell man,'' his sister, Tellecia Strachen, said after the verdict was read. “KC was restrained unnecessarily and disproportionately. There was a lack of engagement, communication and urgency by all those who owed him a duty of care.”

Clarke, a relapsing schizophrenic, had been living at the Jigsaw Project, a residential support service, for about two years up until his death in hospital on March 9, 2018. Officers had seen him earlier that day, but they decided not to detain him for treatment despite concerns from the Jigsaw staff.

The officers’ decision to use restraints was “inappropriate” because it was “not based on a balanced assessment of the risks to Mr. Clarke, compared to the risk to the public and the police,” the jury said. The panel added that the decision by the officers was apparently influenced by the knowledge that police had used a stun gun on Clarke during a previous incident.

“The restraint exacerbated Mr. Clarke’s agitation, leading him to struggle and causing him to become even more exhausted,'' the jury said in a narrative verdict. “Failure to properly supervise also meant opportunities to release the restraints were missed. It is therefore likely the restraint, and serious failures of supervision increased the risk of death more than minimally.”

An ambulance was called after the situation was deemed a medical emergency. The London Ambulance Service has acknowledged that its crew failed to conduct a “complete clinical assessment” when they arrived.

Clarke's cause of death was given as “acute behavioral disturbance, in a relapse of schizophrenia, leading to exhaustion and cardiac arrest, contributed to by restraint struggle and being walked.''

After the verdict, Metropolitan Police Commander Bas Javid apologized for the failings identified by the jury.

“The officers who attended that day found themselves in a very difficult situation dealing with a man undergoing a mental health crisis who clearly needed urgent medical care,'' Javid said. “They made a rapid assessment and within 90 seconds had called for an ambulance.''

Nonetheless, he said, police would learn from their failings.

“The jury has made several observations about how those officers dealt with Mr. Clarke,'' Javid said. “Now we need to carefully consider those observations.''

Inquests are held in Britain to determine the facts of sudden, violent or unexplained deaths.