A police officer has been criticised for using CS spray on a hospital patient who later collapsed and died.
The Independent Police Complaints Commission (IPCC) investigation into the circumstances leading to the death of Victor Massey, a 54-year-old landscape gardener, said using the spray in a confined environment was "not appropriate".
The report also said that officers should have asked hospital staff about Mr Massey's clinical situation, and that of other patients in the vicinity.
Mr Massey had been receiving treatment for acute pancreatitis at Kings Mill Hospital in Mansfield, Nottinghamshire. He died in the early hours of August 8, 2006 after being CS sprayed and restrained by Nottinghamshire Police officers who had been called by hospital staff.
IPCC Commissioner Len Jackson said: "This was a volatile situation police found themselves in, but it is difficult to see why an officer felt it necessary to use CS spray given the hospital environment he was in and that any potential threat posed by Mr Massey could have effectively been dealt with by the officer standing back."
At an inquest into his death in Nottingham, a jury heard evidence that Mr Massey, who had been on oxygen, had been hallucinating - a known consequence of pancreatitis and of the use of tramadol - believing that he was being watched by the police and that his bedside fan was a police helicopter.
The Massey family solicitors, Freeth Cartwright, said Mr Massey had never been in hospital before and appeared to have panicked when another patient in the ward became disturbed earlier that evening. Police had to be called to restrain that patient.
The inquest heard that Mr Massey left his bed shortly before midnight on August 7 and barricaded himself in the shower room off the ward. Hospital staff called the police again and within seven minutes of arriving the police CS sprayed Mr Massey, broke down the door and dragged him into the corridor where they restrained him. Mr Massey suffered a fatal cardiac arrest while doctors tried to inject him with a sedative.
Deputy Nottinghamshire coroner Martin Gotheridge returned a narrative verdict that Mr Massey died of a cardiac arrest following restraint in combination with acute pancreatitis and the use of an opiate painkiller, tramadol.
The family will resume its pursuit of a civil claim for compensation against the hospital and the police, Freeth Cartwright added.