Mark Camm, 43, died four years ago at Leeds General Infirmary of a brain aneurysm, 12 days after being transferred from another hospital where he was taken after having been held for 25 hours in a local jail, the Daily Mail reported Wednesday. He had been arrested in Wakefield when police thought he was intoxicated.

During a six-week hearing, the inquest jury heard 50 instances in which the system failed Camm, the Daily Mail said. The jury returned a narrative verdict Tuesday, criticizing custody staff at the police station and medical staff at the hospital.

"Everybody failed Mark, whether they were police officers, doctors at the police station, or doctors and nurses at the accident and emergency department who first saw him," said Camm's sisters, Michelle Chadwick and Mel Carlton.

"Mark lost a chance of survival. But even if he was ultimately to die, we lost the chance to be with him while he was still conscious, to reassure him, to remind him of how much his family loved him."

West Yorkshire Coroner David Hinchliff recommended that West Yorkshire Chief Constable Sir Norman Bettison review the department's custody procedures.

The Crown Prosecution Service and the General Medical Council also are expected to review the case.

West Yorkshire police and Mid Yorkshire Hospitals have apologized to the family.