The five-member jury comprising two men and three women returned the unanimous verdict after four hours of closed-door deliberations at the Coroner’s Court.

Former lawmaker rues not getting chance to stop Hong Kong protester’s fatal fall

The decision indicates they believed Leung had intended to land on an inflatable cushion set up by firefighters but missed.

Among their recommendations was that police lead similar rescue attempts in the future after the inquiry revealed confusion existed between officers and firefighters over which disciplinary force should be in charge.

Jurors previously heard that Leung was standing on scaffolding suspended from the mall’s fourth floor at around 4pm on the day in question. He was said to have been carrying a boxcutter and to have threatened to cut his own throat when people attempted to approach him.

Police declined offers from a former opposition lawmaker and members of the public to help talk the protester down, saying the move would be too risky. Police negotiators were unable to break the stalemate after hours of dialogue.

Firefighters who were on standby rushed towards Leung at around 9pm after he “suddenly” climbed over the platform’s railing, but he was said to have been “uncooperative” and “vigorously” resisted rescue. He fell four floors, missing the inflatable cushion, and was certified dead in hospital.

During the 10-day inquest, firefighters admitted they did not move the cushion closer as the pavement was not wide enough to accommodate its size, which could not be adjusted.

The panel suggested the Fire Services Department buy additional equipment such as nets and massive blankets, as well as various sized air cushions.

The construction company responsible for managing the scaffolding was also advised to take steps to prevent unauthorised entry to its working sites.

In his closing remarks, Coroner David Ko Wai-hung expressed regret over the length of time between Leung’s death and the inquest, blaming “systemic constraints” such as a lack of coroners and the court’s inability to compel a party to submit evidence.

“It is best to commence an inquiry as soon as possible,” he said. “Any delay is undesirable and unfair to all parties involved.”

Ko also offered condolences to Leung’s family members, who left the city two months after his death and were absent from the inquiry.

Court evidence suggested the protester had looked for places to take his own life two days before the tragedy, with mobile phone records revealing he had searched for keywords such as “jumping in Mong Kok” and “jumping in Admiralty”.

Inquest into death of protester ‘raincoat man’ begins in Hong Kong

Police found a notebook in his backpack in which he appeared to have expressed dejection about current affairs and repeated his political demands. It was also found that Leung had bought life insurance and made arrangements for his own cremation.

Ko had said the jury should return a verdict of death by suicide if they found it relatively likely that Leung had intended to end his life the moment he tipped himself over the scaffold.

A verdict of death by accident would mean he had wished to be saved but failed to grab the structure due to fatigue, the coroner said.

If you are having suicidal thoughts, or you know someone who is, help is available. For Hong Kong, dial +852 2896 0000 for The Samaritans or +852 2382 0000 for Suicide Prevention Services. In the US, call The National Suicide Prevention Lifeline on +1 800 273 8255. For a list of other nations’ helplines, see this page.