Warning: This story contains images and names of Indigenous people who have died.
The way a police officer pinned a young woman on the ground for almost two minutes with his leg on her back contributed to her death, among other factors, the WA coroner has found.
The coronial inquest into the death of a 26-year-old, who is referred to as Ms Wynne at the request of her family, found there was a series of mistakes made by police as well as shortcomings in the health system in the lead up to her death in 2019.
Ms Wynne's father died at the same age after being detained by police 20 years before his daughter.
"Like her father's death, Ms Wynne's death has left young children without a parent," Coroner Philip Urquhart wrote in his report.
The family of the Noongar Yamatji woman has drawn parallels between her death and that of George Floyd who died when he had his neck pinned to the ground by a police officer in 2020.
The coroner ruled Ms Wynne's death was accidental, finding methylamphetamine, her physical exertions before her apprehension and the way she was restrained by police were all contributing factors to a cardiac arrest.
Police failed to adequately monitor breathing: Coroner
Ms Wynne was restrained by police on April 4, 2019 after she fled an ambulance in severe mental distress on Albany Highway, one of Perth's busiest roads.
She was placed in the prone position, lying flat on her stomach with her hands behind her back for about one minute and 50 seconds, while a police officer weighing about 115 kilograms held his leg across her back and handcuffed her.
Another officer placed one of his legs across her hamstrings.
Coroner Urquhart found that "one of the several factors" contributing to Ms Wynne's death was her restraint in the prone position.
In his 100-page findings, Coroner Urquhart stated:
(I) A police officer erred in maintaining his leg hold across Ms Wynne’s upper back for longer than was necessary
(ii) This resulted in police keeping Ms Wynne in the prone position for an unnecessary length of time and:
(iii) Police erred in failing to adequately monitor Ms Wynne’s breathing when she was kept in the prone position.
"Any movement that Ms Wynne may have achieved before she became unconscious was most likely due to her inability to breathe, rather than an attempt to resist or escape," Coroner Urquhart stated.
"She had stopped breathing and [her handcuffs were removed] before police and ambulance officers commenced CPR.
"Ms Wynne had sustained a severe hypoxic brain injury that was non-survivable."
The WA Police Internal Affairs unit said the restraint used by the officers was justified due to the risk of Ms Wynne escaping and running into traffic.
The coroner did not make any findings of fault or blame against the three police officers involved in the restraint.
However, he was critical of the police investigation that found the officers' conduct was in line with procedures.
Police only noticed Ms Wynne had stopped breathing and lost consciousness when they sat her up.
She had not regained consciousness when she died five days later on April 9.
No timely psychiatric treatment
In the days leading up to her death, Ms Wynne had presented at Joondalup Health Campus on March 24, 2019 with her daughter over concerns her child had ingested medication.
An examination by hospital staff found her daughter appeared well, but raised concerns regarding Ms Wynne's mental health.
The on-duty psychiatrist registrar believed she was experiencing drug-induced psychosis.
Her daughter was subsequently taken away and placed in the care of the Department of Communities.
She was referred to Sir Charles Gairdner Hospital for further examination, but escaped the mental health observation area at Joondalup Health Campus while waiting to be transferred.
Coroner Urquhart found a lack of mental health bed availability, which caused a delay in the transfer, created an opportunity for her to escape.
The coroner found having her daughter taken away would have been "devastating" for Ms Wynne.
Inadequate mental health checks
On the day Ms Wynne was fatefully restrained by police, five police officers were conducting a search for an unrelated person, and coincidentally ended up at Ms Wynne's mother's unit.
Both Ms Wynne and her mother were at the apartment and became distressed when police entered.
The coroner found that none of the officers conducted an adequate mental health welfare check of Ms Wynne, despite a note in the police system requiring any police interacting with her to do so.
Ms Wynne suffered a severe mental health episode after police left the premises.
Later that morning, she found herself running away from police along Albany Highway, before she was restrained.
Family feels 'let down' by system
Ms Wynne's family mourns another similar loss more than twenty years ago when her father died in a police watch house in Albany.
Jennifer Clayton said she feels let down and disheartened by police, after both her son and granddaughter died in similar ways.
"Little children [have] got to grow up without their mummy," she said.
Coroner Urquhart found no single person was to blame for Ms Wynne's death.
"There was absolutely no evidence before me that any police officer anticipated or expected, let alone wanted, the tragic outcome for Ms Wynne," he said.
'Erosion of trust' root cause: Indigenous advocate
Coroner Urquhart found racial profiling did not play a part in the events leading to Ms Wynne's death.
While a number of improvements had already been made in the policing and health system, the family said cultural changes were also required to avoid a repeat of what happened to Ms Wynne and her father.
Social justice advocate Gerry Georgatos said a broken relationship between Indigenous people and the police was the root cause of several tragedies, including the death of Ms Wynne.
"An erosion of trust between First Nations people and the police, that is the whole beginning," he said.
Ms Wynne's grand-aunt Barbara Stoeckel-Clayton, who now cares for her four-year-old daughter, said the family was still heartbroken after learning of how Ms Wynne died.
"Pointing the finger at drug use and saying that was the cause ... come on," she said.
"She was not treated right. She was not supported. She was hurt. She was broken."
In his final remarks, Coroner Urquhart echoed the pain felt by the family in a statement from Ms Wynne's mother.
Coroner recommends training and mental health units
The coroner made recommendations to improve the training of police officers using the prone position in a restraint, and backed previous recommendations to improve the system for deploying mental health units alongside police.
"A number of inquests have already identified the [Mental Health Co-Response model] as being a vital mechanism ... when dealing with people afflicted with, not just a drug-induced mental illness, but mental illness generally," Coroner Urquhart stated.
He found WA Police had continued to develop the Mental Health Co-Response model since Ms Wynne's death, and had implemented more sophisticated systems for accessing information, such as requirements for mental health welfare checks.
The coroner said several improvements at Joondalup Health Campus had already been implemented, with systems under the Mental Health Act functioning more effectively than before.
Changes were also made to reduce the chance of patients escaping from mental health units at the hospital.
