A Queensland coroner has recommended the state’s police force review the use of a controversial neck hold after an inquest into the death of an Aboriginal man in custody.
The 39-year-old, known as Noombah or Noomba for cultural reasons, died in February 2018 after his long-term partner called police concerned he was going to kill himself.
He suffered a heart attack shortly after a struggle with two police who came across Noombah while driving to another incident near his house in Townsville.
State coroner Terry Ryan found Noombah died of cardiac arrest in the context of being restrained, pre-existing heart disease and inhaling petrol in the hours before his death.
The coroner found the actions of police officers Zachary Schembri and Shane Warren were lawful, authorised and justified in the circumstances and were not in breach of any police policy or procedures.
Guardian Australia revealed in March last year that one of the officers said in a police interview shortly after the death that he had used a lateral vascular neck restraint (LVNR) hold while trying to restrain Noombah.
The controversial hold is banned in other Australian and international jurisdictions and following the Guardian report Ryan requested Queensland police provide additional information to his office on LVNR training, how its use was governed, and its use in other jurisdictions.
During the inquest, Schembri said he no longer believed he had used the hold during the struggle with Noombah.
Ryan accepted that evidence in his inquest findings, published on Tuesday, but said the Queensland police service should review whether it continued to use the hold – and the training provided regarding its use.
“I accept that a LVNR was not actually achieved in this situation, although that was how Const Schembri [initially] described the restraint he used,” Ryan found.
“Irrespective of whether a lateral vascular neck restraint was activated in the detention of Noombah, there were conflicting views before the inquest about whether this type of restraint has a place in modern policing.”
Ryan found the actions of Queensland ambulance service members who attended, however, “did not optimise Noombah’s chances of survival” after he suffered the cardiac arrest.
The paramedics did not conduct a basic assessment of his vital signs or accurately record them, and after Noombah was found to be in cardiac arrest “the level of treatment was also suboptimal”, Ryan said.
In his evidence, the Queensland ambulance service’s medical director, Dr Stephen Rashford, could not say if Noombah would have survived if the care provided to him had have been adequate. He said that in the most optimal circumstances about 25% of patients who arrest in the presence of paramedics do not survive.
Ryan noted that neither of the paramedics who treated Noombah continued to practise. The Queensland ambulance service has apologised to Noombah’s family.
In his other recommendations, Ryan said Queensland police should develop a mandatory requirement for police officers to request a priority response from the Queensland ambulance service when the demeanour of a person in custody “rapidly declines from a state of heightened emotion and agitation to one of apparent compliance”.
This had occurred with Noombah, who Schembri had described as going from “100 to zero” very quickly. Under the recommendation, the process would be included in the police manual, and the mandatory request would require paramedics to conduct a medical assessment and monitor vital signs.
Ryan also recommended the Queensland government work with Indigenous people in Townsville and other institutions to develop culturally appropriate referrals for “First Nations people in mental health crisis as an alternative to assessment in hospital emergency departments”.
