Inquest into the death of Adam Southwick
Deceased
Adam Douglas Southwick
Demographics
37y, male
Date of death
2013-09-20
Finding date
2015-12-03
Cause of death
methyl amphetamine intoxication while being restrained in a confined space; positional asphyxia as major contributory factor cannot be excluded
AI-generated summary
Adam Southwick, a 37-year-old man severely intoxicated with methamphetamine, was placed in a cramped police charge dock while handcuffed and unable to walk. He died from methamphetamine intoxication complicated by positional asphyxia while restrained in a confined space. Critical failures included: police did not call an ambulance at the scene despite obvious signs of severe intoxication (unable to walk, unresponsive); the custody manager failed to assess Adam for 7 minutes while he remained in the police van; and when placed in the dock measuring 1.488m (Adam was 1.74m tall), his position with neck flexed against the wall compromised his airway. Police did not recognise his deteriorating consciousness or cessation of breathing until after arrest had occurred. There was a 3-minute delay before CPR commenced. Early ambulance attendance and placement in recovery position rather than the dock could have prevented death.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- failure to call ambulance at scene despite obvious severe intoxication
- failure to assess detainee in police van for 7 minutes upon arrival at station
- placement in charge dock too small to allow proper positioning
- neck flexed in awkward position against dock wall compromising airway
- failure to recognize deteriorating consciousness
- failure to recognize cessation of breathing
- delay of 3 minutes before CPR commenced
- inadequate risk assessment by custody manager and attending officers
- handcuffs remained on while in dock despite unconsciousness
Coroner's recommendations
- NSW Police Professional Standards Command to investigate and review the matter
- NSW Police Force to review implementation of policies and training for ill or intoxicated detainees
- Revise Code of Practice for CRIME to include clear demarcation of custody responsibility handover points
- Add requirement to promptly remove persons from police vehicles upon arrival at station for appropriate monitoring and assessment
- Add requirement for face-to-face monitoring if delay in removing persons from police vehicles
- Clarify circumstances in which it is inappropriate to place ill or intoxicated person in dock
- Specify inappropriateness of dragging detainees unable to walk due to illness or intoxication
- Add guidance on appropriate procedure for transport of ill or intoxicated detainees
- Provide training that if detainee unable to sit upright without assistance due to illness or intoxication, medical assistance should be sought
- Specify detainees should not be placed in dock where unable to sit upright without assistance
- Specify detainees with diminished consciousness should not be handcuffed behind back in dock
- Specify no detainee should be placed on floor of dock or confined space restricting movement and breathing
- Implement requirement to closely monitor ill or intoxicated detainees for consciousness level changes
- Consider requiring all custody managers and shift supervisors to complete safe custody course
- Display guidance posters at all NSW Police Stations with custody facilities regarding detainee assessment and consciousness levels
- Include reminder that all police officers regardless of rank may call ambulance
- NSW Police to develop policy or memorandum of understanding with NSW Health and NSW Ambulance regarding transportation and care of intoxicated detainees
Full text
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