Inquest into the death of Jack KOKAUA

Contributing factors

• Positional asphyxia during prone restraint
• Use of taser (three deployments)
• Physical exertion and struggle with police
• Underlying coronary artery disease (severely narrowed arteries)
• Non-compliance with antipsychotic medication (missed depot injections)
• Mental health crisis and psychotic symptoms
• Police officers applying weight to torso during extended prone restraint
• Failure to monitor breathing or establish supervision during restraint
• Inadequate communication between police officers
• Failure to call ambulance at earliest opportunity
• Hospital discharge without coordinated mental health follow-up
• Unstable accommodation and loss of community mental health engagement

Coroner's recommendations

1. Consideration be given to modifying police and ambulance operating procedures and MOU such that police are required to give active consideration to calling an ambulance at the earliest available opportunity when seeking to arrest or return to detention an individual with a known mental health illness or who has absconded from compulsory mental health detention if it is considered that the use of force may be required or it is considered that the individual is at risk of harming himself or at risk of harming others at the relevant time
2. Consideration be given to expanding the funding for and roll-out of the PACER program
3. Consideration be given to developing criteria to determine whether a situation requiring police attendance indicates a person of interest with known or suspected mental health problems (Mental Health Crisis)
4. Either making the four day accredited MHIT training package mandatory for all police officers; or in the alternative, developing and implementing a system requiring where possible the dispatch and early identification of four day MHIT accredited officers as first responders in cases which meet criteria indicating possible Mental Health Crisis
5. Initiating training and policy provision for communication and de-escalation after there has been use of force in a situation involving a possible Mental Health Crisis
6. Consideration be given to developing and implementing a system to ensure any four day MHIT accredited officers attending in cases which meet criteria indicating a possible Mental Health Crisis identify themselves on arrival as having undertaken the four day training
7. Consideration be given to MHIT further developing and implementing for all NSWPF officers the Guardian v Warrior training currently in the Vulnerable Communities Portfolio
8. Consideration be given to MHIT and WTPR establishing and documenting a joint review of STOPAR and de-escalation training including after a use of force, and for that training to be integrated in defensive tactics training for situations involving a person of interest with known or suspected mental health problems
9. Consideration be given to NSW Police Weapons and Tactics Policy and Review developing and implementing training for those tasked with the role of supervisor including through the use of roleplay
10. Consideration be given to requiring one officer to be designated supervisor in any interaction involving 3 or more police officers and use of or likely use of force, with overall responsibility for coordinating response and ensuring ambulance called at earliest opportunity if interaction involves use of force or likely use of force on a person with known mental health illness or who has absconded from compulsory mental health detention
11. Officers communicate and verbalise significant events in the arrest and detention of a POI including any mechanical restraints applied or the availability of any vehicles or other resources for use during the interaction
12. Officers communicate and verbalise reports as to the status and well being of the POI, the extent of their resistance, and the ongoing need for use of force, including to the designated supervisor
13. In all cases an officer be tasked to maintain a time log as to when a POI is placed in the prone position to ensure awareness of the period for which the POI is so placed, that this is reported to the designated supervisor, and that an attempt be made to reposition the POI to minimise the risk of positional asphyxia after the expiry of a defined time interval
14. In all cases an officer be tasked to monitor the breathing of any POI placed in the prone position, and to communicate and verbalise reports as to the status of the POI's breathing, including to the designated supervisor
15. All officers are trained as to these matters
16. RPA require two or more persons (second being physician, clinical nurse consultant, nurse unit manager or supervising Registered Nurse) to jointly determine and provide signed authority for mechanical restraints to be removed even temporarily as regards mental health patients
17. The existing patient safety physical restraint order and observation chart be amended to record this
18. This procedure be expressly required as regards temporary relaxation of one or more hand or leg restraints to allow toileting or for any other purpose
19. RPA explore potential alternative options as to how toileting can be effected for a patient who is mechanically restrained, including the availability of security to assist or that another option may be to ensure the attendance of at least two members of clinical staff to provide additional protection against the patient removing restraints or absconding
20. Western Sydney LHD introduce a policy, procedure or clinical pathway on discharge from inpatient mental health unit where follow up is considered appropriate to seek to ensure that a community mental health team is identified as taking over clinical responsibility for the patient even if the patient will need to access temporary accommodation
21. The Discharge Liaison Officer or clinician under whose care the person was admitted at the inpatient facility is required to check that the patient is accepted for care by that team
22. Where an assertive team recommendation has been accepted in a community mental health setting, that this is communicated both to any inpatient facility to which the person is admitted, to Corrective Services if the person is subject to a parole order or community supervision, and that steps are taken to ensure that that be communicated to any subsequent community mental health team to which the person is admitted
23. Handover procedures be implemented which specifically address the continuation of prescribed medication
24. CSNSW introduce a mechanism or procedure to assess and act upon any risk when a parolee is not contactable for 7 days
25. Community Corrections and NSW Department of Health liaise to develop a means to seek to ensure that as regards offenders where the risk of reoffending has been identified as being linked to their mental health care, discharges from inpatient mental health care are coordinated and subject to ongoing monitoring to facilitate ongoing mental health care, including ongoing provision of prescribed medication, in the community upon discharge, even for those who have access only to temporary accommodation and those for whom ongoing accommodation has not been arranged when discharge is being facilitated