Inquest into the death of Michael Peachey

Contributing factors

• Prolonged prone restraint
• Weighted restraint (some of which)
• Administration of droperidol
• Administration of midazolam
• Oleoresin capsicum spray use
• Taser deployment
• Acute psychosis
• Physical exertion from restraint resistance
• Metabolic acidosis from prolonged exertion
• Failure to move from prone position despite cessation of resistance
• Inadequate monitoring of vital signs
• Inadequate paramedic assessment of risk
• Failure to communicate clinical safety concerns to police

Coroner's recommendations

1. NSW Police Commissioner consider formulating independent policy on restraint providing clear guidance about prone restraint risks, mitigation strategies, and importance of moving person from prone position as soon as possible, particularly in cases of acute behavioural disturbance and emergency sedation
2. NSW Police Commissioner provide specific mandatory training to officers on prone restraint risks and management
3. NSW Police Commissioner consider providing further guidance in NSW Police Force Handbook on importance of having regard to information and concerns expressed by family members about person's behaviour, including changes in behaviour, in determining whether person appears mentally ill or disturbed under Mental Health Act 2007 section 22
4. NSW Police Commissioner provide additional training to officers on consideration of family information in mental health assessments
5. NSW Ambulance and NSW Police Force consider interagency training and/or development of guidance material focusing on respective roles and need for communication where both agencies attend scenes involving acute behavioural disturbance, prone restraint and emergency sedation
6. Hunter New England Local Health District consider introduction of policies for following up voluntary patients who present to emergency department with symptoms of mental illness or disturbance but leave without medical assessment