Coronial
NSWcommunity

Inquest into the death of Omar Mohammad

Deceased

Omar Mohammad

Demographics

33y, male

Coroner

Decision ofDeputy State Coroner Grahame

Date of death

2020-09-23

Finding date

2024-02-19

Cause of death

Irreversible hypoxic brain injury secondary to acute cocaine toxicity

AI-generated summary

Omar Mohammad, a 33-year-old man with recent mental health concerns and drug use, ingested a small plastic bag containing cocaine whilst being arrested for trespass on 10 August 2020. He died 44 days later from irreversible hypoxic brain injury secondary to acute cocaine toxicity. Police attending the scene identified he was acutely unwell and arranged ambulance attendance, but initially for mental health assessment only. Critical delays occurred in informing paramedics about the ingested substance and the seizure activity. Police officers commenced CPR after approximately 5 minutes but ceased it after brief compressions, interpreting apparent gasping (agonal respiration) as normal breathing. Expert evidence revealed CPR should have been continued until paramedic arrival. Systemic failures in NSW Police first aid training were identified: officers lacked clarity on when to commence and continue CPR, did not understand abnormal breathing recognition, and were unaware that pulse checks are unreliable for determining need for resuscitation. The coroner found no evidence that earlier CPR would have changed outcome given the severe cocaine toxicity, but made seven recommendations addressing AED deployment, enhanced CPR training emphasizing recognition of abnormal breathing, urgent dissemination of updated guidance, external first aid training, scenario-based learning, and recertification requirements for senior frontline officers.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

emergency medicinetoxicologyintensive careparamedicineforensic medicine

Error types

communicationdelaydiagnostic

Drugs involved

cocaine

Clinical conditions

cocaine toxicityseizurecardiac arresthypoxic brain injuryhypoxic ischaemic encephalopathydrug-induced psychosis

Procedures

cardiopulmonary resuscitationintubationdefibrillation

Contributing factors

  • Panicked ingestion of cocaine whilst being arrested
  • Delay in informing ambulance service that patient had ingested substance
  • Delay in updating ambulance service about seizure activity
  • Premature cessation of CPR based on misinterpretation of agonal breathing as normal respiration
  • Failure to use pulse checks as appropriate indicator for CPR continuation
  • Inadequate police first aid training in recognition of abnormal breathing
  • Inadequate training on when to commence and cease CPR according to guidelines
  • Initial police doubt about whether seizure was genuine versus feigned

Coroner's recommendations

  1. Urgent consideration be given to equipping all police response vehicles with AEDs for use as standard equipment by frontline police
  2. As an interim measure, urgent consideration be given to AEDs being provided to all mobile supervisor and duty officer vehicles in each Police Area Command
  3. NSW Police Force mandatory annual training for CPR include key emphasis on CPR indication when person is unresponsive and not breathing normally; assessment methods (look, listen, feel); unreliability of pulse palpation; factors identifying abnormal breathing (irregular, slow, noisy, colour change, gasping, gulping); 'if in doubt, have a go' principle; agonal breathing distinction; continued CPR criteria; avoiding interruption to check breathing; and importance of speed
  4. CPR information be provided to all NSW Police Force members on urgent basis via state-wide NEMESIS message, PETE module with mandatory acknowledgment, and appropriate scenario training
  5. Urgent consideration be given to introduction of external first aid training course by appropriate organisation within 6-12 months to establish baseline understanding of CPR and basic life support essentials
  6. Urgent consideration be given to amending 2023-2024 Session Plan for CPR/Tourniquet Practical to include specific reference to abnormal breathing recognition, scenario training, and assessment to ensure content understanding
  7. Consideration be given to requiring police officers at rank of Senior Constable and above involved in first-response general duties policing to be retrained and certified in first-aid every three years
Full text
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