Inquest into the death of Kevin Edwards

Contributing factors

• Methamphetamine toxicity (toxic to fatal blood levels detected)
• Cardiac enlargement with 75% right coronary artery stenosis
• Schizophrenia/drug-induced psychosis with poor insight and evasiveness
• Physiological stress of police altercation and restraint
• Application of OC spray increasing heart rate and blood pressure
• Mechanical pressure of restraint against concrete barrier
• Failure to commence CPR despite unresponsiveness and abnormal breathing
• Possible structural cardiac abnormalities increasing risk of sudden cardiac death

Coroner's recommendations

1. Review and update CPR/First Aid TECC PowerPoint presentation dated 2018-2019 to include emphasis on starting CPR when person is unresponsive/unconscious and not breathing normally
2. Conduct annual mandatory CPR training in venues with equipment to play PowerPoint presentations and training videos demonstrating agonal breathing
3. Review CPR training materials and competency assessment by independent external first aid expert to ensure compliance with Australian Resuscitation Council Guidelines, with focus on recognition of when CPR should be initiated
4. Review and update CPR training materials annually to ensure current information is provided
5. Roll out scenario-based training on identification of abnormal/agonal breathing
6. Consider updates to NSWPF training PowerPoints per Associate Professor Holdgate's recommendations including low threshold for commencing CPR and compliance with ARC guidelines (e.g. not placing casualty in recovery position if not breathing)