Galeano, Antonio Carmelo

Contributing factors

• severe coronary atherosclerosis with up to 80% vessel narrowing
• enlarged heart with cardiomyopathy
• acute amphetamine and methylamphetamine toxicity at toxic levels
• excited delirium syndrome
• multiple taser activations (28 times, 40-60 seconds effective total)
• physical exertion and struggle with police
• adrenergic response to taser application and muscle tetany
• face-down restraint position
• delayed commencement of cardiopulmonary resuscitation
• early acute appendicitis
• mitral valve prolapse
• emphysema
• poorly controlled diabetes

Coroner's recommendations

1. Enquiry regarding neurological tissue testing (MASH test) for excited delirium diagnosis and resource allocation for such testing in forensic pathology
2. QPS should review and standardise timekeeping systems across internal systems (NICE, CAD) to internationally recognised standards
3. Joint QPS-QAS review and protocol development for management of severely disturbed individuals: focus on medical emergency response, early QAS involvement, rapid controlled restraint, and immediate hospital transport
4. Include 'imminent risk' language in threshold for taser deployment policy to replace 'risk of serious harm'
5. Include 'justifiable' alongside 'exceptional circumstances' in policy for repeated or prolonged taser use
6. Mandatory review and audit of every multiple or prolonged taser deployment within short timeframe, including debrief and retraining
7. QPS to investigate safer taser models (X2) that prevent unintended prolonged use, and deployment of taser-mounted or officer-worn video cameras for transparency
8. Cross-reference and integrate sections of OPM dealing with operational use of force, psychotic episodes, and acute psycho-stimulant-induced episode/excited delirium; ensure input from Mental Health Intervention Project and education that drug-induced psychosis is mental illness
9. Enhance police communications centre role in guiding frontline officers with contemporary OPM guidance and early notification of ambulance/health services for high-risk patients
10. QPS and Queensland Health to consult on enabling notification to police of hospital discharges in particular high-risk circumstances, balancing privacy against public safety
11. In-service training of forensic scientific officers on emerging technology such as AFID markers from taser deployment
12. Refocus forensic evidence gathering in death in custody investigations to include resuscitation-related items and police equipment
13. Structured seminars involving multi-rank and multi-disciplinary officers to clarify what 'treating death in custody like a homicide' means and establish appropriate investigative protocols
14. Review of Ethical Standards Command standard operating procedures for death in custody investigations to ensure coordination role and clear chain of authority
15. Organisational reflection and training on leadership and effective communication within police hierarchy during stressful incidents
16. Urgent review of QPS first aid masks in conjunction with QAS to ensure appropriate standard and health/safety quality for CPR use