Mitchell, Herbert John

Contributing factors

• Severe acute alcohol intoxication (blood alcohol concentration 0.358%)
• Inadequate initial clinical assessment of intoxication severity
• Lack of gait assessment to determine severity of incapacity
• Decision to maintain custody in watchhouse rather than transfer to hospital
• Inadequate monitoring protocols to distinguish sleep from unconsciousness
• Absence of clear written guidelines to watchhouse staff regarding warning signs for medical review
• Lack of written communication between QAS and police regarding monitoring expectations
• Possible prior blunt force injuries sustained before arrest

Coroner's recommendations

1. Health care providers, especially QAS and Queensland Health hospitals, should be active participants in development of new watchhouse policies
2. QPS and QAS policies should be complementary; for example OPMs require written report from QAS but QAS policies don't require them to be provided
3. QAS policies should be developed for specific needs of watchhouse prisoner patients, including recognition that busy watchhouse staff cannot provide home-equivalent monitoring of intoxicated persons
4. Health care providers must be made aware of all relevant information in written form before assessment, including trauma history, blood alcohol levels, drug history, and deterioration since custody
5. Health care providers must communicate assessments in writing to police, with clearly spelled expectations for how health care needs should be managed in watchhouse
6. Monitoring mechanisms must effectively distinguish between sleep and unconsciousness and enable assessment of deteriorating consciousness
7. Observable, clearly defined symptoms or numerical values should be specified as basis for obtaining medical attention, rather than subjective medical terms
8. Electronic record-keeping should include forcing functions requiring officers to document responses to medical problems when unable to obtain answers
9. Simplify and standardise decision-making tools, potentially adapting clinical pathway methodology used by nurses
10. Provide mechanisms for junior officers to by-pass hierarchical obstacles and challenge superior officers' decisions when safety is at risk
11. Implement mechanisms to assess compliance with policies to identify aberrant behaviour