Coolwell, Shaun Charles

Contributing factors

• severe coronary atherosclerosis with 80% luminal narrowing
• methamphetamine toxicity
• acute behavioural disturbance secondary to drug intoxication
• prone position restraint limiting diaphragmatic breathing
• physical injuries including deep Achilles tendon laceration and burns
• aspiration of gastric contents
• stress and excited delirium
• failure to recognize clinical deterioration during restraint
• failure to reposition from prone to lateral position
• inadequate vital sign monitoring despite paramedic presence

Coroner's recommendations

1. Queensland Police Service and Queensland Ambulance Service should work together in relation to the joint management of responses to acute behavioural disturbance, including physical restraint, to ensure that officers from both agencies are aware of the requirement for ongoing monitoring of restrained persons, the differential interpretation of observations and the importance of role clarity and teamwork.
2. Develop a formal process to facilitate the early sharing of lessons learned from the investigations of both agencies into adverse events where QPS and QAS officers are co-responders, including access to relevant investigative materials.
3. QPS should incorporate practical understanding of agonal breathing in first aid and restraint training to enable better appreciation of the distinction between respiratory suppression and compliance.
4. Improve inter-agency communication and protocols between QPS and QAS for management of acute behavioural disturbance cases.