Inquest into the death of Wayne Thomas Kerle
Deceased
Wayne Thomas Kerle
Demographics
68y, male
Date of death
2022-12-27
Finding date
2026-06-26
Cause of death
Cardiac arrest - unascertained etiology with multiple contributing factors including physical exertion during police restraint, possible positional asphyxia, and pre-existing ischaemic heart disease, severe COPD, and obesity
AI-generated summary
Wayne Thomas Kerle, 68, was arrested at his home for cannabis possession. Queensland Ambulance Service paramedics assessed him when he reported respiratory distress but cleared him for police custody after a limited examination that omitted functional assessment. Queensland Police transported him in a restrictive handcuffed position in a police van without monitoring. Multiple clinical deteriorations were misinterpreted as behavioral rather than medical. He suffered cardiac arrest in the van and could not be revived. Autopsy revealed severe pre-existing ischaemic heart disease, COPD, obesity, and cardiac enlargement. The coroner found the cause of death was unascertained but resulted from multiple contributory factors including physical exertion during arrest/restraint, possible positional asphyxia, and underlying cardiac and pulmonary conditions. Critical clinical lessons: paramedic functional assessment was essential and omitted; police should have reassessed and recalled ambulance after repeated collapses; handcuff positioning and van pod placement were inappropriate for a patient in respiratory distress; the 'cleared for custody' clearance didn't extend to physical exertion; 'talking means breathing' is a dangerous myth.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- Physical exertion during arrest and police handling
- Possible positional asphyxia due to placement in police van pod while handcuffed to rear
- Restraint with handcuffs to rear limiting respiratory mechanics
- Severe pre-existing ischaemic heart disease with significant coronary stenosis
- Severe COPD with poor functional reserve
- Obesity (BMI 32.1, clinically obese)
- Failure of QAS to conduct functional assessment before clearance
- Failure of QPS to recognize and respond to repeated signs of medical deterioration
- Failure to reassess and recall ambulance after multiple collapses
- Lack of monitoring equipment in police transport vehicle
- Psychological stress of arrest process exacerbating underlying conditions
Coroner's recommendations
- Continue Post Arrest Care training to QPS Officers regarding identification of prisoners suffering medical issues or behavioural disturbance
- Amend QP 0638 Prisoner observation recommendation form to Medical assessment/treatment/recommendation form to provide additional information and recommendations from QAS officers to QPS
- Install CCTV with audio/visual monitoring accessible by driver and passenger in all new QPS vehicles
- Complete replacement of Hyundai iLoad vehicles with Toyota HiAce vehicles (fitted with CCTV) by 31 August 2026
- Remove term 'excited delirium' from QPS training and policy documentation (already undertaken by QPS)
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