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Coroner's Finding: Reid, Paul

Deceased

Paul Reid

Demographics

50y, male

Date of death

2017-05-26

Finding date

2022-12-16

Cause of death

ischaemic heart disease

AI-generated summary

Paul Reid, a 50-year-old Aboriginal man with severe ischaemic heart disease and poor medication compliance, died of a cardiac arrhythmia during his arrest by South Australian Police. He was highly intoxicated (BAC 0.25%) and cannabis-positive when police attended a domestic disturbance call. After arrest, Reid collapsed approximately 7 minutes elapsed before ambulance was called. The coroner found police assumed his unconsciousness was alcohol-related intoxication rather than recognising a medical emergency. Key failure: police did not apply the Brief Coma Scale to assess his impaired consciousness, which would have mandated immediate medical assistance. While the arrest itself was lawful and medical evidence did not support abuse claims, SAPOL's critical deficiency was failure to recognise and respond appropriately to altered consciousness in a high-risk cardiac patient. Earlier ambulance attendance might have offered a slim chance of outcome change, though not proven.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

cardiologyforensic medicineemergency medicineparamedicine

Error types

diagnosticsystemdelay

Drugs involved

alcoholcannabisglyceryl trinitrate

Clinical conditions

ischaemic heart diseasecoronary artery stenosiscardiac arrhythmiaacute alcohol intoxicationimpaired consciousnesscardiac arrest

Procedures

cardiopulmonary resuscitation

Contributing factors

  • severe coronary artery disease with extensive cardiac scarring
  • poor medication compliance
  • high blood alcohol intoxication (BAC 0.25%)
  • cannabis use
  • acute physical and emotional stress during arrest
  • delayed recognition and response to medical emergency by police
  • failure to apply Brief Coma Scale assessment
  • failure to seek immediate ambulance attendance upon collapse

Coroner's recommendations

  1. The Commissioner of Police should reconsider whether the discretionary use of the Brief Coma Scale in the General Order for Custody Management should be upgraded to a compulsory reference for South Australia Police Officers dealing with a person in custody with an impaired state of consciousness.
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