Finding into death of Darren Ricky Culleton
Deceased
Darren Ricky Culleton
Demographics
31y, male
Date of death
2021-02-08
Finding date
2023-09-14
Cause of death
Hypoxic ischaemic encephalopathy following out of hospital cardiac arrest in a man using methamphetamine with an airway obstruction by a foreign body
AI-generated summary
31-year-old Darren Culleton died from hypoxic brain injury after choking on the hood of his coveralls while in police custody. He had presented to St Vincent's Hospital with acute intoxication and self-harm behavior (attempting to light himself on fire), was assessed by psychiatry and deemed not to meet criteria for involuntary admission, then was arrested for outstanding theft matters. In police custody at Melbourne West, he tied underwear around his neck (self-harm), was then dressed in coveralls (worn backwards, placing hood at throat) over which a suicide-resistant gown was placed. While awaiting transfer to the Melbourne Custody Centre, he ingested the coveralls hood and lost consciousness. Key failures: inadequate communication of psychiatric risk to police; use of coveralls with suicide-resistant gown without policy guidance or training; holding him in a divisional van rather than observation cell; poor camera monitoring; and delay in transfer due to administrative confusion. The coroner found this a preventable death resulting from policy gaps, lack of training, and communication failures.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- Acute intoxication with methamphetamine
- Self-harming behavior using coveralls hood
- Coveralls worn backwards with hood positioned at throat
- Coveralls used in conjunction with suicide-resistant gown without safety protocol
- Inadequate communication of psychiatric risk assessment to police
- Lack of policy and training regarding coveralls and suicide-resistant gown use
- Extended period in divisional van instead of observation cell
- Poor quality camera monitoring system in police van
- Delay in transfer to Melbourne Custody Centre due to administrative confusion
- Failure to keep van door open despite high-risk assessment
- Inadequate observation of deteriorating mental state
Coroner's recommendations
- Victoria Police create a policy and guideline in relation to the appropriate use in custody facilities of coveralls and suicide-resistant gowns
- Custody Management Division of Victoria Police engage with Melbourne Custody Centre and the Custodial Health Service to review arrangements and requirements for transfer of prisoners from a police station to Melbourne Custody Centre, including clarification of documents required for transfer based on inadequate facilities and clarification of circumstances for medical grounds transfer
- Victoria Police review training provided to police members and Police Custody Officers to guard against perceived hierarchical barriers which may inhibit communication of relevant information concerning welfare of people in custody
- Victoria Police review training provided to police members and Police Custody Officers to ensure that relevant information recorded on the LEAP system relating to risks attaching to a person brought into custody is efficiently shared with all officers necessary to appropriately manage that person's welfare and safety
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