Inquest into the Death of Phillips, Dennis John

Contributing factors

• alcohol withdrawal seizures
• underlying cardiac disease
• acute intoxication
• failure to obtain complete medical history at admission
• police unaware of seizure predisposition

Coroner's recommendations

1. If there is genuine refusal to provide welfare information on lockup admission, it should be noted as a refusal, not a default entry in the custody system
2. Reference previous admissions to ascertain likely welfare needs such as routine medications
3. Follow up when circumstances have changed or the detainee has settled to re-address specific current concerns, especially where a detainee has made a vague reference to being a 'sick man'
4. Clear indication at shift handover as to the specific reason for a detainee's high risk status, with a request that lack of information be followed-up if no welfare information has been provided
5. Negotiation between senior police and health providers in regions like Kalgoorlie to allow communication about health and welfare concerns for detainees
6. Consider notification to health providers such as Bega when their clients are taken into custody, with appropriate confidentiality safeguards