Inquest into the Death of Mark Anselo Ugle

Contributing factors

• History of cardiac problems and myocardial infarction
• Non-compliance with cardiac medication
• History of seizures
• Low levels of amphetamine and methylamphetamine in blood at time of death
• Possible seizure episode in early morning precipitating myocardial infarction
• Stress of police custody and arrest
• Inadequate monitoring in lockup cells
• Failure of cellmates to alert guards to observed distress
• Limited officer visibility and inability to hear laboured breathing from cells

Coroner's recommendations

1. The Police Service to implement the provision of welfare officers at the East Perth Lockup to assist police in the admissions process, which relies heavily upon self-reporting from prisoners. The welfare officer should be able to talk with the prisoner in a secure environment, away from the main admissions desk.
2. The Police Service liaise with the Health Department in relation to the provision by the Health Department of a full-time, mental health trained registered nurse to screen potential admittees for health problems in a secure environment away from the main admissions desk.
3. The Police Service to install cell call alarms in all cells at the East Perth Lockup.
4. The Police Service to install camera facilities and monitors at the East Perth Lockup, which can be switched into a cell if a problem is perceived. Due to the structure of the second floor at East Perth Lockup, this would mean a camera outside each cell, which would be directed into the cell when necessary.