Medical staff at Sydney’s Long Bay jail failed for periods up of up to eight minutes to do basic CPR on a prisoner who had stopped breathing, a coroners court has heard. They then forgot to remove the cap from resuscitation equipment, which came off in the man’s mouth.

An expert medical witness said David Dungay Jr had little chance of survival once his heart had arrested but “whatever chance he had was lost” by the attempts at resuscitation.

Dungay, 26, died during an attempted cell transfer by staff at the jail’s mental health ward after he refused to stop eating a packet of biscuits. He was restrained face down in the prone position and injected with a sedative. Dungay told the guards at least 12 times that he could not breathe, before eventually losing consciousness and dying.

Dungay’s death is the subject of an investigative Guardian Australia podcast, Breathless.

The New South Wales coroners court is examining Dungay’s death and on Wednesday watched harrowing footage of the failed attempts by staff to revive him. It moved members of Dungay’s family to cry, shout out, and leave the courtroom, and drew gasps from other attendees.

The footage, which began at the moment guards from the jail’s immediate action team (IAT) realised Dungay had stopped breathing, follows video of the first eight minutes released by the court last week.

The video, which cannot be published for legal reasons, was repeatedly paused to allow for highly critical commentary from emergency physician Prof Anthony Brown.

Brown said that it was likely Dungay suffered asystole cardiac arrest – the most serious and usually irreversible – which his restraint and positional asphyxia contributed to.

Brown, who had examined and provided a report on Dungay’s death, said he had no criticisms of the IAT’s resuscitation attempts. But when medical staff including a doctor arrived, there was a clear lack of the continuous and “fundamental basic life support” required.

“I’m looking for ... continuous external cardiac massage ... interspersed with assisted ventilation,” Brown said.

Instead the video showed gaps in basic life support, including at least one period Brown described as “enormously prolonged”.

“I believe there’s been approximately an eight-minute hiatus where there’s been no cardiac massage at any stage except for two compressions,” Brown noted at one point.

To audible gasps in the courtroom, the footage also revealed staff had forgotten to take the cap off a suction device, finding it inside Dungay’s mouth when they rolled him into a recovery position – also an incorrect action to take, Brown said.

“You don’t put someone in the recovery position in the middle of a cardiac arrest, it’s just not helpful,” Brown said. “You shouldn’t ever have to return to the recovery position if you haven’t recovered.”

The video also showed that no one was designated as team leader and that a corrections officer was expected to perform “technically difficult” procedures.

Brown said he thought Dungay suffered an asystole arrest brought about by hypoxia – a lack of oxygen – from his restraint.

“This appears to be a sudden cardiac arrest but the important point is he goes into asystole arrest … which is classic for hypoxic arrest as opposed to a sudden cardiac arrest like a heart attack.”



He expected symptoms of the asystole attack would have been visible by the time the nurse arrived in the cell to give the sedative injection, although he did not think the injection played any part in Dungay’s death.

At some point cardiac arrest becomes inevitable but “prior to that it is preventable”, Brown said.

“If you can call out [that you can’t breathe] … that to me says the brain was working, the lungs were working, the pulse was working, enough to be reversible,” he said. “Whatever challenge there was to Dungay, in terms of the next two minutes and 17 seconds while they waited for the [nurse] to get another injection … in that time is when Dungay slipped into irreversible cardiac arrest.”

The inquest continues.