Since 2008, the restraint technique used on Bradley and Shaun Coolwell has been implicated in the deaths of 24 people

Deaths in custody: family wants answers after two brothers die in similar situations

The Coolwell sisters are not sure when their grief and loss will end.

They have lost two brothers through deaths in custody, and even though both men have been the subject of a coronial inquest – one released just this week – the family still doesn’t have the answers they need to heal and move on.

Two brothers, both troubled and in poor health, died after being restrained face down by police and hospital guards.

“It was the same house, the same hospital,” their sister Sonya Coghill (Coolwell) says.

“We are never going to heal. There’s no justice, so there’s no healing.”

Bradley Coolwell was 39 when he died in 2011. As a young man, he’d been in and out of jail on minor property offences. In 1991, he was diagnosed with schizo-affective disorder and spent much of the next 20 years in full-time residential, involuntary mental healthcare at The Park mental health centre in Brisbane.

In September 2011, police received a call from a member of the public to go to Kingston railway station “due to concerns for the welfare of a large gentleman wearing Superman pyjamas and a Superman T-shirt”.

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“He indicated that he’d been up all night. He’d been battling with Superman. He also believed he was the Hulk … So we obviously made a number of assumptions as a result of that conversation,” police told the coroner.

They took Bradley to Logan hospital where he was transferred to a secluded ward. Nurses tried to take his Superman pyjamas away and dress him in “security linen” – hospital wear that cannot be torn by hand and cannot be used to form a ligature. This caused him great distress, the coroner has said.

“The more he resisted, the greater the effort to make him comply by the security guards. There is no evidence that he tried to strike the security personnel. He struggled and resisted to the point where force was applied first in an effort to bring him down.”

Bradley Coolwell was left naked in a prone position for several minutes, with the “security linen” left for him to dress himself. At the inquest, the nurses disagreed on whether or not he was still breathing when they left the room.

The coroner found that Bradley died from a combination of respiratory failure and cardiac arrest. The inquest took five years to hand down the findings.

Quick guide Deaths inside: Guardian Australia’s investigation into 10 years of deaths in custody cases Show Hide Guardian Australia’s investigation into 10 years of deaths in custody cases found serious systemic failings: 407 Indigenous people have died since the end of a royal commission that outlined ways to prevent Indigenous deaths in custody almost 30 years ago.

Indigenous people are dying in custody from treatable medical conditions and are much less likely than non-Indigenous people to receive the care they need.

Agencies such as police watch-houses, prisons and hospitals failed to follow all of their own procedures in 34% of cases where Indigenous people died, compared with 21% of cases for non-Indigenous people.

Mental health or cognitive impairment was a factor in 41% of all deaths in custody. But Indigenous people with a diagnosed mental health condition or cognitive impairment, such as a brain injury or foetal alcohol syndrome disorder, received the care they needed in just 53% of cases.

Families waited up to three years for inquest findings in some states. Each case has been published in an interactive database.

In 2015, in the same house, Bradley’s young brother Shaun was 33 when he died in 2015 after being restrained face down by police.

The coronial findings into his death were handed down on Monday – just after his birthday – ending three years of waiting to find out what happened to him.

“No one even told me that the findings were being handed down,” Shontay, his twin sister says. “I only found out when my family saw it on TV.”

On the night he died, Shontay says she found Shaun in the bathroom, “wiping his hands uncontrollably down his hips and ankles, like he was trying to get something out of him”. She called triple-0 and told the dispatcher he was affected by methamphetamine and was hurting himself.

According to coronial documents, when police arrived they found Shaun on the bathroom floor, with a bone-deep gash in his foot. They dragged him out by his legs, restrained him face down and put him in handcuffs. Within moments, he stopped struggling, the documents state.

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Shaun was restrained for nine minutes, the inquest found. His breathing worsened. Then it stopped, one minute after an ambulance officer administered a powerful sedative called midazolam.

Police and ambulance officers resuscitated him and wheeled him out of the house on a stretcher. Shontay thought he would be OK.



“I had hope,” she says.

But hours passed and Shontay says she didn’t hear anything.

When the phone rang, her cousin Lindsay, who was there helping clean up, answered it.

“I turned around and looked at Lindsay and then she’s like ‘no, oh no’, then I was thinking no, they’re not gonna say that Shaun’s died, this can’t happen,” Shontay says.

“What upsets me the most, is that the police locked me out of the house,” she says.

“All I wanted to do was to stand next to Shaun and say, “I’m here, brother, Shaun I’m here”, but they wouldn’t even let me do that.”



When news spread of Shaun’s death, their nephew Sean Fisher came over from Stradbroke Island. That night, in grief and frustration, he got drunk and things got a bit rowdy. The police were called for the second time in 24 hours.

“The coppers came back because of the noise complaints I suppose,” says Fisher. “There was a whole heap of family there.”

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According to Shontay, a police officer told her to open the door. She says she refused “because you’ve already come here once today and killed my twin brother”.



Shontay says the police then threatened to kick the door down “and I was thinking, oh no, I’m going to die now as well,” so she let them in. Fisher says he stood up when the door opened “and then bang, they just shot me with a Taser”.

“I remember being on the ground. My aunty was saying “he’s choking, he’s choking”. She had to put her hand down my mouth and pull my tongue out,” Fisher says.

Fisher says he passed out after being shot with the stun gun.



“I woke up in the same hospital where my uncle’s body was only a few hours before.”



Fisher was not charged with anything, but Shontay was fined for obstructing police.

“I’m still trying to pay it off,” she says.

***

On Monday, the coroner found that Shaun had “died as a result of cardiorespiratory arrest during restraint”.

Since 2008, the restraint technique used on Bradley and Shaun has been implicated in the deaths of 24 people. More than half of those who died were Indigenous, affected by methamphetamines, or struggled with mental health problems.

Experts are divided on whether prone restraints can lead to asphyxia and cardiac arrests. But the warning factors are now part of the training of corrections officers and medical staff in every jurisdiction in Australia. Changes to policy and procedure seem to come only after someone has died.

The Coolwell family has called for someone to be held accountable for Shaun and Bradley’s deaths. But the majority of prone restraint cases investigated by coroners have not been referred for prosecution because of a lack of evidence.



Professor Bernadette McSherry, head of the National Seclusion and Restraint project at Melbourne University, says coroners are aware of the difficulties in establishing that a criminal act has taken place in the cases.

“You have to prove beyond reasonable doubt, so the legal threshold, if you like, is quite high,” she says.

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It’s no consolation to Shontay Coolwell and her sister Sonya Coghill.

Their only brothers are dead, and they still don’t really know why.

Sonya says Queensland needs to adopt a custody notification service – “pay a lawyer to stay awake and answer when you need them” she says – so that families can get immediate help in de-escalating conflict with the police and health authorities.

People with mental health issues should not be in jails, she says.

“We can manage this, our way. Let them do the rest of their time on country. They are healing and they’re healing their country – Jagera country.

“When things go wrong, they’re too windy [scared] to call the police. They’ll try anything, call any other mob, rather than the police. ‘Cause look what happens.

“Hopefully the doors of justice will open for us somewhere. We want to change the legislation: stop taking our children, stop locking up our people with mental health issues.

“I know families out there who feel the same grief and frustration – there’s no closure, and that impacts the whole family and community.”