Shaun Coolwell died in hospital after being handcuffed and injected with the sedative midazolam

This article is more than 1 year old

This article is more than 1 year old

Queensland police and paramedics dealing with an Indigenous man during a violent, drug-induced episode failed to recognise the sudden deterioration of his health, a coroner has said.

Shaun Charles Coolwell died in hospital after being sedated and restrained in his sister’s Logan home, south of Brisbane, in October 2015.

The Queensland coroner, Terry Ryan, has found Coolwell struggled only for a very short time after being handcuffed and police should have been able to see when he no longer needed restraining.

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Emergency services were called to the home after the 33-year-old began banging his head on a bathroom floor and doorframe, yelling and turning hot water on and off.

He was placed in a prone position and restrained with handcuffs so he would not be able to further hurt himself or those trying to treat him.

To calm him down, paramedics injected a sedative, midazolam. Use of the sedative was also examined at last year’s inquest into the 2015 death of David Dungay in Sydney’s Long Bay jail.

Paramedics tried to revive Coolwell after becoming concerned about his vital signs. He was taken to Logan hospital, where he later died.

After a three-day inquest in March 2018, Ryan found on Monday that had Coolwell been moved from the prone position after he stopped resisting, his chances of survival would have increased.

“The paramedics and police officers who were present interpreted Mr Coolwell’s behaviour as compliance with the restraint,” Ryan said. “There was a basic failure to recognise and respond to his clinical deterioration.”

Coolwell struggled for only “a very short time” after he was restrained, the coroner found. The rest of the time he was restrained, he “required urgent medical attention”.

“They (police) should have recognised from their own observations in relation to Mr Coolwell’s pulse, breathing and vomiting that restraint was no longer required,” Ryan said.

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Ryan found Coolwell, who had heart problems, died as a result of cardiorespiratory arrest during restraint.

He stopped short of concluding the restraint alone caused his death. But he labelled the administration of midazolam by ambulance officers “inappropriate”.

Two police officers told the inquest they did everything they could to help Coolwell when they arrived and found him “uncontrollable”, bleeding and incoherent.

“I still believe that it was in Mr Coolwell’s best interest to be restrained at the time,” Constable Tamzin Zarycki said.

“He was unclothed at the time. He was face down on the floor.”