Tristan Naudi wanted an ambulance, instead he was transported to hospital in a "dog box".

Key points: Small metal enclosures known as 'dog boxes' are fitted in 175 NSW police vehicles

Small metal enclosures known as 'dog boxes' are fitted in 175 NSW police vehicles Tristan Naudi was transported to hospital in one of the enclosures, after an ambulance did not arrive

Tristan Naudi was transported to hospital in one of the enclosures, after an ambulance did not arrive A former triple-0 operator alleges some ambulance jobs were overridden, in a practice called "dirty downgrading"

The dog box was where he spent some of his final moments before dying, handcuffed and bleeding, at Lismore Base Hospital on January 18, 2016.

Earlier that night, the 23-year-old and his friends had called triple-0 for help after he suffered an uncharacteristically violent reaction to MDMA.

The coronial inquest into Tristan's death has drawn attention to the unauthorised practice of some emergency control centre supervisors manually overriding requests for ambulances.

A whistleblower, formerly a NSW Ambulance triple-0 operator, has told Background Briefing she believes the practice still continues.

The inquest, completed last month, has also drawn attention to the use of the small metal prisoner-transport enclosure known colloquially by police as a "dog box".

In evidence at the inquest, one police officer described the box as "obviously the worst place for someone suffering from mental illness, or drug-affected people."

Background Briefing has learned that the enclosures are fitted inside 175 Mitsubishi Pajeros used by NSW Police.

NSW state coroner Teresa O'Sullivan was critical of the enclosure in her findings, but said police had little other choice on the night.

"The use of the Pajero for transporting Tristan to Lismore Base Hospital was far from ideal and it undoubtedly contributed to Tristan's physiological stress," she said.

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These Pajeros are the predominant first response vehicle in the Tweed Byron Local Area Command, and the vehicle was the only one available to transport Tristan on the night of his death.

NSW Police declined an interview and did not answer questions about the use of the dog box.

In a statement, police said they were considering recommendations following the inquest and would respond "in due course".

Tristan's sister, Angela Tallon, said she was horrified her brother was placed into the enclosure while he was suffering a drug-induced psychosis.

"Tristan wasn't a dog, I don't want anyone to even refer that he was anything like that," she said.

"I really don't know any situation where those cages would be helpful, but definitely not someone either with mental health issues or associated with drugs."

Angela Tallon, foster-sister of Tristan Naudi, said she was horrified by the enclosure he was transported to hospital in. ( ABC News: Baz Ruddick )

Police placed Tristan inside the cage while they were waiting for an ambulance, which never arrived.

Emma Harrison, who worked in the control centre that handled Tristan's call, told Background Briefing it was not uncommon to manually override ambulance jobs, sometimes without telling police or patients.

The former triple-0 dispatcher said she witnessed the arbitrary downgrading of ambulance jobs involving mentally ill or drug affected patients.

"If the public truly knew the extent of what goes on behind a triple-0 call, they would be up in arms, there would be riots"

The night Tristan died

The inquest heard Tristan was gentle and kind. He spent his days working as an apprentice chef and his afternoons surfing.

Tristan Naudi was living in Bangalow at the time of his death. ( Supplied )

"Tristan just had that way of really seeing you — the good, the bad, the ugly — and he accepted you full-heartedly regardless," Ms Tallon said.

"He just had a way of making you feel good about whoever you are."

She said he lived by a motto: "No shirt, no shoes, no worries."

"He just wanted to be out in nature. I just think that is a testament to how he lived his life."

The coronial inquest heard Tristan Naudi was gentle and kind. ( Supplied )

At the time of his death Tristan was living in Bangalow. On Monday, January 18, he and a friend bought what they thought was LSD, but was later discovered to be MDMA.

He took a small amount of the drug around 6.30pm, and within 90 minutes began behaving erratically. He became violent and unpredictable, at one stage tackling a female housemate to the ground.

The coronial inquest heard his behaviour was completely out of character.

One friend later told police: "I've never ever seen any sort of anger out of him to that level."

"That person that I was talking to on that night was not Tristan."

During the psychosis, Tristan tried to call triple-0, as did friends and housemates.

Triple-0 operators repeatedly said an ambulance was on its way.

The ambulance that never arrived

At least two ambulances were scheduled to help, one designated as urgent.

Unbeknownst to police officers or local paramedics, the jobs were downgraded and never dispatched.

Do you know more about this story? Email: christodoulou.mario@abc.net.au

The inquest heard there was an "unauthorised practice" by some NSW Ambulance control centre supervisors of manually overriding ambulance jobs.

Ms Harrison said she worked at NSW Ambulance's Northern Control Centre between 2014 and 2017 but left after experiencing bullying.

She said the practice of manually overriding ambulance jobs was called "dirty downgrading."

NSW Ambulance declined an interview request from the ABC. ( ABC News: Billy Cooper )

She said it was often an attempt to manage resources and "palm" jobs on to police.

"It's a snap judgment on people who are just in the worst moment of their life and require help," she said.

"We're meant to be their safe haven."

'Cover Ass, Retain Employment'

She said the decision was often arbitrary, and in some cases the patient was never told an ambulance wasn't on its way.

Ms Harrison believes the practice may have resulted in loss of life and that staff have been too scared to speak up.

She said there was a toxic culture, encapsulated by an acronym — CARE.

"C-A-R-E means Cover Ass, Retain Employment."

She believes the practice continues today.

"I absolutely think that, and I still have contact with those people that still witness it," she said.

During the coronial inquest, NSW Ambulance described the downgrading of ambulance jobs as "an unauthorised practice for a limited period."

Director of NSW Control Centres Tony Gately told the inquest supervisors had been told to stop the practice, but could not confirm everyone had followed this advice.

NSW Ambulance said in a statement that it did "not allow staff to manually downgrade ambulance jobs" and that the policy had been "reinforced to staff at Northern Control".

NSW Ambulance declined an interview request, but said it was looking at a number of "operational matters" in the wake of Tristan's death and had since opened a new station in the region.

It said there were no adverse findings against it in the coronial inquest, and stressed it had a zero-tolerance approach to bullying.

The only vehicle available

On the night of Tristan's death police arrived and handcuffed him before placing him in the "dog box" to wait for an ambulance.

After 17 minutes officers transported him to hospital themselves, fearing paramedics would not be able to get close enough to assess him.

The interior of an enclosure similar to the one Tristan was held in. ( Supplied )

He was locked in the box for almost an hour in total, sweating profusely and kicking the roof of the enclosure.

The coronial inquest later said he likely sustained further injury while inside.

He died shortly after being removed from the box at Lismore hospital. The cause of death was a mix of MDMA intoxication with physical restraint.

At the coronial inquest, the "dog box" was examined. Solicitor Tony Nikolic of Drayton Sher Lawyers, who represented Tristan's family, saw the enclosure first hand during a viewing.

"I thought, 'Oh, my goodness, it looks like dogs are being transported better than human beings,'" he said.

Australian Human Rights Commissioner Edward Santow told Background Briefing he could not comment on Tristan's case directly.

But he said he was disturbed by video of the box.

"Looking at that footage of that incredibly enclosed space made me deeply worried," he said.

Angela Tallon said emergency services may have made assumptions about the type of person her brother was. ( ABC News: Baz Ruddick )

Police told the inquest the vehicles with the enclosure were introduced to the area in 2011. They said they had received no training in how to use the enclosure safely.

The coroner later recommended NSW Police review their guidelines on managing drug-affected people, and called for air-conditioning and padding in caged vehicles.

According to Ms Tallon, the attitude of emergency services needs to change.

She believes people who ask for help should receive it, no matter who they are.

"I think they've just made an assumption of the type of person that he was, and maybe the night unfolded the way that it did because of those assumptions," she said.