A man who was Tasered and held down by police in Sydney’s inner west died from a heart condition with multiple contributing factors, including positional asphyxia, the use of the Taser and physical exertion, a Coroner has found.
Jack Kokaua, 30, had been admitted to Royal Prince Alfred Hospital as an involuntary mental health patient on February 18, 2018, after members of the public reported him acting erratically and called police. He absconded when his restraints were removed to allow him to use the toilet, and police were called to bring him back.
An inquest in the NSW Coroners Court heard an officer spotted Mr Kokaua near Sydney University Village in Camperdown at 1.21pm.
By 1.22pm he had been capsicum sprayed, and between 1.23pm and 1.25pm he was Tasered three times. Officers also put their weight on Mr Kokaua as they tried to restrain him.
At 1.30pm, an officer said in a police radio broadcast: “I need an ambulance to my location immediately. The male is unconscious and not breathing at this stage”. An ambulance arrived seven minutes later and Mr Kokaua was taken back to RPA, where he was pronounced dead at 2.28pm.
One of the officers involved in the altercation told the inquest she tried to explain to Mr Kokaua that he had to go back to hospital because he was sick, but he “launched himself” at her and another officer after asking “you wanna fight me? you wanna fight me?”
“We weren’t on the same planet at that time. We weren’t having the same conversation,” Senior Constable Jacqueline Buchanan said in 2019.
She said police were in “the mother of all wrestles” with Mr Kokaua as they tried to keep him down and handcuff him, and she felt “we were fighting for our lives”. She said the first time anyone realised anything was wrong was when one of the officers asked “is he breathing” and her heart sank.Advertisement
In findings on Wednesday, delivered to a packed court including Mr Kokaua’s family, State Coroner Teresa O’Sullivan said the 30-year-old died of malignant ventricular arrhythmia influenced by multiple factors, including positional asphyxia, exertion and the use of a Taser, superimposed on coronary heart disease.
She said there “appears to have been many occasions” on which a different intervention by police, doctors, nurses, mental health service providers or his parole officer might have prevented Mr Kokaua’s ultimate fate.
Ms O’Sullivan made a number of recommendations, including that police give active consideration to calling an ambulance as soon as possible when dealing with a mental health patient who has absconded; that RPA require two staff members to be present when restraints are removed from a mental health patient, even temporarily; and consideration be given to all police receiving a four-day mental health training program focusing on de-escalation.
She also recommended police consider designating one officer to be the supervisor in a physical interaction involving three or more police officers, with that officer required to take responsibility for the situation including calling an ambulance; that other officers give verbal updates including whether physical resistance is ongoing; and that one officer be tasked to watch the person’s breathing.
Ms O’Sullivan recommended that there should also be a time log initiated when a person is placed in a prone position, with an attempt made to reposition the person after a certain period of time to lessen the chance of positional asphyxia.
The Coroner looked at Mr Kokaua’s family after delivering the recommendations, and said with emotion: “I’m hoping that they will make things better”.
She extended her sincere condolences to Mr Kokaua’s family, including his mother Queenie who travelled from New Zealand to hear the findings.
“At all times during the inquest the family carried themselves with such dignity and grace,” Ms O’Sullivan said.
“I particularly wish to acknowledge the family’s moving tribute to Jack on the last day of the inquest, when the Haka was performed in his honour, and the song that was most evocative and beautifully sung. Jack is so clearly loved by all of you, and he has been honoured by you throughout these proceedings. I know he’ll continue to be missed and mourned by those who loved him.
“This brings us to the end. I hope that lessons have been learned, and I thank you.”
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