Inquest begins into death of 58-year-old man in police custody

Victoria Police has apologised for the death of a man who spent hours unresponsive with a brain injury in a Broadmeadows cell as he waited for paramedics.

CCTV footage played in the Coroner’s Court on Monday showed three officers carrying John Makai’s limp body into a holding cell about 1.15am on September 10, 2023.

Police had arrived at Makai’s Sunbury home about an hour earlier, following a report the 58-year-old had fought with his adult son after both consumed alcohol.

Opening the inquest into the death on Monday, Rachel Ellyard, counsel assisting the coroner, told the court Makai struck his son, Terewa, in the head with a mug and continued to approach him, despite warnings not to.

Makai was then punched twice and fell to the floor, Ellyard said.

In a phone call played in court, a friend could be heard contacting Triple Zero to ask for an ambulance before changing his mind as others in the background told him to hang up. A dispatcher then created a police job instead.

Body-worn camera footage showed officers arrived at a Timins Street house at 12.11am to find Makai and his son injured. Although both declined treatment, police requested paramedics attend.

“They were advised there would be delays because of workload pressures that night on Ambulance Victoria,” Ellyard said.

She described Makai as “argumentative” in the body-worn camera footage, which captured him standing up, losing his balance, and falling back into a bookcase, where he hit his head.

“He just blacked out, hey,” a man could be heard saying.

The body-cam footage then showed Makai’s former partner tending to him and saying he was fine.

Makai’s son told police: “This has never happened before.”

Ellyard told the court police then designated Makai as having breached family violence laws, so he could be taken to Broadmeadows police station as paramedics weren’t immediately available.

He was carried from his home to the police divisional van.

“With the benefit of medical evidence, it appears … a developing brain injury was impeding his ability to walk,” Ellyard said.

Video from inside the van shows Makai’s head was bumped again as he was dragged out by the ankles on arrival at Broadmeadows police station.

“That vision shows John has experienced a serious decline in his consciousness and capacity to walk since he was put in that van,” Ellyard said.

Members of Makai’s family shook their heads in court on Monday as CCTV footage showed him being carried in a prone position onto a cell bed.

Custody officers reported Makai was snoring, but Ellyard told the court there were no signs of voluntary movement.

“What was perceived as a deep drunken sleep may have actually been a traumatic injury and bleeding into the brain,” she said.

A custody sergeant called a police dispatcher at 1.25am to check on ambulance availability, but the court heard he was told crews were still busy. Another call was made at 2.18am, but the dispatcher said Ambulance Victoria was still dealing with 40 to 50 pending jobs.

A dispatcher’s error then led to the ambulance being cancelled about 3am, the court heard. The custody sergeant asked his subordinates to check on Makai every 15 minutes, but the court heard this did not occur as frequently as required.

Ellyard said cell footage showed Makai remained basically motionless from about 2am to 6am.

“Apart from a very small movement to shield his eyes from glare ... no movement was recorded at all,” she said.

No police entered the cell during this four-hour period. When a new watchhouse sergeant arrived after 6am and realised Makai was unable to be roused, officers entered his cell and tried to wake him by rubbing his sternum and pinching his arm. The custody sergeant called Triple Zero after learning the earlier ambulance had been cancelled.

“We were all expecting the ambulance here five hours ago,” he said in a phone call aired in court. “I’ve never known anyone not to stir like this.”

Paramedics arrived at 6.29am and discovered Makai had a traumatic brain injury. He was taken to hospital, where he recorded a blood alcohol level of .13, and was later found to have suffered unsurvivable trauma. He died on September 12.

Barrister Andrew Imrie, representing the police chief commissioner, said custody officers failed to complete a medical checklist and risk assessment at the Broadmeadows police station.

“It’s a situation which we work tirelessly to avoid,” Imrie said. “In this case, however, my client acknowledges at the outset of this inquest that the standards of care in custody fell short of expected standards.

“As the evidence currently stands, its unclear whether these shortcomings would have made a difference to the tragedy in this case … but [the chief commissioner] apologises.”

The inquest continues.

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