The death of John Benedict Munkara came before the Northern Territory coroner as Mr Munkara died whilst in police custody. All deaths in custody must be investigated by the coroner (Inquest into the death of John Benedict Munkara [2017] NTLC 016, [39]).

Mr Munkara was 44 years old with a long history of alcohol abuse and consequent poor health. On the night of 15 September 2016, whilst heavily intoxicated, he was bashed.  The next morning, he reported to Rangers that he had a sore back and asked them to call an ambulance. At 7.41am, the Rangers contacted police to report both the presence of a group of people consuming alcohol in the park and the request for an ambulance.  The Ranger said “I figured we’d give you guys [police] a call as you’d probably be better equipped to assess it”.

Police were despatched to the scene but the police call taker did not call an ambulance nor was it recorded that an ambulance had been requested.  On arrival, at 7.50am, police asked the group to move on but did not look for or deal with Mr Munkara, remembering that at that time they had not been advised that a person was requesting an ambulance.

At 8.42am, rangers again called police. At 9.37am, police arrived and found Mr Munkara sitting next to the toilets and unresponsive.  They decided to take him into protective custody. They assisted him to his feet but ‘after a few steps he seemed to go limp and they carried him the remaining distance. They decided to take him straight to the Hospital’ ([20]).  They got him to the police car and on examination could not find a pulse. They removed him from the car, and at 9.50am contacted their coordination centre to request an ambulance.

The Coroner reported the final events in Mr Munkara’s life at [22]-[31]:

The log of that call [at 9.50am] states that they required an ambulance for an Aboriginal male of 40 years of age that was non-responsive, currently breathing and highly intoxicated. A minute later Constable Chisolm called again asking for urgent assistance as the breathing of the deceased had become very shallow.

One minute later at 9.52am Constable Chisholm reported that cardio pulmonary resuscitation (CPR) had commenced. He also asked for backup and a mouth to mouth face shield.

At 9.59am a Border Force vehicle with four Customs personnel arrived and supplied a face shield and one of them commenced mouth to mouth resuscitation while Constable Ascoli continued with cardiac compressions.

At 10.01am Police vehicles 556 and 400 arrived at the location. The face shield was changed for an Oxy-viva unit from car 556.

At 10.03am the Ambulance arrived. The paramedics took over the airway and gave the deceased adrenalin and intravenous fluids. Senior Constable Ascoli remained doing the compressions.

At 10.10am the deceased was given more adrenalin and an AutoPulse machine was used to undertake the compressions. At 10.15am and 10.20am he was given more adrenalin.

At 10.25am the deceased’s pulse returned. He was placed in the Ambulance and taken to Royal Darwin Hospital, arriving at 10.38am.

On assessment at the Hospital he was unconscious, a laryngeal mask airway was in place but he was found to have pulseless electrical activity.

CPR was once more commenced and he was given more adrenalin. His pulse returned after 7 minutes but his blood pressure was very low (50/30) and his PH was 7.8. He was given fluids, an adrenalin infusion and lactate. However his prognosis was very poor and when his blood pressure dropped to 30/20 despite fluids it was considered that further efforts were futile. The adrenaline infusion was stopped at 11.27am and he was pronounced life extinct at 11.33am [16 September 2016].

An autopsy was undertaken. In the opinion of the Forensic Pathologist, Dr Rutherford the deceased died of natural causes. He listed the cause of death as “coronary artery disease superimposed upon chronic obstructive pulmonary disease with alcohol toxicity as an aggravating factor”.

My first impression is that’s a significant response.  The first call for an ambulance was made at 9.50am. By 10.03am three police vehicles, a border force vehicle and an ambulance were all on scene with police, ambulance and border force officers all working together to try to save Mr Munkara’s life.  The Coroner said (at [39]-[43], emphasis added):

The deceased died very shortly after being taken into Police custody. Section 26(1)(a) of the Coroner’s Act requires that I must investigate and report on the care, supervision and treatment of the deceased while he was being held in custody. Because he died so soon after being taken into custody, there is a limited period to be examined.

The Police decision to take the deceased into protective custody was reasonable and appropriate. He was sitting in an area making it difficult to access the toilet facilities and close the door and when approached was barely responsive and smelt of alcohol. The Police assisted him to his feet and when he collapsed they were there to take his weight. At that point they decided to take him to the hospital. However when they got to the van they checked his pulse and soon thereafter commenced CPR and called for an ambulance. The conduct of the Police Officers who attended to the deceased was of a very high order. The only criticism is the failure to have available a face shield.

Mention should also be made of the conduct of the Border Force personnel who supplied the face mask and undertook the breaths. They were not called to give evidence during the inquest but their ready and willing assistance and expertise was also of a very high order.

By the time St John Ambulance arrived the deceased had died, however the evidence indicates that the paramedics carried out their duties efficiently and professionally and transported the deceased to Royal Darwin Hospital after re-establishing a heartbeat. I also thank St John Ambulance Service for their attendance and assistance at the inquest.

In my opinion the care, supervision and treatment of the deceased was appropriate.

With respect to the police that first attended and tried to assist Mr Munkara the Coroner later said (at [53]) ‘I was also impressed by the Police Officers who attended Vestey’s Beach in relation to this matter on both occasions. They were clearly very caring and compassionate officers and distinguished themselves in both their actions on the day and when giving evidence during this inquest.’

The coroner did make comments on some matters.  With respect to the fact that the first police on scene found that their first aid kit did not contain a face shield he said (at [58]) ‘police are trained in first aid and to be unable to provide the breaths in CPR due to failure to keep the First Aid kit in the Police vehicle appropriately equipped is not acceptable’.  He noted the response by NT Police and they now had regular checks of kits and vehicles were ‘taken off line’ until kits were replenished ([59]).

The coroner made the most significant comments (at least relevant to this blog) with respect to the police call taker who failed to record, or pass on, the request for an ambulance when the call was first made at 7.41am.   As the coroner said (at [44]) ‘If an ambulance had been called at 7.41am when the Council Ranger passed on the request to Police Communications, the deceased may have received attention and treatment two hours earlier than he did.’  The Corner listened to the recording of the call and said (at [48]-(50)):

… the best that can be said is that the call taker was casual in dealing with the information. The worst that might be said is that she was dismissive, an allegation she rejected.

However, whatever the reason, it was not her place to filter the information. She should have noted the request for an ambulance in the CAD entry, a fact she readily conceded.

By filtering out that vital information she prevented those checking her entries from being able to correct her mistake.

The NT police conceded that the performance by, and training of, the call taker had been ‘deficient’.  They gave evidence of the training they were now introducing to assist and equip ‘call takers, dispatchers, call centre supervisors and dispatch supervisors based on the Victorian training package’ ([51]).

Given the problems with the police response (information not passed on and first aid kit incomplete) the Coroner said that he ‘was impressed by the ability of the Police to view these matters objectively and work toward fixing the gaps in their systems’. He said ‘I wish to commend Police on their approach to this inquest and on their desire to improve their systems’ [52]).

The Coroner did make adverse comments on the way Mr Munkara had been treated by the Top End Health Service which had failed to properly deal with him under the Northern Territory’s Alcohol Mandatory Treatment scheme on previous occasions including his last presentation in May 2015 but these matters are beyond the scope of this blog on emergency law.

Lessons learned

In my work people in the emergency sector report terrible fear of the coroner. The biggest threat is ‘well you can explain to the coroner why ….’  I can’t say what the experience of appearing before the coroner was for the police in this case, but the coroner was clear in his praise of their conduct both in the emergency and before the court.

The coroner did identify shortfalls in police procedures but was also willing to recognise the efforts the police had gone to o  order to fix their systems.  And if the inquest identified ‘gaps in their systems’ ([52]) then that’s good, and exactly what an inquest is meant to do. If with better training and processes information is recorded and passed on, and first aid kits are checked and police vehicles not used until they’re restocked, then lives may be saved.

The lesson learned – appearing before the coroner isn’t always a bad thing.