In this post I am going to report on a decision of the ACT Coroner in An Inquest into the Death of Siauto Eliuta Tunumafono  ACTCD 19 (29 November 2018). Before I do that, I want to reflect first on some earlier coronial decisions that talk about the quality of first aid responses.
I was recently invited to give a presentation to Allens Training on the Sunshine Coast. They asked me to address coroners’, first aid and first aid training. Because that was in Queensland I looked at the Queensland Coroners Court findings and found three relevant inquiries. No doubt there are more but there’s a limit on what you can present at a conference. Naturally first aid arises in Coroners courts as they are investigating deaths and often people receive first aid in an effort to save their life. When they do die the administration of first aid will form part of the circumstances of their death. These cases were all reported to the coroner because they involved deaths in police custody and those deaths must be reported.
Inquest into the death of Allan Duncan Lee-Chue (10 February 2009)
Mr Lee-Chue had been arrested and was being transported to the police station.
During conversation with one of the officers he stopped talking mid sentence and began to convulse. The officers removed him from the vehicle, by which time he had stopped breathing, had lost consciousness and had no pulse. Despite treatment from Queensland Ambulance Service officers, who arrived some minutes later, he never regained consciousness and was declared deceased at the scene.
On observing Mr Lee-Chue’s collapse:
The officers removed Mr Lee-Chue from the vehicle and placed him on the road in the ‘recovery’ position. Both officers indicate their initial concern was there may be an obstruction of Mr Lee-Chue’s airway. Once in the recovery position it appeared that Mr Lee-Chue’s tongue may have been obstructing his breathing. Each of the officers said they returned to the vehicle to obtain a plastic mouthpiece normally used for roadside breath tests. This was then placed in Mr Lee-Chue’s mouth in an attempt to pry open his lips and clear his airway. It is likely only one of them initiated this process and I doubt both made attempts to use it on Mr Lee-Chue. In any event this was ineffective.
Neither officer attempted to perform CPR on Mr Lee-Chue. They said variously they did not think it appropriate when they hadn’t established an airway; they did not know what the problem was and therefore know whether CPR would be effective; and, that by the time it might have been appropriate to perform CPR they could hear the sirens of the approaching ambulance.
Unfortunately, the first aid kit normally kept in the police vehicle had been left at the police station after being taken out to be refurbished.
Further, while both officers had been trained in first aid and CPR techniques, neither was up to date with their training. Indeed both officers indicated their knowledge of CPR procedure was scant.
These factors combined, perhaps, with the unpleasantness of the task, may have left the officers reluctant to commence CPR…
The autopsy showed that Mr Lee-Chue
… had severe narrowing of the coronary arteries. Apart from this severe narrowing, he had evidence of recent haemorrhage into atheromatous plaque within the right coronary artery, this haemorrhage compromising the lumen of the right coronary artery and precipitating fatal heart attack.
Correspondents to this blog may think the police would come in for harsh criticism for not attempting CPR, not ensuring the car was equipped with a first aid kit and improvising an airway using a breathalyser tube. If you believe the rhetoric that I hear, that courts will ‘get you’ if you depart from anything other than your exact training that may be what you expect, but it’s not what happened. The Coroner said:
While their first aid response was not perfect, I accept Mr Lee-Chue’s condition, the lack of a first aid kit in their vehicle and a lack of recent first aid training all may have contributed to this suboptimal performance to some extent. However, I am also satisfied no first aid which could have been given at the road side would have saved Mr Lee-Chue.
The police were not criticised for their response and the cause of death was not put down as some failure to perform first aid. Mr Lee-Chue died of ‘natural causes namely acute myocardial infarct due to or as a consequence of coronary atherosclerosis’.
Inquest into the death of Amit Kumar (11 March 2015)
Mr Kumar had booked to go on a chartered fishing trip. He had had previous dealings with the charter boat operator who had banned him from coming on future trips so he had booked this trip under a false name. On arrival the crew identified him as the person who had been banned and he was told that he was not allowed to go on the fishing trip. Mr Kumar hit the female representative of the charter boat company. Further violence occurred involving the customers and crew of the charter boat company. Mr Kumar was pushed to the ground and held there by at least four men.
A triple zero call was made and in the recording the sounds of the struggle can be heard. The coroner reported that the following words could be heard:
A male voice: “You’re not going nowhere pal”;
Mr Kumar: “Oh my brother, I can’t breathe”;
A male voice: “Not our problem bud”;
In another triple zero call ‘Mr Kumar is heard to be saying at least three times in what appears to be a very panicked tone and in very short bursts: “I can’t breathe”.’
In order to relieve them from the physical effort of restraining Mr Kumar, zip or cable ties were used to restrain him. These were applied between 5.40 and 5.44am. When Mr Kumar was restrained by the zip ties, everyone stood up and it was then realised that Mr Kumar had stopped moving. CPR was commenced at 5.46am. At that point, Dr Yates one of the passengers on the intended fishing trip
… did assume control over the group in relation to Mr Kumar’s medical situation once they realised he was in trouble. Dr Yates and/or Mr Dempster rolled Mr Kumar over onto his left side. Dr Yates observed his pale tongue hanging from his mouth and could see he was not breathing. Dr Yates said he located some vomit inside and smelt a strong smell of alcohol when he did this. Dr Yates then gave Mr Kumar a sternum rub and shook him with no response.
He then gave Mr Kumar a closed fist whack to the centre of the chest (a ‘sternum thump’) with no response. It is noted that Dr Yates’ sternum thump methodology was probably unorthodox based on the current CPR training, however, is unlikely to have had any impact on the outcome.
Dr Yates and/or Mr Dempster then instructed Mr Daraz to cut the zip ties, which he did. They then commenced CPR. Dr Yates stated that from the time Mr Kumar went limp (and they realised he was in trouble) until the time they commenced CPR was about two minutes.
At the time Dr Yates commenced CPR, he called for Mr Daraz to tell him the time. Mr Daraz had looked at his mobile phone and stated that the time was 5:46am.
Dr Yates initially performed the chest compressions and Mr Dempster gave mouth to mouth resuscitation with two breaths to 30 compressions. Mr Dempster vomited as a result of air he was breathing into Mr Kumar’s mouth coming back out into his mouth. He stated that he smelt what he thought was a ‘spewy alcohol smell’.
Dr Yates stated that he and Mr Dempster had difficulty getting breaths into Mr Kumar because of the thickness and narrowness of his neck and the difficulty of maintaining a clear airway.
Police arrived and provided a resuscitation face mask and assisted with compressions pending arrival of Queensland Ambulance.
The autopsy was inconclusive as to the cause of death. The Forensic Pathologist, Dr Storey:
… noted that Mr Kumar’s coronary atherosclerosis was of a sufficient degree to potentially result in sudden death. In this context, the potential for sudden abnormality in heart rhythm may have been heightened in circumstances of agitation, when circulating stress hormones were increased.
Dr Storey was unable to pinpoint a singular cause of death. He was of the opinion that the medical cause of death was a complex interplay involving a number of factors such as the elements of agitation, restraint, obesity, prone position, and coronary atherosclerosis…
What did the coroner say of the first aid particularly that provided by Dr Yates, a medical practitioner? His was comment was that Dr Yates
… should have had a higher level of awareness of the dangers… It was unacceptable … to put aside his medical training and experience on the basis that he was given just one job to do – to restrain Mr Kumar’s right arm. [He] … did take control of the situation once CPR was required, but he should have taken more control … earlier… I find that his failure to do so was unreasonable.’
But that finding by a coroner is not a finding of either criminal or civil liability. No charges were recommended against anyone involved in the restraint of Mr Kumar. The cause of death was not poor first aid but ‘The combined effects of restraint and coronary artery atherosclerosis in a man with centripetal obesity’. The Coroner’s recommendation was that:
… first aid training providers consider including a component in their training to raise awareness about the dangers of positional and restraint asphyxia.
Inquest into the death of Neville Royston Reading (9 June 2015).
Neville Reading died in similar circumstances to Mr Kumar. Mr Reading was involved in a violent altercation on the street. Neighbours intervened, and cable ties were used to restrain Mr Reading, and he was held on the ground, restrained by people applying their body weight to him, for 5-10 minutes pending the arrival of police.
In that time some [witnesses] said Mr Reading had periods of wakefulness, and those where they thought he was asleep or unconscious. Some heard snoring, a snort, and others nothing.
Police arrived and determined that MR Reading was unconscious, and he was placed in the recovery position. Shortly after it was determined that he did not have a pulse.
Resuscitation efforts commenced during a torrential downpour and he was transferred to the Cairns Base Hospital. He did not regain consciousness and was declared deceased at 7:58pm on 2 November 2013.
Dr Botterill, a Forensic Pathologist conducted an autopsy. Based on the autopsy and pathology results he:
… considered that the cause of Mr Reading’s death was most probably a cardiac dysrhythmia during restraint. He considered it likely that the factors of restraint, the stress of the altercation, equivocal heart enlargement, heart valve disease and significant alcohol intoxication may each have contributed to the death to some extent. However, Dr Botterill was unable to quantitate the relative contribution of those factors to the death.
Dr Botterill considered that in this instance the circumstances were in keeping with a death that occurs during a restraint event. It was difficult to identify a single disease process or injury to explain the death. In combination the risks associated with each of those individual processes or conditions adds up and, in many cases of restraint, results in death.
With respect to first aid, the coroner said (emphasis added):
I consider that the continued application of force to restrain Mr Reading on the ground in a prone position after the cable ties were applied was unnecessary. He was clearly immobilised. Two of the persons involved in the restraint had previously undergone first aid training. Those persons should have placed him in the recovery position…
Both appeared to be unaware of the importance of placing restrained or unconscious persons in the recovery position, and the evidence of both men was that they did not receive any training in relation to the risks associated with persons being placed in a prone position.
With respect to the police:
Constables Daniell and Taylor did not hold current first aid qualifications while Constable Hall did. However, I should note that there is nothing in the evidence to suggest that the first aid response of these officers was inappropriate or had any bearing on the sad outcome in this case.
What did the coroner conclude? The coroner did not conclude that the cause of death was poor first aid or that anyone could be liable for anything. The cause of death was the various underlying conditions. The decision to restrain Mr Reading by both the citizen bystanders and the police was reasonable. With respect to the bystanders and their understanding of first aid, the Coroner noted the recommendation from the Inquest into the death of Amit Kumar (discussed above) and said:
The relevant government website indicates that 526 providers are registered to provide course HLTAID003 – Provide First Aid. I note that this and related courses now include a requirement that candidates demonstrate a knowledge of “airway obstruction due to body position”.
Increased awareness of the risks of positional asphyxia by those who may in the future become involved in the restraint of persons, particularly on the ground, may lead to fewer deaths occurring in these circumstances.
The coroner did not recommend any action against the constables or Queensland police. The Coroner’s only recommendation was:
… that the Commissioner of the Queensland Police Service consider incorporating relevant CPR and other first aid response training into annual Operational Skills & Tactics Training provided to police officers.
Inquest into the Death of Siauto Eliuta Tunumafono  ACTCD 19 (29 November 2018).
This then brings me to the discussion of the findings of the ACT Coroner. Ms Tunumafono’s death was not in police custody but the coroner did comment on the care provided by ACT Fire and Rescue and ACT Ambulance. Ms Tunumafono
…was a 43 year old woman at the time of her death. She was found unresponsive at home by family members on 11 December 2013. Triple zero was called. Officers of ACT Fire and Rescue (ACTF&R) attended first and commenced providing treatment. They were followed shortly thereafter by officers of the ACT Ambulance Service (ACTAS) who took over treatment. Ms Tunumafono was then transported to Calvary Public Hospital in Bruce where she was treated further before a decision was taken to cease resuscitation efforts. Her death was reported to the Coroner because she died unnaturally in unknown circumstances.
The post mortem was inconclusive. At :
The pathologist who conducted the examination opined that Ms Tunumafono most likely died from a fatal cardiac dysrhythmia, the cause of which could not be established.
The critical facts are set out in paragraph . Ms Tunumafono collapsed sometime between 20:45 and 21:10 when she was discovered. CPR was commenced, and an ambulance called. ACT Fire and Rescue attended (though their time on scene is not given). The firefighters used an Automatic External Defibrillator to administer one shock. ACT Ambulance (ACTAS) arrived at 21:31. They did not administer any further shocks even though the ‘AED advised defibrillation at 21:24 (probably actually 21:31), and that the code summary from the ACTAS monitor (not supplied) showed VF [ventricular fibrillation] when the crew arrived (21:31)’. The next use of a defibrillator was at 22:17 at hospital.
An independent expert, Associate Professor Drew Richardson, was commissioned to report on the emergency response by ACTAS. He said ():
Based on the patient response at Calvary, there is doubt as to whether earlier defibrillation would have resulted in a stable heart rhythm, but based on the Ambulance Case Review there is no doubt it was indicated and not done at 21:31. In assessing the prognosis of a relatively young patient with cardiac arrest, even if the heart responds to treatment, the neurological outcome is the usual determinant of survival. The earliest that defibrillation could have occurred was 9 minutes after the ambulance call and approximately 20 minutes after the cardiac arrest, but may have been up to 45 minutes from the arrest. At the lower end of this range the neurological prognosis was very poor; at the upper end survival would have been essentially impossible because of brain damage. In my opinion, the delay in defibrillation was not a likely contributor to the cause of death. Had defibrillation occurred when indicated, the prognosis would still have been very poor because of the prolonged time since collapse.
The Coroner accepted that there were failures in treatment in that there was a ‘failure to recognise the need to defibrillate when required’ () but that ‘these errors were not likely to have contributed to Ms Tunumafono’s death’ (). The Coroner (at ) made ‘no adverse comment in relation to any of the individual ACTF&R or ACTAS officers involved’.
The Coroner was satisfied that both ACTF&R and ACTAS had taken steps to resolve issues around the use of their defibrillators and to ensure ongoing training.
The three Queensland inquiries are related as they are all deaths in police custody. As noted I found them as I was asked to give a presentation in Queensland not because they are dramatic findings. What causes me to put them together with the very recent findings of the ACT Coroner is that they show, in my view, the misguided view that is so often repeated to me in person or in comments on the website.
In discussions I have had people express fear about the use of defibrillators and potential liability should they fail. Even more often is the fear of having to explain to the coroner why a person dies and the belief that any departure from any training will lead to criticism and liability.
Here are four cases, maybe a representative sample, maybe not, but in any event four cases that have come before the coroner where anyone with first aid training and experience can see that there are issues in the care provided. Everyone who’s done a first aid course should know to put a person in the recovery position and to commence CPR. People warn constantly about diverging from exact training but here police attempted to improvise an airway with a breathalyser tube and a doctor peformed a procedure that ‘was probably unorthodox based on the current CPR training’.
ACTF&R and ACTAS had difficulties working with each other’s defibrillators and the treating paramedics failed to administer a shock even when one was indicated.
But the coroner did not condemn the officers involved. The cause of death was never the failure to provide proper CPR or use of a defibrillator. The coroner looked at all the circumstances. Everyone tried hard, and whilst one person’s conduct was described as ‘unreasonable’ the decisions and actions were understood. No-one was recommended for prosecution and the coroner did not say that anyone was negligently contributed to the deaths under investigation.
I would hope that these examples may go some way to put people’s minds at rest and avoid the misconception that the courts and judges are just waiting to condemn first aiders, and paramedics, and the only thing that stops the judges for pursing their personal crusade to punish wayward first aiders is rigid adherence to protocols and special legislation.
For other cases where coroners did not condemn the emergency services personnel even though someone died see:
- Coroner’s review of response by ACT Ambulance (March 2, 2018)
- Coroner’s inquest into death of FRNSW firefighter (March 2, 2018)
- Coroner’s positive comments on the provision of first aid and ambulance response in the NT (November 16, 2017)
- NSW Coroner’s findings into Dungog floods (October 2, 2017)
- No adverse comments regarding paramedics following death of a woman in Ballarat, Victoria (April 3, 2017)
- Coroner’s inquiry into the Wambelong (Coonabarabran) bushfire, January 2013 (September 29, 2015)
Of course it doesn’t always go that way. For a coroner’s inquiry that was very critical of the response by the leaders of the emergency services, see:
- 2003 Canberra bushfires, the coroner and litigation (June 26, 2009)