Coroner's Finding: Reid, Paul

CORONERS ACT, 2003 SOUTH AUSTRALIA FINDING OF INQUEST An Inquest taken on behalf of our Sovereign Lady the Queen at Adelaide in the State of South Australia, on the 21st, 22nd, 23rd and 27th days of September 2021 and the 16th day of December 2022, by the Coroner’s Court of the said State, constituted of Ian Lansell White, Deputy State Coroner, into the death of Paul Reid.

The said Court finds that Paul Reid aged 50 years, late of 24 Bardsley Avenue, Parafield Gardens, South Australia died at Parafield Gardens, South Australia on the 26th day of May 2017 as a result of ischaemic heart disease. The said Court finds that the circumstances of his death were as follows:

1. Introduction 1.1. As at 26 May 2017, 50-year-old proud Aboriginal man Paul Reid was very unwell with a serious and long-term heart condition.

1.2. Unfortunately, in the early hours of that morning, Mr Reid was involved in an episode of heightened physical and emotional stress with his family and then South Australia Police.1 He was also intoxicated and had cannabis in his blood system at that time. As will be detailed later in this Finding, soon after SAPOL arrived Mr Reid died at home in front of his family. The Court was given permission from his family to refer to him as Mr Reid.

2. Cause of death 2.1. Dr Stephen Wills, forensic pathologist at Forensic Science South Australia,2 performed a detailed post-mortem examination on Mr Reid at 1:55pm that day.3 He was also

1 SAPOL 2 FSSA 3 Exhibit C2a

called out to Mr Reid’s home by SAPOL that morning to examine him after he had died. At the scene he noticed ‘minor bruises and abrasions…around the wrists and…areas of abrasion upon the chest in keeping with resuscitation’.4

2.2. Mr Reid’s heart was referred by FSSA for further specialist examination by forensic cardiologist, Dr Tony Thomas. He performed both a macroscopic and microscopic examination of the heart before reporting back to Dr Wills. The results quoted in the post-mortem report state: 'Specialist examination of the deceased’s heart by Dr Tony Thomas revealed evidence of severe ischaemic heart disease with stenosis of the major epicardial coronary vessels and extensive scarring within the muscle of the heart.' 5

2.3. Dr Wills later concluded: 'Taking all the findings into consideration, in my opinion the cause of this gentleman’s death may be regarded as ischaemic heart disease. Individuals with enlargement and scarring of the heart and significant narrowing of the epicardial coronary arteries are known to be at increased risk of cardiac dysfunction, arrhythmia and sudden, unexpected death. Increased stimulation of the heart through physical and/or emotional stress may have played a role in the precipitation of a fatal arrhythmia at this time, however the deceased would have still been at increased risk of sudden unexpected death in the absence of physical exertion or emotional stress.' 6

2.4. I shall now detail other features found at the post-mortem examination at FSSA.

2.5. Dr Wills found that there were no external injuries to Mr Reid’s head, neck or chest.

Further, there were no significant injuries seen to his legs. His head and face showed no internal bruising within the scalp or facial soft tissues and no skull fractures or bleeding in or around the brain. There was an interior bruise on his throat area. This will be discussed further in this Finding.7 As stated, there were rib fractures consistent with the CPR performed on him at his house.

2.6. I accept his opinion that the cause of death was ischaemic heart disease and make a finding accordingly.

4 Exhibit C2a, page 3 5 Exhibit C2a, page 3 6 Exhibit C2a, page 4 7 Paragraphs 7.32-7.39 and 11.4

3. Recent medical history of Mr Reid 3.1. Cardiologist Dr Kumaril Mishra treated Mr Reid in 2016. He provided evidence relating to Mr Reid's heart condition. Dr Mishra stated that as at November 2016 Mr Reid's long term prognosis was not good and his non-compliance with medication increased the risk of a cardiac event.8

3.2. Dr Mishra’s opinion was that as at 26 May 2017, Mr Reid was at risk of a sudden cardiac death in any situation. Any physical or emotional stress would increase the chances of a fatal cardiac episode. Dr Wills gave evidence supporting this opinion and had independently noted this in his post-mortem report.9

3.3. Statements provided by pharmacist Johnny Tran10 and Brevet Sergeant Corey Pearson11 indicated that Mr Reid had been non-compliant with taking his medication for his heart condition for many months in the lead-up to his death.

4. Chronology of events of 26 May 2017 4.1. A focus of the oral evidence at this Inquest was the role that the actions of SAPOL may have played in precipitating a medical episode for Mr Reid and whether they failed to react appropriately.

4.2. The simplest way to outline the series of events that occurred in the early hours of the morning of Friday, 26 May 2017 is by way of a chronology, based on the SAPOL Investigating Officer’s Significant Incident Investigation12 report13 into Mr Reid’s death.

4.3. This chronology was compiled and based on SAPOL recorded emergency calls and radio transmissions14 together with South Australian Ambulance Service15 recorded communications16 and interviews.

8 Transcript, page 158 9 Exhibit C2a 10 Exhibit C15 11 Exhibit C26

12 SII 13 Exhibit C35c 14 Exhibit l 7/B76645-10-SAPOL recorded communications disc

15 SAAS 16 Exhibit l 7/B76645-13-SAAS recorded communications disc

Time Events of 26 May 2017 Mr Reid’s wife, Ms Hadley, called 000. In this 19 second call, no 02:28:31am details were provided before the call was completed.

Ms Hadley called 000 and reported Mr Reid was intoxicated and 02:28:50am attempting to hit her with a didgeridoo at 24 Bardsley Avenue, Parafield Gardens.

SAPOL Elizabeth uniform patrol officers Brookes and Ashenden were 02:31:46am tasked to 24 Bardsley Avenue, Parafield Gardens in response to Ms Hadley’s calls.

Ms Hadley called 000 and stated her children were restraining the 02:36:31am deceased.

SAPOL officers Brookes and Ashenden arrived on scene. The 02:37am deceased and his sons Paul Reid Jnr and Christopher Sneddon-Reid were on the front porch.

Brookes spoke to the deceased and Mr Reid Jnr. Ashenden spoke to Ms Hadley.17 According to SAPOL, an altercation took place between Mr Reid Jnr and Mr Reid.

Brookes and Ashenden restrained Mr Reid to prevent a breach of the peace. Mr Reid was moved to the front yard and was released.18 Mr Reid went inside the front door, obtained a pen and paper to write Brooke's name and number on an envelope.19 Ashenden and Brookes confirmed Ms Hadley and Mr Sneddon-Reid were prepared to provide statements.

Brookes informed Mr Reid he was under arrest for an Aggravated Assault.

Ashenden handcuffed one arm of Mr Reid who went down onto his knees. Ashenden finished handcuffing him behind his back.20 Brookes advised SAPOL Communications21 that Mr Reid had been 02:47:18am arrested.

SAPOL Elizabeth uniform patrol officers Delaat and Gray arrived at 02:47am the scene.

17 MD #53 - Interview I of S/Const Brookes p 5 Ll45. Given for SII 18 MD #53 - Interview I of S/Const Brookes p 6 Ll80. Given for SII 19 MD #53 - Interview I of S/Const Brookes p 6 Ll92. Given for SII 20 MD #56 - Interview of P/Const Ashenden P5 Ll56. Given for SII

21 COMMS

Time Events of 26 May 2017 Brookes requested SAAS attend for the purpose of determining the 02:54:08am suitability of Mr Reid for custody.

He was placed on his right side. Brookes and Ashenden monitored his breathing.

Gray commenced taking a statement from Mr Sneddon-Reid. Delaat commenced taking a statement from Ms Hadley.

Brookes and Ashenden maintained observations on Mr Reid who began snorting and demonstrating signs of irregular breathing.

Brookes requested SAAS to quicken their response as Mr Reid had 02:56:30am breathing difficulties.

Ashenden could not find Mr Reid’s pulse. The handcuffs were removed by Ashenden. He was placed from the recovery position onto his back.22 Brookes advised COMMS Mr Reid was not breathing and they were 02:58:50am commencing CPR.

SAAS tasked to attend. Originally a Priority Two response was given 2:59am but upgraded to Priority One.

03:00:42am SAAS advise SAPOL the ETA for first unit was three minutes.

SAAS arrived on scene. A defibrillator and intravenous access were 03:07am prepared.

03:09am SAAS’ second unit was on scene and commenced medical assistance.

SAAS commenced medical assistance. SAPOL officers Delaat and 03:10am Gray relieved from administering CPR.

03:57am SAAS medical treatment completed.

04:00am SAAS pronounced Mr Reid’s life extinct.

5. Events prior to SAPOL arriving at Mr Reid’s house 5.1. Consistent with the results of the FSSA toxicology report, Mr Reid was drinking a lot of alcohol prior to SAPOL arrival at his house. He was at his home with his defacto wife, Ms Rosemary Hadley, and their two sons, Paul Reid Jr and Christopher Sneddon-Reid.

Also present was Paul Reid Jr’s partner, Ms Sarah Bendessi.

22 MD #56 - Interview of P/Const Ashenden Pl8 L576. Given for SII

5.2. As seen above, in the time period between 2:28am and 2:36am, Ms Hadley called 000 three times to request police assistance concerning alleged domestic violence by Mr Reid towards her. She reported to SAPOL at 2:36am on the third call, that her sons were restraining Mr Reid.

5.3. As the chronology above outlined, the first SAPOL officers to arrive at the scene were Senior Constable Mark Brookes23 and former Probationary Constable Kieran Ashenden.24

5.4. The evidence varied considerably between SAPOL and the civilians about what happened after SAPOL arrived. This will be detailed later, but what is common ground is that Mr Reid was arrested at his home for the charge of aggravated assault. As he was being arrested it became clear he suffered his fatal medical episode, commonly known as a heart attack.

6. Arrest and mandatory Inquest 6.1. Mr Reid’s arrest meant that he was officially in SAPOL custody. According to the Coroners Act 2003,25 a mandatory Inquest into the cause or circumstances of his death must occur.

6.2. On 7 June 2021, section 3(3) of the Act came into operation. This states that: 'For the purposes of this Act, a reference to the circumstances of an event may be taken to include matters related to or arising out of the event or its aftermath.'

6.3. This Inquest began after 7 June 2021. There is no definition of ‘circumstances’ in the Act. Therefore, it is important to outline guidance from the Supreme Court of South Australia26 of interpretation of the phrase ‘cause or circumstances’. I refer to the decision of WRB Transport and others v Chivell27 where Lander J stated: 'In my opinion, the jurisdiction given by the Act to the Coroner is quite extensive. It is not limited, as suggested, to a particular inquiry into the direct cause of death of the deceased.

The Coroner has a jurisdiction and, indeed, an obligation to inquire into all facts which may have operated to cause the death of the deceased and as well to inquire into the wider circumstances surrounding the death of the deceased.' 23 SC Brookes 24 PC Ashenden 25 the Act 26 the Supreme Court

27 [1998] SASC 7002

He also went on to say with respect to ‘cause’: 'In determining those events which may be said to give rise to the cause of death, the Coroner is not limited by concepts such as ‘direct cause’, ‘direct or natural cause’, ‘proximate cause’ or the ‘real or effective cause’.' and: 'The Coroner, therefore, has to carry out an inquiry into the fact surrounding the death of the deceased to determine what, as a matter of common sense, has been the cause of that person’s death. The inquiry will not be limited to those facts which are immediately proximate in time to the deceased’s death. Some of the events immediately proximate in time to the death of the deceased will be relevant to determine the cause of death of the deceased. But there will be other facts less proximate in time which will be seen to operate, in some fact situations, as a cause of death of the deceased.'

6.4. I am mindful of this guiding statement from the Supreme Court in considering the evidence and issues raised in this Inquest.

7. Evidence and submissions from Mr Reid’s family 7.1. Mr Reid’s family provided SAPOL with statements following the morning’s events and some of them were provided on a subsequent occasion. I acknowledge that providing a statement on the morning of Mr Reid’s death must have been a very difficult task for them. I shall deal with a summary of their statements which were received at the Inquest as evidence.

7.2. Paul Reid Jr Mr Reid Jr gave the first of his two statements at 7:23am on 26 May 2017. This first statement was completed later on 10 August 2017 at the Aboriginal Legal Rights Movement28 office in Adelaide.

7.3. His second statement was also given at ALRM, shortly after completing his first statement that day.

7.4. In his first statement, Mr Reid Jr acknowledged that his dad was ‘a big drinker…and would drink most nights’.29 Mr Reid Jr warned Mr Reid that he needed to ‘slow down’ his drinking which seemed to have an effect. He noticed that his father ‘had a lot of health problems particularly issues with his heart’.

28 ALRM 29 Exhibit C6

7.5. Mr Reid Jr alleged that in the early hours of 26 May 2017, his father picked up a didgeridoo in the house and advised his mother to call SAPOL. He noted his dad was ‘pretty drunk’ and ‘pretty unsteady on his feet’. Mr Reid Jr and his brother restrained their father whilst waiting for SAPOL to arrive.

7.6. When SAPOL did arrive, Mr Reid Jr was standing at the front door with his father who was arrested at that time for assault. Mr Reid Jr stated that his father did not resist arrest and one of the SAPOL officers ‘…looked like he was elbowing him in the throat’.30 He stated that the police were ‘mean’ once they arrested his father and that the family ‘…tried to tell the police that he had heart problems and to be careful with him’.31 He noted that as his father was being walked out to the street he ‘…fell to the ground but the police caught him and stopped him from falling to the ground and hitting his head.

They lowered him to the ground and lay him on his side’.32

7.7. In his second statement,33 Mr Reid Jr provided more background information as to the argument that was occurring between his mother and father, prior to SAPOL being called. He described that he and his brother were restraining their father on the couch on the front porch until SAPOL arrived. They were holding him down by ‘…his shoulders but he was too strong’.34 Mr Reid Jr stated his father ‘…tried to get off the couch but we wouldn’t let him in case he would go at mum’.35

7.8. They gave him his glyceryl trinitrate nitrolingual36 spray and it looked like he was going to use it until police intervened. When SAPOL arrived his father went inside and tried to shut the front door. A note was found inside the house written by Mr Reid.37 This tended to suggest he was beginning to note the identities of SAPOL officers SC Brookes and former PC Ashenden and was upset by their presence.

7.9. Mr Reid Jr outlined that he saw one of the officers ‘…held both of dad’s arms behind his back and the other copper elbowed dad in the apple part of his throat, in the front, with his right arm while he held dad’s head with his left hand. It was pretty hard’.38 30 Exhibit C6 31 Exhibit C6 32 Exhibit C6 33 Exhibit C6a 34 Exhibit C6a 35 Exhibit C6a

36 GTN 37 The note 38 Exhibit C6a

7.10. The SAPOL officers released Mr Reid from their grip and he walked inside. Mr Reid asked one of the officers for his number which he gave him and began writing the note whilst he was shaking and having trouble remaining standing.39

7.11. Mr Reid Jr alleged that his father was pushed by the taller officer which resulted in his father’s back hitting the door frame.

7.12. It was at this point that SAPOL arrested Mr Reid and started to put handcuffs on him.

That is when Mr Reid collapsed stating ‘Give me my red spray’. ‘Chrissy’40 was trying to give the GTN spray to police but they did not take it.

7.13. Finally, Mr Reid Jr alleged that SC Brookes and former PC Ashenden laughed when Mr Reid had collapsed and during the course of his heart attack urinated himself.

7.14. Christopher Sneddon-Reid Mr Sneddon-Reid, also the son of Mr Reid, gave his first statement to SAPOL at 7:30am on 26 May 2017.41 It was a comparatively brief statement confirming his father’s health issues and his behaviour that evening prior to SAPOL arriving. He included his father being upset. He and Mr Reid Jr tried to calm him down but to no avail.

7.15. When SAPOL arrived his father became very upset and was shouting. He tried to give his father the GTN spray which he said his father asked for at the time of his arrest and handcuffing. The ‘shorter’ SAPOL officer with black hair refused to take it saying ‘he can have it later’.42

7.16. Mr Sneddon-Reid described his father’s collapse and that ‘We thought Dad was playing dumb, which he has done before, but he wasn’t’.43

7.17. In the later statement of 24 September 2021 made to ALRM, he stated that they did not touch his father’s neck at any time and that his father ‘…became more upset and agitated’ after SAPOL arrived.44 39 Exhibit C35 MD20 40 Mr Sneddon-Reid 41 Exhibit C7 42 Likely to be former PC Ashenden 43 Exhibit C7 44 Exhibit C7a

7.18. Sarah Bendessi Ms Bendessi lived with the Reid family and was in a relationship with Mr Reid Jr. She also gave a statement on the morning of Mr Reid’s death.45 She described Mr Reid being upset and angry prior to SAPOL being called by ‘Rosie’.46 She described that ‘Chris and Paul were trying to restrain Big Paul by holding him just inside the front door’.47

7.19. She described that former PC Ashenden and SC Brookes were trying to restrain Mr Reid, including one of them using his arm to hold it against Mr Reid’s throat. Once outside with the police Mr Reid ‘…looked like he was fake breathing and holding his breath’.48

7.20. Her statement also dealt with the aftermath of Mr Reid’s collapse including SAPOL and SAAS’ attempts to resuscitate him by CPR.

7.21. Rosemary Hadley Ms Hadley gave her statement at approximately 7am on 26 May 2017 at her home, but was unable to finish it because she was too emotional. It was completed at ALRM on 1 August 2017. Ms Hadley outlined that she and Mr Reid had been together for about 21 years, having first met in Whyalla. They had 10 children together.

7.22. Ms Hadley gave a history of Mr Reid’s health problems including in 2014 suffering a minor heart attack. She mentioned the use of his GTN spray. He would sometimes ‘forget’ to take his medication as prescribed. He drank alcohol, usually Victoria Bitter beer and smoked cannabis.

7.23. In the weeks prior to Mr Reid’s death they had been arguing more than usual and that by 11:30pm on 25 May 2017 he was ‘extremely intoxicated’.49 He picked up a didgeridoo and held it whilst yelling at her. She went to the bedroom. Her son’s Mr Reid Jr and Mr Sneddon-Reid grabbed Mr Reid by the arms and walked him outside to the porch where they sat down with him. Ms Hadley stated that ‘Paul struggled with 45 Exhibit C8 46 Ms Hadley 47 Exhibit C8 48 Exhibit C8 49 Exhibit C5

the boys for a little while and tried to get free but he couldn’t’.50 She called ‘000’ on two occasions which she believed to be about half an hour apart.

7.24. When SAPOL arrived, Mr Reid became more upset and was yelling at them.

Ms Hadley alleged that the taller police officer grabbed Mr Reid by his t-shirt and then ‘…pushed Paul with his forearm against his neck and then grabbed at his face with his hand’.51

7.25. The officer let Mr Reid go and he went inside. He came back out before re-emerging with a pen and paper that Ms Hadley later saw Mr Reid had written on. When Mr Reid headed back inside he was advised he was under arrest and handcuffs were put on him whilst he was on the porch.

7.26. Ms Hadley outlined that once the handcuffs were on, Mr Reid asked Mr Sneddon-Reid for his medication because his ‘…heart was playing up’.52 She stated that when Mr Sneddon-Reid retrieved the GTN spray and tried to give it to Mr Reid he was not allowed to have it. This was moments before Mr Reid collapsed, falling forward onto the ground. After pleading with police to take the handcuffs off, Ms Hadley told them to call an ambulance. By this time, further SAPOL officers had arrived and ‘…after a long time’ the police took the handcuffs off him and started CPR.

7.27. Ms Hadley stated that after Mr Reid had died, he was uncovered until 8:30am which she found disrespectful.

7.28. There are clearly different accounts from his family members who were present. The differences included the type of force allegedly applied and where Mr Reid was when this force was applied. It was submitted that it is not unusual in an emotional and stressful situation like this that witnesses might take note of different events or recall events differently. That statement is absolutely true.

7.29. Specifically, there were various widely conflicting accounts about the force used by SAPOL against Mr Reid's neck and where that took place. It was submitted that the 50 Exhibit C5 51 Exhibit C5 52 Exhibit C5

Court could not rely on those tendered affidavits of Mr Reid’s family to make a finding that there was any such force applied to Mr Reid's neck.

7.30. The arresting officer’s evidence provided further disparity. SC Brookes denied that he touched Mr Reid's neck at any stage.53 It was put to him that he had put his arm against Mr Reid's throat and held him against the door. SC Brookes denied that allegation.54

7.31. Former PC Ashenden gave evidence that shortly before the arrest he had looked over and into the doorway. He saw Mr Reid with his arm up in front of his neck.55 SC Brookes had one and then two hands on his arm. Former PC Ashenden said that SC Brookes did not make contact with Mr Reid's neck at any point in time.56

7.32. Dr Wills provided evidence about the bruise on the interior of the throat area of Mr Reid. He stated it was unlikely that it was caused by a forearm being pressed against the neck although it was possible. It could have been caused by the bone on the wrist being pushed into the neck. It could have been caused by Mr Reid being grabbed from behind or it could have been caused by an elbow to the neck.

7.33. Dr Wills was unable to age the bruise with any particular specificity. That is, he was not able to say whether it was possibly caused before SAPOL or during SAPOL’s attendance while Mr Reid was conscious. It may have occurred during CPR that was performed on him at the house by SAPOL and then SAAS. A further possible explanation was it could have been caused before SAPOL arrived when Mr Reid was being held down by his sons.

7.34. There was no finding on the post-mortem examination that conclusively indicated undue force by SAPOL before or during the arrest. It is true that the absence of findings does not mean that there was not force used. It is also true that the existence of that bruise is not necessarily corroborative of any undue force by SAPOL, or anyone else who may have caused it.

7.35. In any event, Dr Wills’ evidence was that the bruise had no bearing on Mr Reid's death.

He believed that if there was force applied to the neck, it was consistent with occurring within a series of events of heightened by physical and emotional stress. He could not 53 Transcript, page 51 54 Transcript, page 78 55 Transcript, pages 223-224 56 Transcript, page 226

say any pressure to the neck that may have caused that bruise would have more significantly increased the risk of a fatal cardiac episode.

7.36. The evidence suggested that Mr Reid was making threats with a didgeridoo, was restrained while awaiting SAPOL arrival and yelled at people in the presence of SAPOL. This allows me to find that the arrest by SAPOL put Mr Reid in a situation of heightened physical and emotional stress.

7.37. There is no doubt that there was a physical encounter of some sort between SC Brookes and Mr Reid in the front doorway based on what former PC Ashenden described of seeing an arm up in front of Mr Reid's neck and SC Brookes' hands on that arm. It does not mean the bruise was caused by this action.

7.38. I remind myself of the authority of Briginshaw v Briginshaw57 as it applies to the Coroners Court. The Court should not make adverse findings against, or comments about individuals or entities unless the evidence provides a comfortable level of satisfaction that they caused or contributed to the death. It was submitted that there was insufficient evidence to make an adverse finding against SC Brookes or former PC Ashenden in relation to the force that was used in the lead up to and during the arrest.

7.39. As earlier stated, this injury was of interest to Mr Reid’s family who had suggested that he may have been subject to unnecessary force during his arrest, including to his neck area. As noted, the medical evidence does not support such a contention for the reasons already set out and, based on the observations of Dr Wills.58

8. Post arrest events 8.1. Mr Reid required medical attention from the moment of his arrest at approximately 2:47am. It was argued that there was a delay in seeking medical attention for Mr Reid.

8.2. I heard various descriptions of Mr Reid's presentation immediately following his arrest.

There were descriptions of mumbling, groaning, being limp and urinating.

57 Briginshaw v Briginshaw (1938)60 CLR 336 and in particular Dixon J at 361-362. See also SJ Berry Pty Ltd and Another v McEntee and Another [2022] SASCA 133 per Livesey P and Bleby JA 58 In particular Exhibit C2a, page 4

Unfortunately, all four SAPOL officers, namely former PC Ashenden, SC Brookes and Constables Braydon Delaat and Jake Gray assumed that Mr Reid's presentation at that time was simply due to him being intoxicated. Constables Delaat and Gray arrived moments after Mr Reid’s arrest.59

8.3. The toxicology report of blood taken from Mr Reid at the post-mortem examination indicated that Mr Reid had a high blood alcohol concentration of 0.25%.60 The evidence showed Mr Reid did present consistently as an intoxicated person when SAPOL were dealing with him on that evening. It seemed that SAPOL failed to turn their minds to Mr Reid presenting in this manner for any reason other than intoxication.

8.4. SC Brookes, as the arresting officer, was obliged in accordance with the SAPOL General Order Custody Management to make a continual risk assessment of Mr Reid once arrested.61 SC Brookes detailed how he undertook this risk assessment.62 The first communication of Mr Reid’s arrest was made at 2:47am. It was not until 2:54am that the first call was made for SAAS. In that passage of time, the officers were awaiting the arrival of a SAPOL custody vehicle that SC Brookes had requested.

8.5. The audio recording of SC Brookes advising COMMS of Mr Reid’s arrest was tendered.63 SC Brookes stated ‘Can we get the cage down here, please’ and then advised ‘One under arrest for aggravated assault, no rush’. SC Brookes confirmed in the seven minutes he monitored Mr Reid, he was breathing and he was making a snoring noise. At approximately 2:54am SC Brookes stated to COMMS ‘Can I have SAAS at our location, please. The arrested person has decided to feign unconsciousness.’ The COMMS calls that followed demonstrated at least some ongoing risk assessment from 2:54am.64 They were also indicative of the state of mind of SC Brookes at that time.

8.6. Moments later, SC Brookes told COMMS that Mr Reid ‘…was up and shouting and yelling prior to the cuffs going on and he suddenly decided to go non-responsive, but no episode preceding it to indicate he has any injuries or underlying issues’.

59 Exhibit C35, MD3 60 Exhibit C4 61 Exhibit C35, MD19. Arrest and Reporting Procedures. The Custody Order.

62 Transcript, page 123 63 Exhibit C35, MD17 64 The 2:54am COMMS call

8.7. His evidence was that at the 2:54am COMMS call, Ms Hadley had told him to be careful with Mr Reid and that Mr Reid had a puffer, but that he did not consider his presentation at that time to be consistent with an asthma attack.65

8.8. Former PC Ashenden did have information at the 2:54am COMMS call that Mr Reid had a heart condition, however he admitted he did not pass that information on to SC Brookes. This was consistent with the evidence of Mr Reid’s family who said they told SAPOL of his heart condition. It was also consistent with the evidence of former PC Ashenden who says he knew that Mr Reid had a heart condition. SC Brookes said that at 2:54am he did not know that Mr Reid had a heart condition. This was also consistent with the other evidence.

8.9. At 2:54:24 an inquiry was made by COMMS concerning Mr Reid’s breathing.

SC Brookes replied ‘Roger, he is, I don't believe his condition’s any more serious than being a 102 but just want to have SAAS check him out before he goes to the cells’.66 That communication demonstrated that at that time SC Brookes believed Mr Reid was presenting this way because he was intoxicated.

8.10. The frequency of the contact with COMMS from this point indicated a continual risk assessment was being undertaken as required by the Custody Order. At 2:56:30 SC Brookes stated ‘Can we get SAAS here a bit more quickly’. At 2:56:38 SC Brookes stated ‘Just trying to work out ... rouse him at this point’.

8.11. SAPOL’s Custody Order does make reference to heart attacks and angina.67 The Custody Order outlines common symptoms of upper body discomfort, shortness of breath, nausea, vomiting, light headedness and fainting. However, based on all the descriptions of Mr Reid in the minutes following his arrest, there was no particular symptom which should have made it clear to SAPOL that he was having a heart attack or angina presentation, as opposed to being intoxicated.

8.12. The Custody Order deals with management of intoxicated persons. It states: 'Alcohol related offending accounts for a significant proportion of all arrests. Identifying a health problem where a detainee is suffering from the effects of alcohol generally takes longer to identify and the health of an intoxicated detainee is also likely to deteriorate more quickly than a non-intoxicated detainee.

65 Transcript, page 132 66 Exhibit C35, MD17 67 Exhibit C35, MD19

A person found drunk and incapable of looking after themselves must be treated as a high need person who is in need of medical assistance.' 68

8.13. The Custody Order mandates that a detainee who cannot walk to a cell and say a few coherent words must not be put in a cell, but transferred to hospital. It also refers to a table named the Brief Coma Scale.69 The BCS is a discretionary guide as set out in the Custody Order. Therefore, there was no issue of non-compliance with it.

8.14. The Custody Order states: 'The Brief coma scale is an assessment tool which can70 be used by a member as a guide when coming into contact with a person (particularly when in police custody) who is or appears to be suffering from an impaired state of consciousness.

Using table 1 – Brief coma scale (further in this General Order) a member must71 initially assess and respond accordingly – continue to reassess and respond (in accordance with the scale) to any changes in the person’s response.

Urgent medical attention is required when the person’s verbal response rates less than four.

Where a person’s best verbal response alters over time a member should act accordingly.' 72

8.15. The directions for the BCS have a general indication that it is discretionary in the first paragraph by use of the word ‘can’. This direction seems to be contradicted by the word ‘must’ in the second paragraph of directions.

68 Exhibit C35, MD19. Page 96 69 BCS. Exhibit C35, MD19(d). Pages 89-90 70 My emphasis 71 My emphasis 72 Exhibit C35, MD19. Page 88 of 121

8.16. It is impossible to find whether Mr Reid collapsed due to his level of intoxication or a medical episode. However, his presentation at that point was such that medical attention should have been sought immediately under those SAPOL guidelines.

8.17. The mere fact Mr Reid was presenting in this manner, whether simply intoxicated or as happened through suffering a medical episode, meant he would have warranted urgent medical assistance according to the BCS. SAPOL officers attending agreed with that proposition. Therefore, an ambulance needed to be called immediately. SC Brookes conceded that he was not aware of the BCS that night. In fact, the evidence was that none of the officers considered the BCS when dealing with Mr Reid when he first fell to the floor and appeared to be unconscious.

8.18. The uniform assumption of SAPOL that they were dealing with an intoxicated person meant that Mr Reid was critically unwell for approximately seven minutes before the first contact was made with SAAS. The assumption by SAPOL that Mr Reid was intoxicated must be assessed against the background of former PC Ashenden having been to the premises a number of times previously to deal with Mr Reid when he had been intoxicated. There was also the prominent background information SAPOL had been given about how much alcohol he had consumed on this particular night. Further, it seemed that at least some family members may also have thought that Mr Reid was feigning consciousness, as SC Brookes described it. Mr Sneddon-Reid said in his statement that when Mr Reid collapsed, ‘We thought he was playing dumb, which he has done before’.73

8.19. The evidence does not definitively identify when Mr Reid's medical episode began. In other words, it is not possible to find it began when he fell to the floor shortly after his arrest at 2:47am, or sometime later before his breathing changed, according to SAPOL officers. However, Mr Reid was unresponsive on the floor from the time of arrest. He was at least very heavily intoxicated. Therefore, medical attention should have been sought for Mr Reid at that point. Whilst his cardiologist Dr Mishra could not conclusively say whether earlier SAAS attendance could have made a difference, Mr Reid was deprived of medical attention for a number of minutes in the lead-up to his fatal cardiac episode.

73 Exhibit C7

8.20. As has been noted, the attending SAPOL officers were not aware of the BCS on this night. I believe it would be better if SAPOL mandated the use of the BCS for consideration by officers who have civilians in custody whether at the arrest stage or within SAPOL cell stations.

9. GTN spray 9.1. The final issue which was the subject of oral evidence was whether SAPOL were aware that Mr Reid used GTN spray and, if so, whether that should have been given to him.

Dr Mishra explained the role of the GTN spray was not ‘…for blood clots, it only works on the arteries to either relax them and improve flow’.74 He gave evidence that while Mr Reid was still conscious he should have been given the GTN spray if there were symptoms. He was clear in his evidence that it would be inappropriate to administer the GTN spray if there were no symptoms of angina, for example shortness of breath, heaviness of the heart and chest pain.75

9.2. Each of Mr Reid's family members provided statements that Mr Reid did request his GTN spray post-arrest. Mr Sneddon-Reid said that post-arrest as Mr Reid was being walked outside he asked for his heart spray.76 Mr Reid Jr said that when Mr Reid collapsed he called out ‘Give me my red spray’.77 Ms Hadley said that as soon as Mr Reid had the handcuffs on he asked Mr Sneddon-Reid for his medication and said his heart was playing up.78

9.3. SC Brookes’ evidence was that he was aware of Mr Reid having what was reported to him as a puffer prior to arrest but not a spray. SC Brookes stated in his second record of interview with SAPOL that Ms Hadley had told him to be careful and that Mr Reid might need his puffer when they were taking him into the front yard.79 When SC Brookes arrested Mr Reid, Ms Hadley repeated this. SC Brookes saw the GTN spray for the first time when the paramedics arrived. By this stage Mr Reid had no pulse and was unconscious.

74 Transcript, page 171 75 Transcript, page 169 76 Exhibit C7 77 Exhibit C6a 78 Exhibit C5 79 Exhibit C35c, SII Report

9.4. Former PC Ashenden said he was aware of the spray and he had been told of the existence of the spray by family members before Mr Reid collapsed.80 Both SC Brookes and former PC Ashenden gave evidence that they did not hear Mr Reid ask for his spray at any time. SC Brookes said he did not hear Mr Reid ask at any time for his spray nor make any complaint about how he felt.81

9.5. Former PC Ashenden maintained, despite knowing that Mr Reid had a heart condition and knowing that there was a spray that could be used for his heart condition, he was not aware that that was something that Mr Reid needed at that particular time. He did not recall telling SC Brookes that Mr Reid had a heart condition or about the spray.

SC Brookes gave evidence that he was unaware that Mr Reid had a heart condition or a spray to assist it until after he was unresponsive.

9.6. In light of these circumstances, it was submitted I should find that former PC Ashenden did not communicate that information to SC Brookes. However as Dr Mishra said, GTN spray can only be taken while a person is conscious. Therefore, it was possible to do so as the family requested when Mr Reid was cuffed. However, that opportunity was fleeting as Mr Reid dropped to his knees shortly after. SC Brookes said that nobody told him at the time of the arrest that Mr Reid needed a heart spray.82 Former PC Ashenden said he might have said it to another officer.

9.7. The Custody Order stated that ‘A member must obtain as much information about the detainee’s medication prior to administering it and when there are any concerns do not give the medication and seek advice from a health care professional’.83 Former PC Ashenden referred to the Custody Order to explain his decision to not give the GTN spray to Mr Reid because it did not have his name on it and he did not know its purpose. SC Brookes stated that if it was explained to him that Mr Reid had angina and that this was a way of relieving his heart condition then he potentially would have allowed him to take it.84

9.8. Based on the evidence before the Court, SAPOL were aware of the existence of GTN spray. I accept the submission that former PC Ashenden's assessment of taking the GTN spray with them to the police station, rather than administering it at the scene 80 Transcript, page 243 81 Transcript, page 96 82 Transcript, page 83 83 Exhibit C35, MD19. Page 90 of 121 84 Transcript, pages 140-141

was appropriate based on the Custody Order. If former PC Ashenden discussed this matter with his senior partner SC Brookes, Mr Reid may indeed have been given his GTN spray. However, there is no medical basis to conclude that if Mr Reid received it prior to losing consciousness the outcome for him would have been different.

10. SII by SAPOL 10.1. A comprehensive report was prepared by Detective Sergeant Stephen Hill following SAPOL’s SII into Mr Reid’s death.85

10.2. Although the report claimed that it ‘may be subject to a claim of privilege’, no such claim was ever made.

10.3. I comment now that it is hard to see how such a claim could be sustained except for the reason of public interest immunity.86 Quite properly, SAPOL’s methodology in some cases would be subject of PII, but in general SAPOL have duties under the Act to cooperate with the Coroner in investigating reportable deaths. In any event, the report into Mr Reid’s death was presented in full.

10.4. This comprehensive SII report identified eleven issues concerning events preceding Mr Reid’s death and the aftermath at the property. It is not necessary to identify all eleven issues other than to quickly summarise the findings on some of them, namely: a) The actions of SC Brookes and former PC Ashenden were ‘…reasonable and appropriate’ in deciding to arrest Mr Reid based on the allegations reported to SAPOL by members of his family’.87 b) The arrest of Mr Reid was lawful.88 c) That SAPOL took ‘…all reasonable action to save the life’ of Mr Reid ‘…by monitoring his condition, requesting the attendance of SAAS and administering first aid as soon as they became aware the deceased was unconscious’.89 I refer to my comments already made about the Custody Order’s requirements compared with the actions of SAPOL. Insofar as there is a difference, I will prefer my assessment and finding on this topic to that in the SII.

85 Exhibit C35c

86 PII 87 Issue 2 88 Issue 4 89 Issue 6

d) It was acknowledged that family members mentioned the GTN spray to SC Brookes and former PC Ashenden and produced the GTN spray to former PC Ashenden prior to Mr Reid becoming unresponsive. Former PC Ashenden was unable to administer the GTN spray to Mr Reid due to the need to secure him after his arrest and the undetermined nature of the medication.90 I have already made comments about the evidence on this topic at the Inquest.

e) All SAPOL general orders were complied with.91 Subject to my comments concerning the BCS in the Custody Order, I agree with the finding.

f) There was no ‘…undue delay in covering the body of the deceased’. It was acknowledged that Mr Reid’s body was uncovered at his home after his death for 3 hours and 50 minutes. The SII said this was unavoidable ‘…due to scene and body examination requirements’.92 I respectfully disagree. Mr Reid’s family were present from the moment he collapsed and saw his uncovered body. Despite the finding of the SII, I believe more could have been done by SAPOL to better handle this issue.

11. Findings 11.1. I have set out the position of Mr Reid’s family and SAPOL concerning the facts around the arrest of Mr Reid.

11.2. I note that SAPOL did not seek any of Mr Reid’s family to be called to challenge their statements that contradicted evidence by SAPOL officers. I have been asked by Ms Powell, acting for the family, to prefer the statements of the family to the evidence and interviews of SAPOL officers.

11.3. I am mindful, as I said, of the principle announced in Briginshaw v Briginshaw.93 The evidence needs to comfortably satisfy me that the SAPOL officers acted inappropriately before such a finding of fact could be made.

90 Issue 9 91 Issue 10 92 Issue 11 93 Briginshaw v Briginshaw (1938) 60 CLR 336 and in particular Dixon J at 361-362

11.4. The medical evidence, in particular the post-mortem observations by Dr Wills, was very important concerning the lack of injuries to Mr Reid that are in any way consistent with a violent struggle. The internal bruise to the throat area has many possible explanations, the vast majority of which involve little and/or incidental force to cause that bruise.

11.5. I am not convinced that SAPOL acted inappropriately regarding the arrest of Mr Reid but may have done better concerning the welfare of Mr Reid post collapse. In particular, had the BCS been known and adhered to in assessing those vital minutes post arrest and collapse, then SAAS would have been called earlier.

12. Conclusions 12.1. All counsel in the Inquest addressed me on the facts and the interpretation of them that I should adopt. No one sought recommendations to be made.

12.2. The trauma of Mr Reid’s death happening in front of his family whilst in SAPOL’s custody was widespread. His family diligently attended the Inquest and heard upsetting evidence. They urged the Court to find that SAPOL’s behaviour was unduly rough in arresting their father/husband. I have considered their submissions closely together with the evidence produced via the statements. I am unable to find as they wish.

12.3. Mr Reid was not at his best due to alcohol and cannabis consumption together with his dislike of the SAPOL presence on the night. He had placed himself in an emotional and stressful state which was very dangerous to his health. I find this ultimately must have been a contributing factor to his sudden death due to ischaemic heart disease.

12.4. The SAPOL officers, in particular SC Brookes and former PC Ashenden, were confronted with a potentially very volatile situation and reacted swiftly. When they realised this was not a SAPOL situation of just dealing with a very intoxicated arrested person, they reacted quickly to try and preserve Mr Reid’s life.

12.5. Ultimately, I find that SAPOL were justified in attending Mr Reid’s premises and arresting him based on the allegations conveyed through COMMS and his behaviour upon arrival.

12.6. When Mr Reid’s life was lost, he lay in front of his family uncovered for far too long.

That situation should not be repeated in the future should anything similar in nature happen to any other family.

13. Recommendations 13.1. Pursuant to section 25(2) of the Coroners Act 2003 I am empowered to make recommendations that in the opinion of the Court might prevent, or reduce the likelihood of, a recurrence of an event similar to the event that was the subject of the Inquest.

13.2. I have decided that only one recommendation need to be made based on the evidence in this Inquest.

13.3. The following recommendation is directed to the Commissioner of Police. It is recommended that:

1. The Commissioner of Police reconsider whether the discretionary use of the Brief Coma Scale in the General Order for Custody Management be upgraded to a compulsory reference for South Australia Police Officers that are dealing with a person in custody with an impaired state of consciousness.

Key Words: Death in Custody; Police; General Order Brief Coma Scale In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 16th day of December, 2022.

Deputy State Coroner Inquest Number 19/2021 (0973/2017)