Inquest into the death of Michael Peachey

Case Number: 2021/144151

Date of Findings: 28 November 2024

Magistrate: Elizabeth Ryan

CORONIAL LAW – Death as a result of police operation, First Nations death, restraint of person in the prone position, was the response of police and ambulance officers appropriate, and consistent with policy and training, recommendations.

Responses

Recommendations to	Response
NSW Commissioner of Police	Awaiting
Commissioner and Chief Executive of NSW Ambulance	Awaiting
Chief Executive Officer of the Hunter New England Local Health District	Awaiting

Recommendations

To the NSW Commissioner of Police

1. That the Commissioner consider:

a) formulating an independent policy on restraint which provides clear guidance to officers of the NSW Police Force about the risks of prone restraint, the ways in which to mitigate those risks, and the importance of moving a person from the prone position as soon as possible, particularly in cases where there has been acute behavioural disturbance and emergency sedation; and

b) providing specific mandatory training to NSW Police Force officers on the above.

2. That the Commissioner consider:

a) providing further guidance material in the NSW Police Force Handbook, on the importance of having regard to information provided, and concerns expressed by, family members or others close to the person about the person’s behaviour, including changes in that behaviour, in determining whether a person appears to be mentally ill or disturbed for the purposes of section 22 of the Mental Health Act 2007; and

b) providing additional training to NSW Police Force officers in the above. 

To the NSW Commissioner of Police, and the Commissioner and Chief Executive of NSW Ambulance

3. That NSW Ambulance and NSW Police Force consider carrying out interagency training and/or development of guidance material, which would focus on the respective roles of the two agencies and the need for communication, where both agencies attend a scene involving acute behavioural disturbance, prone restraint and emergency sedation.

To the Chief Executive Officer of the Hunter New England Local Health District

4. That the Hunter New England Local Health District consider the introduction of polices for following up voluntary patients who present to an emergency department with symptoms of mental illness or disturbance, but leave without having received a medical assessment.