4 days ago
Detainee waited alone in police cell for 'critical' 41 minutes after officers decided to call ambulance
A coroner has recommended a police officer be physically present with a detainee at all times while waiting for an ambulance after a man was left alone in his cell and deteriorated during a "critical 41-minute" period.
The recommendation was made after an inquest into the death of an Adelaide man heard that after deciding emergency care was required, an officer arranged a police escort before calling for an ambulance.
In her findings, South Australia Coroner Sally Giles noted Duy Ngoc Pham, 35, was considered a "high need detainee requiring medical attention" before he suffered a cardiac arrest in a police cell at Elizabeth, in Adelaide's north, and later died in hospital.
He had been arrested after he was found semi-conscious and slumped over the steering wheel of a car parked at a service station on Thursday, April 18, 2019.
Mr Pham was taken to hospital and diagnosed as suffering opioid toxicity and experiencing drug withdrawal, before being deemed fit for release into police custody.
He was taken to the Elizabeth Police Station Cell Complex and charged with trafficking in a controlled drug and driving dangerously to escape police pursuit over an earlier incident.
He was refused police bail, and because it was the Easter weekend, was remanded in the cells at Elizabeth to await his first court appearance which would have occurred on the following Tuesday, April 23, 2019.
Due to his diagnosed drug withdrawal, Mr Pham was assessed as "presenting a high level of risk" and placed in an observation cell.
While detained, he was returned to hospital due to concerns about his health, and was again deemed fit for custody and discharged and returned to a police observation cell.
In her findings, Ms Giles noted Mr Pham's condition deteriorated further in the early hours of April 21, 2019, and he was observed "howling and guarding his stomach".
He was also seen twice falling in his cell.
Ms Giles noted that after the first fall at 4.19am officers had "agreed Mr Pham needed to be returned to hospital", but an ambulance was not called until 4.38am, after a police escort was first arranged.
Ms Giles said CCTV of Mr Pham's cell indicated his breathing appeared "rapid" and he appeared "noticeably uncomfortable".
"I find that SAAS should have been contacted earlier than 4:38am; SAAS should have been contacted shortly after 4:19am," she said in the findings.
Ms Giles said the officer had called the non-urgent number, rather than triple-0, and when the ambulance officers attended at about 5am, he had stopped breathing and was "found to be in cardiac arrest".
"Earlier ambulance attendance may have led to a more favourable outcome for Mr Pham," Ms Giles said.
During that time, she said Mr Pham was monitored remotely, but no one was in in the cell with him which "may have contributed to the failure to recognise his deterioration".
"Consistent physical presence could have increased the likelihood of noticing signs of decline," Ms Giles said.
She said it was later discovered that while Mr Pham was suffering from withdrawals, he was also suffering from an undiagnosed duodenal ulcer — a sore in the lining of the small intestine — which "may have subsequently been exacerbated by narcotic withdrawal" and had perforated.
Ms Giles noted that an expert had told the inquest it was "impossible to be certain about the timing" of the perforation.
In her findings, Ms Giles noted SA Police had made some changes to their custody management practices, but recommended a further update that police make it a "requirement that an officer be physically present in the cell with the detainee at all times while awaiting an ambulance".
She further recommended it be "abundantly clear that for a high need detainee requiring medical assessment, an ambulance must be called immediately, and nothing need occur before that", including arrangements for a police escort.
An SA Police spokesperson said "a number of changes" had been made to custody management practices since Mr Pham's death.
"SAPOL will also give further consideration to the two recommendations made during the Inquest," the spokesperson said.
