Findings of death of Geelong man after police pursuit published

A mentally ill Geelong man died after running away from and being handcuffed by police.

A coroner has made a recommendation to Chief Commissioner Shane Patton after the death of a Geelong man. Picture: NCA Newswire / Nicki Connolly

Police failed to start CPR in a timely way on a mentally ill Geelong man who died after being handcuffed, an inquest has found.

Ricky James Broughton was 47 when he died on May 3, 2018 in Buninyong after he ran away from police who were meant to facilitate his transfer to hospital.

Coroner Paresa Spanos’ findings from the inquest into the death of Mr Broughton, who had moved to Ballarat due to lack of suitable housing in Geelong, were recently published.

The medical cause of his death was complications of acute agitation in the setting of a prolonged struggle in an acutely psychotic man with a history of chronic schizophrenia, she found.

He had become unresponsive after vigorously resisting restraint.

Ms Spanos said the use of handcuffs to restrain him after it was evident to attending police that he was unconscious was inappropriate and impeded their ability to accurately assess his condition and identify his deterioration.

“In the absence of unequivocally reassuring signs of life and in the context of increasingly urgent requests for an ambulance … there was a collective failure to commence CPR in a timely way,” she wrote.

“Although the weight of available evidence leads me to conclude that CPR was unreasonably delayed, it does not enable me to find to the applicable standard that Ricky’s chances of survival would have materially improved or that his death might have been prevented if CPR had commenced earlier than it did.”

By 5.44pm police commenced CPR — nine minutes after Mr Broughton had stopped resisting restraint and eight minutes after it was clear to members that he was unconscious.

Paramedics arrived, but Mr Broughton was declared dead at the scene.

Ms Spanos recommended the Chief Commissioner of Victoria Police consider the need to clarify, reinforce or enhance guidance and/or training provided to its members to equip them to respond to life-threatening emergencies in a person in their care or custody.

She also recommended the health department consider, in consultation with police and Ambulance Victoria, the need to revise protocol for the transport of people with mental illness to ensure its guidance is consistent with the principle of least restrictive practice.

Mr Broughton was being evicted from a boarding house and taken to hospital under an inpatient assessment order on the day he died.

He had previously been a long-term patient of the Barwon Mental Health Service and he was managed via compulsory psychiatric inpatient treatment at the Swanston Centre, compulsory treatment provided in the community and voluntary community treatment.

He lived in a range of accommodation types with varying levels of support.

In 2017 Mr Broughton, who was an NDIS participant, could no longer live at the supported accommodation he was in due to issues including his “poor compliance with management”.

After a stint at the Swanston Centre Mr Broughton, who grew up in the Geelong region, was discharged to a supported residential service in Ballarat.

Ms Spanos wrote a key part of discharge planning was locating suitable accommodation for Mr Broughton, but unable to find him a suitable place to live in the Geelong area, his case manager looked further afield.

Mr Broughton lived in a number of places in the Ballarat area before his death.

Ms Spanos wrote he was at perpetual risk of homelessness.

Originally published as Findings of death of Geelong man after police pursuit published