Inquest into the death of AAB

CORONER’S COURT OF NEW SOUTH WALES Inquest: Inquest into the death of AAB Hearing dates: 7 November 2024 Date of Findings: 7 November 2024 Place of Findings: Coroner’s Court of New South Wales, Lidcombe Findings of: Magistrate Derek Lee, Deputy State Coroner Catchwords: CORONIAL LAW – death in New South Wales Police Force custody, cause and manner of death, Critical Incident Investigation, cocaine and alcohol toxicity, seizure activity, resuscitation efforts File number: 2023/132562 Representation: Ms J Curtin, Counsel Assisting, instructed by Ms I Pearson (Crown Solicitor’s Office) Findings: AAB died on 25 April 2023 at St Vincent’s Hospital, Darlinghurst NSW 2010.

The cause of AAB’s death was acute cocaine and alcohol toxicity.

AAB died whilst in the lawful custody of the New South Wales Police Force following a period of altered behaviour with features suggesting paranoia as a result of cocaine and alcohol intoxication, followed by a series of convulsive seizures terminating in cardiorespiratory arrest from which he could not be resuscitated.

Pseudonym order: See Appendix A

Table of Contents

1. Introduction 1.1 On the afternoon of 25 April 2023, AAB, a 26-year-old man, checked into a hotel in the Sydney CBD.

A short time later AAB was seen by hotel staff to be behaving erratically and in an unusual manner.

Due to a concern for AAB’s welfare, a call was made to the NSW Police Force (NSWPF) and officers arrived at the hotel shortly before 6:00pm.

1.2 The attending NSWPF officers formed a suspicion that AAB may be in possession of a prohibited drug and searched him, finding a plastic resealable bag containing some white powder. As a result, AAB was detained by the NSWPF officers. About 15 minutes later, AAB began to experience a seizure. An ambulance was called and the NSWPF officers present attempted to manage AAB’s seizure activity.

After a short time, they noticed that AAB had suddenly stopped breathing and was unresponsive.

1.3 Resuscitation efforts were commenced by the NSWPF officers present. After NSW Ambulance (NSWA) paramedics arrived at the scene a short time later, AAB was taken to hospital where resuscitation efforts continued. However, AAB could not be revived and was later tragically pronounced life extinct.

2. Why was an inquest held?

2.1 Under the Coroners Act 2009 (the Act) a Coroner has the responsibility to investigate all reportable deaths. This investigation is conducted primarily so that a Coroner can answer questions that are required to be answered pursuant to the Act, namely: the identity of the person who died, when and where they died, and what was the cause and the manner of that person’s death.

2.2 NSWPF officers have powers to detain persons suspected of having committed a criminal offence.

By depriving a person of their liberty, the NSWPF assumes responsibility for the care of that person as the person is unable to, for example, independently take steps to seek medical assistance. Section 23 of the Act makes an inquest mandatory in cases where a person dies whilst in lawful custody. In such cases the community has an expectation that the death will be properly and independently investigated to ensure that NSWPF officers have exercised the lawful powers available to them in a reasonable and appropriate way.

2.3 In AAB’s case, after the quantity of white powder was found on his person he was detained at the scene, no longer free to leave, and therefore in the lawful custody of the NSWPF officers present.

AAB’s death whilst he was in such custody makes an inquest mandatory.

2.4 Two things should be noted at the outset. First, section 23 of the Act also makes an inquest mandatory in circumstances where a person has died as a result of police operations. Whilst the detainment of a person in lawful custody is regarded as a NSWPF operation, there is no evidence that AAB died as a result of such a NSWPF operation on 25 April 2023. Second, there is no suggestion that any NSWPF officer involved in this matter exercised the lawful powers available to them in anything other than a reasonable and appropriate away.

2.5 Separate from the above, it should also be recognised that the operation of the Act, and the coronial process in general, represents an intrusion by the State into what is usually one of the most traumatic events in the lives of family members who have lost a loved one. At such times, it is reasonably expected that families will want to grieve and attempt to cope with their enormous loss in private. That grieving and loss does not diminish significantly over time. Therefore, it should be acknowledged that the coronial process and an inquest by their very nature unfortunately compels a family to re-live distressing memories several years after the trauma experienced as a result of a death, and to do so in a public forum. This is an entirely uncommon, and usually foreign, experience for families who have lost a loved one.

3. AAB’s life 3.1 Inquests and the coronial process are as much about life as they are about death. A coronial system exists because we, as a community, recognise the fragility of human life and value enormously the preciousness of it. Understanding the impact that the death of a person has had on those closest to that person only comes from knowing something of that person’s life. Therefore, it is important to recognise and acknowledge the life of that person in a brief, but hopefully meaningful, way.

3.2 AAB was born on 20 May 1996 in New Zealand. He had a younger brother. When AAB was a young child the family moved to Australia.

3.3 AAB attended Hurstville South Primary School and later Blakehurst High School where he completed Year 12 in 2013. AAB began tertiary studies at TAFE but later attended the University of Western Sydney where he studied animal science. After about a year, AAB transferred to the University of Technology Sydney but did not eventually complete his degree.

3.4 After leaving university, AAB worked at a variety of different jobs, and in 2021 he began working at the American Insurance Association. AAB’s manger and colleagues described him as intelligent, a quick learner, and with much potential.

3.5 Regrettably, little else is known about AAB’s life, other than he was particularly close to his mother.

There is little doubt that AAB’s sudden and untimely death has been deeply felt by his family and loved ones, and that the enormity of his tragic loss has caused them immeasurable grief.

4. AAB’s medical history 4.1 In 2019, AAB commenced frequent drug use (cocaine, 3,4-Methylenedioxymethamphetamine, cannabis and alprazolam) and experienced issues associated with alcohol abuse. In 2021, AAB began suffering from a sleep disorder and he reported to his general practitioner (GP) that he had been consuming 16 standard drinks a night for 18 months. In May 2022, AAB reported to a different GP that he was binge drinking (15 drinks a night) each week.

4.2 On 15 February 2020, NSWPF officers were called by one of AAB’s neighbours to attend AAB’s home.

AAB had consumed alcohol, cocaine and alprazolam and reported hearing noises from his parents’ bedroom even though they were not home. He had also taken a large kitchen knife and locked himself in his brother’s bedroom before climbing onto a balcony and asking his neighbour for help.

When NSWPF officers arrived, AAB ran at them with the knife but was disarmed and handcuffed. He was later arrested, charged, convicted and sentenced on 18 May 2020.

4.3 In 2020, AAB was referred to a psychologist and attended five sessions. It was noted that AAB’s anxiety and depression had intensified, and that he reported hallucinations, paranoia, and disassociation from reality.

4.4 On 24 January 2021, AAB again armed himself with a large kitchen knife and attempted to stab himself after consuming a quantity of alcohol. AAB’s mother contacted the NSWPF and officers attended the home. AAB was taken by ambulance to St George Hospital where he was involuntarily detained. Following assessment, AAB was discharged with counselling provided regarding alcohol abuse and advice to follow up with his GP in relation to chronic health issues associated with alcohol abuse.

4.5 In March 2021, AAB was prescribed amitriptyline for his sleep disorder and his previous medication, escitalopram, was ceased.

4.6 Between February and July 2021, AAB attended eight sessions with another psychologist.

5. The events of 24 April 2023 5.1 On 24 April 2023, AAB’s mother drove him to work. According to one of his colleagues, AAB appeared very excited, and said that he was meeting friends after work, staying in the city, and was planning to go drinking and take drugs.

5.2 After leaving work, AAB went home and then made his way into the city at around 9:00pm. Travel and mobile phone records indicate that AAB visited several locations within the Sydney CBD until 3:23am. From there, mobile phone records indicate that AAB remained in the vicinity of the Spanish Quarter, although his precise movements during this period are unknown.

6. The events of 25 April 2023 AAB’s arrival at the YEHS Hotel 6.1 At 8:00am on 25 April 2023, AAB attempted to check into the YEHS Hotel (the Hotel) but was informed that the Hotel was at capacity, and asked to return at midday. AAB left and went to a nearby licensed premises where he consumed three beers.

6.2 At 12:27pm, AAB returned to the Hotel, checked in and was allocated to Room 505. Between 5:17pm and 5:33pm, CCTV cameras in the vicinity of Room 505 captured AAB entering and exiting the room multiple times, having trouble opening the door to his room on occasion, wandering the corridor, appearing to be unsteady on his feet and confused, and appearing to be speaking into a television remote.

AAB’s behaviour at the Hotel 6.3 At around 5:36pm, AAB returned to the Hotel lobby and approached the reception desk where he spoke to Hotel staff. One staff member observed that AAB had red eyes and showed paranoid behaviour by asking whether someone had come to his room, and formed the view that AAB was affected by a substance or substances. At around 5:43pm, AAB was captured by CCTV cameras to be unsteady on his feet and appearing to be confused.

6.4 A short time later, AAB walked out of the Hotel and stood near the entrance, looking back inside. He was captured by CCTV cameras to be talking to himself, pacing up and down, and placing the television remote he was still holding up to his ear as if it was a phone. Witnesses observed that AAB was moving and making hand gestures in a manner which gave the impression that he was intoxicated or hallucinating.

6.5 AAB remained in this location for about 10 minutes and continued behaving in the same manner. At one point a Hotel staff member approached AAB and asked if he could return the television remote.

AAB gave an incomprehensible reply.

6.6 At around 5:54pm, AAB stumbled and fell, impacting with some glass panelling at the front of the Hotel. AAB did not get up and sat on the ground. A hotel staff member checked on him and later called the NSWPF, describing AAB to have red eyes, to be acting strangely and appearing to be drugaffected. This information was broadcast over NSWPF radio at 5:55pm. AAB remained seated on the ground where he was observed to be rocking back and forth.

Attendance of NSWPF officers 6.7 A short time later, Sergeant Ross Nichols and Constable Kirby Wilson came across AAB whilst on their way to conduct a business inspection at a nearby premises. Both NSWPF officers spoke to a Hotel staff member who described AAB’s unusual behaviour. At the time, AAB was sitting in the middle of the footpath, obstructing passers-by, whilst still holding the television remote and talking to himself.

Sergeant Nichols, having earlier heard the NSWPF radio broadcast, concluded that AAB was the subject of the broadcast.

6.8 Sergeant Nichols and Constable Wilson attempted to persuade AAB to stand up although initially it was difficult to get his attention. Eventually, AAB began to stand up but then sat back down again.

Constable Wilson observed that AAB’s eyes were glazed over and that his movements and behaviour were erratic. Sergeant Nichols formed the view that AAB was under the influence of a substance or substances. Both NSWPF officers found it difficult to engage AAB in conversation.

6.9 At around 5:58pm, both NSWPF officers toook hold of AAB’s arms, lifted him up off the ground and assisted him into the Hotel. CCTV cameras captured AAB to stumble and appear to be unsteady on his feet. AAB was assisted to some seats in front of the reception desk. At this time, Sergeant Nichols formed a suspicion, from AAB’s demeanour and behaviour, that he may be in possession of prohibited drugs. Accordingly, both NSWPF officers searched AAB. Constable Wilson found several clear resealable plastic bags with one containing white-coloured powder, one containing whitecoloured powder residue, and the rest empty.

6.10 At around 6:03pm, Sergeant Nichols used his police radio to confirm that he and Constable Wilson were dealing with the earlier NSWPF radio broadcast relating to AAB, to request that some checks be performed regarding AAB, and to request other NSWPF officers to attend to supply a drug security bag. By this time, AAB was sitting on a couch near the reception desk. Sergeant Nichols told AAB he was being detained but did not place him under arrest. Both Sergeant Nichols and Constable Wilson considered that AAB was not free to leave and therefore he was in the lawful custody of the NSWPF officers from this time onwards.

AAB’s seizure activity 6.11 At around 6:16pm, AAB began to convulse, rocking back and forth, and waving his arms, before stopping. CCTV cameras captured Constable Wilson to place his left foot on AAB’s right foot, and then place his left hand to the right side of AAB’s face as AAB’s head moved towards the wooden frame of the seat he was sitting on. AAB subsequently fell to the floor and continued to exhibit uncontrollable seizure-like behaviour.

6.12 At around 6:17pm, Sergeant Nichols called for an ambulance using his radio. He reported that AAB was conscious, breathing but not responding to any communication, “drug-induced”, and “going into a seizure”. Constable Wilson rolled AAB onto his right side and placed him in the recovery position. AAB’s seizure-like activity continued for around five minutes before ceasing at around 6:20pm. Sergeant Nichols leaned towards AAB, to check his pulse, and Constable Wilson also made periodic checks of AAB’s pulse and whether he was breathing.

6.13 At around 6:21pm, Sergeant Nichols used a Hotel phone to speak to a NSWA dispatcher. He reported that AAB was likely drug-affected, and that his breathing was “a bit laboured and shallow”.

6.14 At around 6:25pm, Senior Constable Alan Alphonso and Constable Marcel Hammer arrived at the Hotel, carrying a set of scales and the drug security bag that had earlier been requested by Sergeant Nichols. The four police officers at the scene had a brief conversation about none of them being equipped with a Body Worn Video camera due to there being limited resources because it was Anzac Day. At this time, AAB remained lying on the ground in the recovery position, not moving.

AAB’s sudden deterioration 6.15 At around 6:27pm, Sergeant Nichols and Constable Wilson both looked down at AAB and noticed that he appeared to be not breathing. Sergeant Nichols checked AAB’s pulse and found none, or any other signs of life. Sergeant Nichols immediately commenced chest compressions whilst Constable Hammer used his radio to request that the attendance of paramedics be expedited and that additional NSWPF officers attend the scene, and that resuscitation of AAB was in progress.

6.16 NSWA paramedic Max Marshall and probationary paramedic Lucinda Smillie arrived on scene a short time later. Paramedic Marshall asked the NSWPF officers to continue cardiopulmonary resuscitation (CPR) whilst he and Paramedic Smillie set up their equipment, including an Automatic External Defibrillator (AED). However, as AAB was subsequently found to have a non-shockable rhythm the AED was not utilised. Instead, a Laryngeal Mask Airway (LMA) was placed over AAB’s mouth as

resuscitation efforts continued. Following the arrival of intensive care paramedics at around 6:38pm, a decision was made to replace the LMA with an endotracheal tube. A cannula was also inserted and AAB was given eight bolus doses of adrenaline together with intravenous fluids.

6.17 At around 6:55pm, a Lund University Cardiopulmonary Assist System (LUCAS) device was applied to deliver automatic chest compressions to AAB, whilst a nasogastric tube was also inserted. At around 7:12pm, AAB was placed into an ambulance to be transferred to St Vincent’s Hospital. By this stage, AAB was still in cardiac arrest, in asystole and with no return of spontaneous circulation.

6.18 At around 7:20pm, AAB arrived at St Vincent’s Hospital. Resuscitation efforts, including chest compressions, artificial ventilation and administration of adrenaline intravenously, continued.

However, after about 10 minutes it was determined that AAB’s condition was incompatible with life and that continued resuscitation efforts would be futile. Resuscitation was ceased and AAB was pronounced life extinct at 7:35pm.

7. Police investigations 7.1 On the evening of 25 April 2023, NSWPF officers searched Room 505 and found some white powder on the bed inside the room, and on the floor of the bathroom. The powder was later analysed and found to be cocaine.

7.2 Also on the evening of 25 April 2023, the NSWPF declared the circumstances of AAB’s death to be a Critical Incident. A Senior Critical Incident Investigator, Detective Chief Inspector Gavin Beck, was appointed and a Critical Incident Investigation Team assembled to investigate the circumstances of AAB’s death and the conducted of a number of NSWPF officers who were identified as directly involved officers.

8. The post-mortem examination 8.1 AAB was subsequently taken to the Department of Forensic Medicine where a post-mortem examination was performed by Dr Lena Quinto, forensic pathologist trainee, on 27 April 2023. This examination identified the following relevant findings:

(a) haemopericardium and rib and sternal fractures consistent with injuries associated with resuscitation;

(b) an enlarged heart with mildly enlarged myocytes but a normal architecture;

(c) aspiration and blood in the large and small airways;

(d) no evidence of subarachnoid haemorrhage or acute traumatic injury following neuropathological examination; and

(e) toxicological analysis identified a blood alcohol level of 0.137 g/100m (expected to result in some degree of intoxication), a lethal level of cocaine and its metabolites, and a non-toxic concentration of levamisole, a common adulterant added to cocaine. with low levels of diazepam and its active metabolite.

8.2 In the autopsy report dated 24 August 2023, Dr Quinto opined that the cause of Mr AAB’s death was acute cocaine and alcohol toxicity.

8. Expert evidence 9.1 As part of the coronial investigation, the following three independent experts were instructed to provide reports addressing a number of questions regarding the circumstances of AAB’s death:

(a) Professor Mark Cook, neurologist and epileptologist, and Director of the Neurology Unit at St Vincent’s Hospital, Melbourne;

(b) Professor Anne-Maree Kelly, senior emergency physician and Academic Head of Emergency Medicine at Western Health, Footscray, Victoria; and

(c) Dr Alex Wodak AM, Emeritus Consultant, Alcohol and Drug Service, St Vincent’s Hospital, Sydney.

9.2 Each of the experts was asked to address a number of specific questions posed to them covering several different topics arising from the circumstances of AAB’s death. Each expert prepared a report answering the questions posed.

AAB’s behaviour at the Hotel 9.3 Professor Kelly considered that AAB’s behaviour was consistent with cocaine toxicity because he appeared to be exhibiting confusion, paranoia and unsteady gait. Professor Cook similarly considered that the course of AAB’s behaviour – from consciously interacting with the NSWPF officers to suffering a series of epileptic convulsions and then going into cardiorespiratory arrest – was “consistent with cocaine intoxication and well described in the literature”. Professor Cook further explained that there is no evidence that AAB had a pre-existing medical condition or disorder that made him more susceptible to experience a seizure on 25 April 2023.

9.4 Dr Wodak explained that the symptoms of acute cocaine toxicity can include agitation, flushed, anxiousness, rapid pulse, dilation of pupils, high blood pressure and loss of contact with reality (for example, psychosis). Dr Wodak also considered that AAB’s presentation and behaviour was consistent with someone suffering from cocaine toxicity, “but not specifically consistent with someone suffering from cocaine toxicity”. This distinction is important because, to an observer, there may have been other explanation for AAB’s behaviour other than he was drug affected. As Dr Wodak noted, it would be “asking a lot” of Hotel staff and the attending NSWPF officers “to assume that they could recognise what was happening”.

Response of the NSWPF officers to AAB’s presentation 9.5 Professor Kelly expressed the view that the initial response of Sergeant Nichols and Constable Wilson when AAB was exhibiting symptoms of cocaine toxicity was reasonable. At this stage, Professor Kelly considered that AAB was not obviously unwell and in need of medical attention, and that AAB’s behaviour did not pose any risk to himself or to others.

9.6 Professor Kelly opined that it was reasonable for Sergeant Nichols and Constable Wilson to take a short time to conclude that AAB was experiencing a seizure. Professor Kelly explained that this is because it can be difficult for people who are not clinicians to be sure whether a person is having a seizure. Dr Wodak expressed the view that numerous other drugs could have caused AAB’s presentation and behaviour, and that “a person who becomes increasingly confused and then begins to have epileptic seizures also occurs to some people without drugs”.

9.7 Professor Cook similarly noted that both NSWPF officers were understandably initially uncertain “whether the episode they were witnessing was organic” but that they quickly appreciated that the situation was serious.

9.8 Once Sergeant Nichols and Constable Wilson reached this view, Professor Kelly considered that they acted reasonably, and in accordance with prevailing guidelines, by:

(a) trying to prevent AAB from hitting his head;

(b) promptly calling for an ambulance when AAB did not regain consciousness and had further seizures;

(c) monitoring AAB’s condition, especially his breathing, prior to the arrival of paramedics;

(d) identifying that AAB had stopped breathing; and

(e) initiating CPR.

9.9 Professor Kelly also explained that placing AAB in the recovery position is consistent with the Australian and New Zealand Committee on Resuscitation seizure guideline.

9.10 Professor Kelly noted that the attempt by the NSWPF officers to pull AAB into a sitting position at around 6:18pm was inconsistent with prevailing guidelines but acknowledged that it may have been done to prevent AAB from injury by coming into contact with nearby furniture. Professor Kelly went on to note that this lasted only 30 seconds and that it is “very unlikely to have had any bearing on the outcome”.

9.11 Professor Cook also expressed the view that the NSWPF officers acted appropriately in placing AAB on his side to protect his airway, not restraining him, moving away objects that might cause injury, calling for an ambulance and not attempting CPR. As to this last matter, Professor Cook explained that there was no indication that AAB required CPR at this stage and that it is often mistakenly thought that people having convulsive seizures require CPR, which can cause injury. Overall, Professor Cook expressed this view regarding the conduct of the NSWPF officers: I would say that the behaviour of the police officers present was exemplary, they acted quite appropriately in the circumstances, and quickly appreciated the nature of the situation. Their interventions were prompt and followed established guidelines. They seem to have had the highest regard for the safety of [AAB] at all times. There is often a little uncertainty when people observe the

onset of seizure activity, even by medical and nursing staff, especially when it is superimposed on altered behaviour related to intoxication particularly, so the momentary hesitation they exhibited identifying the nature of the situation is not unexpected.

Adequacy of the resuscitation efforts 9.12 Professor Kelly expressed the view that the resuscitation efforts conducted by the NSWPF officers on the scene were “timely, adequate and appropriate”. Professor Kelly explained that it was reasonable for the NSWPF officers to conduct chest compression only, and not deliver rescue breaths, as AAB was a known drug user and “his body-fluid-borne infection status was unknown and could pose a serious risk to their health”. Professor Kelly also explained that in out-of-hospital cardiac arrest, “chest compression only CPR has been shown to have similar effectiveness to CPR plus rescue breaths”.

9.13 Finally, Professor Kelly considered that the resuscitation efforts of the NSWA paramedics was also timely, adequate and appropriate, and consistent with prevailing advanced cardiac life support guidelines, and that it was reasonable to deploy the LUCAS device and transfer AAB to hospital.

10. Conclusions 10.1 After considering all of the evidence gathered from the coronial investigation, no organisation or individual was identified as having a sufficient interest in the subject matter of the coronial proceedings in accordance with section 57(1) of the Act. Accordingly, neither the Commissioner of the NSWPF or any individual NSWPF officer was considered to be a sufficiently interested party in the inquest.

10.2 Similarly, unlike most other inquests, the inquest did not consider any discrete issues other than the statutory requirements pursuant to section 81 of the Act. This is because the totality of the evidence gathered during the coronial investigation, and in particular the consensus of the expert evidence, did not suggest that any aspect of AAB’s death, including the conduct of NSWPF officers, NSWA paramedics and Hotel staff, warranted specific examination or consideration.

10.3 That said, as an inquest is mandatory, and because the circumstances of AAB’s death was declared to be a NSWPF Critical Incident, it is appropriate to give some consideration to the conduct of a number of NSWPF officers who attended the Hotel on 25 April 2023 and interacted with AAB.

10.4 Having regard to the above, the available evidence establishes the following:

(a) Having regard to the white powder found on AAB’s person and the white powder found on the bed and bathroom floor of Room 505 (which was later identified as cocaine), it is most likely that AAB self-administered a quantity of cocaine prior to making his way to the Hotel foyer;

(b) Whilst AAB’s presentation and behaviour at the Hotel on the evening of 25 April 2023 was consistent with cocaine toxicity, it would not have been apparent to either attending NSWPF officers or Hotel staff that this was the only explanation for his behaviour;

(c) AAB’s presentation when he was first spoken to by NSWPF officers gave no indication that he was at imminent risk of a sudden medical event;

(d) Whilst Sergeant Nichols and Constable Wilson considered that AAB was under the influence of a substance or substances, AAB was not displaying any signs or symptoms that suggested he required urgent medical attention;

(e) It is understandable that Sergeant Nichols and Constable Wilson did not immediately recognise AAB’s seizure activity once it commenced, and any delay can be described as only “momentary hesitation”;

(f) However, once Sergeant Nichols and Constable Wilson correctly recognised the seriousness of the situation and AAB’s condition they took appropriate steps to keep AAB safe, monitor his breathing, and call for emergency medical services;

(g) Although the attempt made by Sergeant Nichols and Constable Wilson to move AAB into a sitting position was not in accordance with applicable guidelines, this appears to have been done to prevent AAB from injuring himself and there is no evidence to suggest that it materially affected the eventual outcome; and

(h) Sergeant Nichols and Constable Wilson correctly recognised that AAB had stopped breathing and become unresponsive, and initiated resuscitation efforts in a timely and appropriate manner. The resuscitation efforts provided by NSWA paramedics was equally timely and appropriate.

10.5 Overall, the evidence establishes that each of the NSWPF officers directly involved in AAB’s detainment on 25 April 2023, and in his subsequent deterioration and cardiac arrest, acted reasonably and appropriately, and with the intention of keeping AAB safe and preserving his life.

9. Findings 9.1 Before turning to the findings that I am required to make, I would like to acknowledge, and express my gratitude to Ms Juliet Curtin, Counsel Assisting, and her instructing solicitor, Ms Imogen Pearson from the Crown Solicitor’s Office. I am most appreciative of the assistance that they have provided throughout all stages of the coronial process, their thoroughness and diligence, and the sensitivity and empathy that they have shown, particularly in their communication and interactions with AAB’s family.

9.2 I also thank Detective Chief Inspector Beck for his role in conducting a comprehensive Critical Incident investigation and, Detective Sergeant Tom Zervas, the NSWPF Officer-in-Charge, for his role in the investigation and compiling the brief of evidence.

9.3 The findings I make under section 81(1) of the Act are: Identity The person who died was AAB.

Date of death AAB died on 25 April 2023.

Place of death AAB died at St Vincent’s Hospital, Darlinghurst NSW 2010.

Cause of death The cause of AAB’s death was acute cocaine and alcohol toxicity.

Manner of death AAB died whilst in the lawful custody of the New South Wales Police Force following a period of altered behaviour with features suggesting paranoia as a result of cocaine and alcohol intoxication, followed by a series of convulsive seizures terminating in cardiorespiratory arrest from which he could not be resuscitated.

9.4 On behalf of the Coroners Court of New South Wales, I offer my sincere and respectful condolences, to AAB’s family, and in particular, AAB’s parents and brother, for their most tragic loss.

9.5 I close this inquest.

Magistrate Derek Lee Deputy State Coroner 7 November 2024 Coroners Court of New South Wales

Inquest into the death of AAB Coroner’s Court File Number: 2023/132562 Appendix A: Pseudonym order

1. Pursuant to the Court’s implied or incidental powers, AAB shall be referred to by the pseudonym “AAB”.

Magistrate Derek Lee Deputy State Coroner 7 November 2024 Coroners Court of New South Wales