Inquest into the death of Jamie Brian Campbell

CORONERS COURT OF QUEENSLAND FINDINGS OF INQUEST CITATION: Inquest into the death of Jamie Brian Campbell TITLE OF COURT: Coroners Court

JURISDICTION: BRISBANE FILE NO(s): 2021/1200 DELIVERED ON: 31 March 2025

DELIVERED AT: BRISBANE HEARING DATES: 19 – 20 December 2023, written submissions February 2024 – April 2024 FINDINGS OF: Terry Ryan, State Coroner CATCHWORDS: Coroners: inquest, police restraint, ambulance, amphetamine use, administration of sedative during restraint, droperidol, monitoring post sedation, hypoxic ischaemic encephalopathy, cardiac arrest, sympathomimetic toxicity, veteran.

REPRESENTATION: Counsel Assisting: Ms J Pietzner-Hagan Commissioner of Police: Ms E Cooper, Counsel instructed by QPS Legal Unit QPS Officers: Mr C Gnech, Gnech & Associates Critical Care Paramedic Reus: Ms S Robb KC, Counsel instructed by Corrs Westgarth Chambers

Advanced Care Paramedic Palmer: Ms AC Freeman KC, Counsel instructed by Gilshenan & Luton Qld Ambulance Service, Advanced Care Paramedic Ames & Professor Stephen Rashford: Ms D Callaghan, Counsel instructed by QAS Legal Findings of the inquest into the death of Jamie Brian Campbell Page 1 of 28

Contents The actions of the Queensland Ambulance Service (‘QAS’) officers in The monitoring by QAS officers of Mr Campbells health status following the Whether the training provided to Ambulance officers to respond to like incidents is Whether the Police officers involved complied with the Queensland Police Service

Introduction [1] Jamie Brian Campbell was aged 43 when he died in the Intensive Care Unit (ICU) at The Prince Charles Hospital (TPCH) on 17 March 2021. He had been transferred to TCPH following an attendance by police and ambulance officers at the Eatons Hill Hotel in the early hours of 14 March 2021.

[2] The post-mortem examination found Jamie had died from “Hypoxic ischaemic encephalopathy, due to or as consequence of, cardiac arrest of unknown cause.” [3] Detective Sergeant Theresa Downey, of the Internal Investigations Group (IIG), Ethical Standards Command (ESC) led the coronial investigation. Det Sgt Downey’s coronial report included witness statements, digital recordings, and medical records.

[4] Records obtained during the coronial investigation indicated that Jamie served in the Royal Australian Navy from 16 January 1995 to 31 October 1997. He had a history of severe depression and anxiety, and PTSD following a workplace injury. He also had a history of cannabis and methylamphetamine dependence. He had been admitted to a residential drug and alcohol rehabilitation program in September 2020.

The Inquest [5] Jamie’s death was a reportable death under s 8(3)(h) of the Coroners Act 2003 (the Act) as the death occurred in the course of a police operation. The Act presumes that an inquest will be held in relation to these deaths unless the coroner is satisfied that the circumstances do not require an inquest.

[6] The primary purpose of an inquest is to inform the family and the public about the matters required by s 45 of the Coroners Act 2003, including when, where and how the person died and what caused the death. A coroner may also comment on ways to prevent deaths from happening in similar circumstances in the future.

[7] A coroner is not able to include in the findings or any comments or recommendations any statement that a person is, or may be, guilty of an offence or civilly liable. Where a coroner suspects that an indictable offence has been committed, a referral must be made to the Director of Public Prosecutions.

[8] Information about a person’s conduct in a profession can be given to the disciplinary body for that profession if the coroner believes the information might cause the body to inquire into or take steps in relation to the conduct.

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[9] Following a pre-inquest conference on 2 August 2023, the Inquest was held in Brisbane from 19 to 20 December 2023. Oral evidence was heard from eight witnesses:

• Sergeant Gregory Crockett

• Senior Constable Daniel Baulderstone

• Detective Sergeant Theresa Downey

• Advanced Care Paramedic Kate Palmer

• Advanced Care Paramedic Robert Ames

• Critical Care Paramedic Darren Reus

• Associate Professor Katherine Isoardi, Emergency Physician and Clinical Toxicologist

• Professor Stephen Rashford, Emergency Physician and Medical Director, QAS.

[10] The issues for inquest were settled as:

1. The findings required by s. 45(2) of the Coroners Act 2003 (Qld); namely the identity of the deceased, when, where and how he died and what caused his death.

2. The circumstances surrounding the death including the reasonableness of: a. The actions of the Queensland Ambulance Service (‘QAS’) officers in administering Droperidol to Mr Campbell.

b. The monitoring by QAS officers of Mr Campbells health status following the administration of Droperidol.

3. Whether the Ambulance officers involved complied with the QAS policies and procedures then in force.

4. Whether the training provided to Ambulance officers to respond to like incidents is appropriate.

5. Whether the Police officers involved complied with the Queensland Police Service (‘QPS’) policies and procedures then in force.

6. Whether any preventative changes to procedures or policies could reduce the likelihood of deaths occurring in similar circumstances or otherwise contribute to public health and safety or the administration of justice.1 [11] Following the Inquest, written submissions were received between February 2024 and April 2024.

1 The issues for inquest were amended, without objection. 19 December 2023, T 1-3, L 10.

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[12] I am satisfied there is sufficient evidence to make the findings required by s 45 of the Coroners Act.

The Evidence [13] On Saturday, 13 March 2021, Jamie went to the Eatons Hill Hotel with a female acquaintance, who checked into room 104 in the hotel’s accommodation section at around 10:30pm.2 Jamie went to a nearby kebab shop before returning to wait for his friend on the driveway of the hotel. They had spent the day together. Jamie had indicated he wanted to go to Newcastle.

He was behaving erratically during the day and had consumed Ice. He had unsuccessfully tried to hire a car at the Brisbane airport to drive to Newcastle.

[14] At around 11:11pm, Jamie spoke with the duty manager Ashwin Prasad. Jamie was denied entry to room 104 because he had no proof of identification and was not a registered guest.3 [15] Around 11:23pm, Queensland Police Service (QPS) officers Sergeant Gregory Crockett and Senior Constable Daniel Baulderstone were patrolling around the Hotel. The officers conducted a street check of Jamie, who consented to a pat down search. No items of interest were found. The officers also spoke to the woman Jamie was with. Those interactions were captured by the officers’ body worn cameras.4 [16] Sergeant Crockett’s observation of Jamie was that he appeared: ‘Quite lucid. He was talking to us. He could answer questions. He provided reasonable answers’… ‘He didn’t – seem to be in any sort of medical distress or reason that we could either detain or arrest him, because he had no outstanding matters. He was allowed to go on his way.’ 5 [17] Senior Constable Baulderstone’s observation of Jamie was that he appeared to have a ‘muscular sort of twitch and an elevated sort of disposition.’ 6 Senior Constable Baulderstone considered that Jamie may have been affected by some substance.7 [18] Around 11:28pm, the woman and Jamie were allowed to enter room 104 together.8 They told hotel staff they were siblings and wanted to go to the room together because their mother had passed away and they wanted to have a coffee and arrange for her funeral.

2 An order prohibiting the publication of the name was made under s 41 of the Coroners Act 2003 3 Exhibit D18.

4 Exhibit A6, 3. Exhibit B3. Exhibit D1. Exhibit D2. Exhibit D26.

5 Exhibit B6.1 at [133]. 19 December 2023, T 1-6, L 43.

6 Exhibit B7.1 at [116].

7 19 December 2023, T 1-18, L 24.

8 Exhibit A6, 3.

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[19] On Sunday, 14 March 2021, around 01:55am, Jamie exited room 104 with a towel around his waist. CCTV recorded him walking a short distance down the hallway before returning to the room.9 [20] At 02:07am the duty manager, Mam Sarkar10 was conducting a “floor walk” when she heard banging and screaming from room 104. Ms Sarkar tried calling room 104 from the reception desk and returned to the room with security staff at 02:16am.11 The woman with Jamie answered the door and Ms Sarkar observed damage inside the room, before the woman quickly closed the door and refused entry. As a result, hotel staff requested police assistance.12 [21] At around 02:25am, Sergeant Crockett and Senior Constable Baulderstone entered room 104 with hotel staff, after security staff requested an inspection of the room.13 The woman known to Jamie allowed entry and told police that Jamie was ‘having a mental breakdown.’ The body worn camera footage captured sounds of banging and a shower running. Sergeant Crockett and Senior Constable Baulderstone attempted to gain collateral information from the woman and asked if Jamie ‘had taken anything.’ The woman told police that it was ‘just mental health.’ 14 [22] Police saw Jamie in the bathroom, naked, writhing around on the floor. The shower was running, there was significant damage to the bathroom, including holes in the walls and smashed tiles. The towel rail had been ripped from the wall. There was an iron cord loosely wrapped around Jamie’s leg and torso.

[23] At 02:31am Sergeant Crockett and Senior Constable Baulderstone entered the bathroom and removed the cord and iron and turned the shower off. They gave verbal instructions to Jamie to stay on the ground. Jamie continued to writhe around on the floor, at points flailing his arms while briefly on his back, before kicking his legs. Jamie made brief verbal, incoherent grunting noises. Jamie did not appear to have control of his bodily movements.15 [24] Senior Constable Baulderstone described his observations of Jamie: ‘He was clearly having a fairly serious psychotic – I don’t know – deliriumrelated issue’… he was clearly hyped up on something. I’ve seen – in my time in the job, I’ve seen a variety of issues. I’m not medically trained. His muscles were tight; he was thrashing violently. He was moving at a rate and just flailing around with considerable sort of force… He was moving towards the doorway, then on the ground, and had been kind of rolling – you know, had large muscle movements as he was coming towards the door. I took out my handcuffs, grabbed the right arm, which was up, and cuffed that right arm. I gave verbal commands to provide the other arm.

9 Exhibit D29.

10 Exhibit B4 11 Exhibit D29.

12 Exhibit B4. Exhibit A6, 3.

13 Exhibit D29.

14 Exhibit D3.

15 Exhibit D3. 19 December 2023, T 1-18, L 40.

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He wasn’t able to exactly, but I was able to reach across his body from a kneeling position and grab that arm, bring it to the front and cuff him’.16 ‘He wasn’t actively resisting, and he seemed to understand what I was saying, but because of the state he was in, it didn’t seem like he had full control of his body…I thought there was a need to physically restrain him to prevent him from hurting himself or anyone else, and I was aware I didn’t want to inhibit his breathing… His teeth were making, like, the loudest sort of gnashing noise I’ve ever heard. You know, his head was still banging on the ground and there was a real risk of danger of biting and that sort of stuff.’ 17 [25] Sergeant Crockett’s observations of Jamie in the bathroom were as follows: ‘Lying on his back on the floor with sort of almost, like, a glazed look on his face, and he’s spinning around like the hands on a clock if someone was manipulating them. He would spin from back to front.’ 18 ‘We can’t leave him like that. We’ve got to do something. He’s going to injure himself. The hotel room’s iron is in there, and the extension cord was sort of wrapped around his leg and torso. Depending on what way he spun on the floor, it would tangle around his arm as well… I thought he was having some sort of drug-induced psychosis episode, for want of a better term, because he just didn’t seem like he was consciously present with us. His eyes were open. He was breathing. He was making grunts, words which were unintelligible to me, but he was not unconscious in any way, shape or form, and his movements seemed very rapid, very quick, and not as sort of jerky as I have said before.’ 19 [26] At 02:33am, two more police officers arrived. At 02:44am, one of the officers requested that the Queensland Ambulance Service (QAS) attend urgently.20 [27] Jamie eventually moved towards the door of the bathroom and offered his arms up to police to be handcuffed by Senior Constable Baulderstone. QPS officers told Jamie they were getting an ambulance. They asked Jamie if he had taken anything today and he responded ‘no’. Jamie was rotated onto his side by the officers and held in place to prevent him from hurting himself further. The QPS officers were mindful of Jamie’s breathing, and conscious that restraint by them could potentially inhibit his breathing.

[28] Jamie continued to speak and/or grunt incoherently and involuntarily writhed around on the floor while the officers cautiously restrained him to prevent Jamie from hurting himself further. The officers continued to speak to Jamie, giving verbal commands to ‘calm down’, while also communicating among themselves to co-ordinate their actions in restraining and monitoring Jamie’s breathing and positioning, while awaiting QAS arrival. 21 16 19 December 2023, T 1-19, L 10. Exhibit B7.1 at [94].

17 19 December 2023, T 1-19, L 31.

18 19 December 2023, T 1-7, L 35. Exhibit B6.1 at [139].

19 19 December 2023, T 1-8, L 15. Exhibit B6.1 at [542].

20 Exhibit B7.1 at [94]. Exhibit G1, 2.

21 Exhibit D4. Exhibit D3.

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[29] At 02:37am a QPS officer requested an update on QAS arrival and reported that Jamie was ‘heavily UID and having to be restrained from hurting himself.’ 22 Senior Constable Jeff Peate, Senior Constable Ian Matthews and Sergeant Darren Thomson also attended. 23 [30] Between 03:02am and 03:04am QAS officers, ACP Palmer, and ACP Robert Ames (Unit 501106) arrived on scene. Critical Care Paramedic (CCP) Darren Reus (Unit 506205) arrived soon after. 24 [31] QPS officers provided a briefing to the QAS officers and described Jamie as: ‘Male, mid-thirties, coming down off something, he’s just got anxiety, he’s been flipping out in here just smashing property, not verbally responsive, breathing is fine, but still struggling.’ [32] QAS officers asked the woman known to Jamie, what, if anything Jamie may have taken. Following searches of their QLite devices, Police told the QAS Officers that Jamie had a known history of drug use.25 [33] ACP Palmer was designated as the primary treating officer. ACP Palmer and ACP Ames made a decision to give Droperidol to Jamie to sedate him so that he could be moved from the room. The Droperidol was drawn up by ACP Ames. CCP Reus arrived before the first dose of Droperidol was administered.

CCP Reus agreed that a dose of Droperidol was clinically indicated.

[34] The timeline of the interactions between Jamie and the attending QAS officers was provided to the court by Prof. Stephen Rashford, Medical Director for the QAS.26 Within that timeline, Prof. Rashford made several observations of Jamie’s clinical presentation and the actions of the QAS officers in attendance.

[35] Prof. Rashford was assisted by members of the QAS Professional Standards Unit. He noted that he had the benefit of hindsight and his extensive medical experience to enable him to identify any shortfalls in the clinical care provided to Jamie.

[36] Submissions were made on behalf of Ms Palmer that the witnesses in attendance (both the QAS officer and QPS officers) were best positioned to assess when Jamie became unconscious, and that Prof. Rashford’s assessment was based on what he could hear from the patient on the camera footage.27 [37] I do not accept the submission that the evidence of the QAS and QPS officers regarding Jamie’s state of consciousness should be preferred over Prof.

Rashford’s evidence.

22 Exhibit D5.

23 Exhibit A6, 3-4.

24 Exhibit G1, 3.

25 Exhibit D3.

26 Timeline taken from the critical incident report prepared by the QAS professional standards unit.

27 Submissions on behalf of Kate Palmer at [9] - [15].

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[38] While I acknowledge that Prof. Rashford has extensive medical experience in comparison to the QAS officers in attendance, and that they were confronted with a dynamic and complex situation, they were in a position to assess Jamie’s level of consciousness if they had applied the knowledge and skills acquired in their training and made use of the equipment at their disposal.

[39] However, I accept it is possible that the “human factors” at play (as discussed at the Inquest) affected their assessment of the situation. I also accept that QPS officers are not trained clinicians, unlike the QAS officers.

[40] Counsel for CCP Reus submitted that CCP Reus did not recognise that Jamie was unconscious at the time Prof. Rashford was able to identify such from the body worn camera footage, and other first responders identified behaviour such as gnashing of teeth, clenching of fists and muscle stiffness as indications that Jamie was resisting and conscious as opposed to demonstrative symptoms of sympathomimetic toxicity due to a lethal combination of methamphetamine.

[41] Counsel for CCP Reus also submitted that the finding that Jamie was experiencing sympathomimetic toxicity due to a lethal combination of methamphetamine could only be arrived at having had regard to the trajectory of Jamie’s interaction with first responders (the duration and intensity of the experience), knowledge that he had a lethal amount of methamphetamine in his system, and the expert opinion of Dr Isoardi which were matters that were not known to the QAS or QPS officers on 14 April 2021.28 [42] While the QAS officers may not have been able to immediately assess that Jamie was experiencing sympathomimetic toxicity, they should have recognised that he was critically unwell. After he was sedated he required comprehensive monitoring and treatment, high flow supplemental oxygen and the application of airway support.

[43] I also do not accept the submission of Counsel for CCP Reus that the fact that the experts recognised Jamie was unconscious much earlier than the first responders present demonstrates the disconnection between the environment and expertise on the ground and that enjoyed by the experts.29 28 Submissions on behalf of Kate Palmer at [9] - [15].

29 Submissions on behalf of CCP Darren Reus at [12a].

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[44] I accept the following timeline and observations as detailed in the expert report of Prof. Rashford: Time Description 0308h Officer Palmer provides the QPS officers the plan regarding the administration of droperidol, into Mr Campbell’s arm. The narrative documents Mr Campbell to possess a Sedation Assessment Tool (SAT) score of ‘+3’. This would require Mr Campbell to be combative, violent, out of control, and/or, speech that involves continual loud outbursts.

Arguably, Mr Campbell at this point in time can be said to be combative and out of control. It is accepted that droperidol may be appropriate at this administration point.

However, Officer Palmer is seen to perform a grossly inadequate assessment of Mr Campbell at this point in time. For instance, the VSS reflects a respiratory rate of 36 breaths per minute with a normal depth. The BWC reveals the breaths are counted at over 50 breaths per minute and shallow. Officer Palmer does not appear to make this assessment in the BWC footage.30 0313h The QPS officer provides an update on Mr Campbell’s movements, describing them as ‘little twitches and half struggles, fading away to almost nothing’. Mr Campbell has made no verbal sound for some time, prior to the first administration of droperidol.

The QPS officer then provides that he’s ‘pretty happy now’ with Mr Campbell’s safety.

I would say with certainty, that according to the SAT score discussed above, Mr Campbell is a ‘-3’ and unconscious.

0316h Mr Campbell is heard groaning sporadically and his breathing remains rapid.

0318h A QPS officer is heard asking whether the QAS officers intend to take clinical observations on Mr Campbell. Officer Palmer responds that Mr Campbell is required to ‘calm down’ further before this is conducted.

Discussions also occur regarding a second dose of droperidol.

CCP Reus is heard advising that Mr Campbell will likely require a second dose. CCP Reus has made little to no attempt, from the BWC footage, to comprehensively assess Mr Campbell.

30 Ms Palmer gave evidence that she did undertake an assessment of Jamie’s respiratory rate but accepted after watching the footage post events, she incorrectly assessed Jamie’s respiratory rate. Submissions on behalf of Kate Palmer at [8c].

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0319h The eARF documents that at this time, Mr Campbell is breathing at a rate of 34 breaths per minute, with a normal depth. Further, a peripheral oxygen saturations (SpO2) measurement is also provided, of 99%.

The respiration rate is incorrect, Mr Campbell’s respirations were still 54 per minute and shallow.

No SpO2% was assessed, the Corpuls monitor was not powered on at this time.

0319h A second dose of droperidol is administered.

In my view, there are two issues with this administration. Firstly, it is a requirement to wait a 15-minute time period between two administrations, which did not occur. Secondly, at a minimum, to be indicated for droperidol Mr Campbell is required to be ‘very anxious and agitated’ and/or speaks with ‘loud outbursts’, forming a SAT score of at least ‘+2’.

Mr Campbell is neither, as he is unconscious. Droperidol is neither indicated nor appropriate.

0324h The extrication of Mr Campbell commences some five minutes – following the second dose of droperidol, which has not had time 0325h to take effect.

Mr Campbell is limp, makes no voluntary movement but groans as he is dragged from the hallway to the awaiting stretcher.

Mr Campbell is seen as he is lifted from the ground to the stretcher. He is deeply unconscious, pale and saturated in sweat.

His breathing is still rapid.

0326h According to the eARF, at this time, the following vital signs are – assessed: 0327h - Pulse rate (150);

• Respiratory rate (35);

- SPO2% (99);

• Capnography (CO2) (35);

- GCS5 (7/15).

From the BWC:

• I have seen no attempt to assess Mr Campbell’s GCS by any QAS paramedic. Further, Mr Campbell’s GCS is 3/15, the lowest possible score.

• Mr Campbell’s respiratory rate is 54 respirations per minute and shallow.

From the Corpuls data: Findings of the inquest into the death of Jamie Brian Campbell Page 11 of 28

• Other than capnography (CO2), no VSS were assessed.

0332h Officer Palmer is traveling in the patient care seat, in the back of the ambulance. QPS Officer Lawrenson is traveling backwards, behind Mr Campbell’s head. CCP Officer Reus is driving the ambulance, Code 2 (no lights and/or siren) to hospital.

According to the eARF, at this time, the following vital signs were assessed:

• Pulse rate (150);

• Blood Pressure (166/126);

• Temperature (40.2 oC);

• Electrocardiogram (ECG);

• Blood sugar levels (4.1);

• Respiratory rate (36);

• SpO2 (96%);

• Capnography (CO2) (35);

- GCS (7/15).

From the BWC:

• I have seen no attempt to reassess Mr Campbell’s GCS by any QAS paramedic. Further, Mr Campbell’s GCS is 3/15, the lowest possible score.

• Mr Campbell’s respiratory rate is 42 respirations per minute and shallow.

• A large traumatic marking is seen on Mr Campbell’s left forehead.

• Mr Campbell is significantly diaphoretic.

From the Corpuls data:

• The SpO2 reading was 70% and displayed a warning ‘!’ to alert the clinician.

0336h Officer Palmer identifies the Corpuls has provided an inaccurate blood pressure reading of 166/126. She reads this to CCP Officer Reus, who responds from the front of the ambulance, ‘if he’s got a heart rate and he’s breathing mate I reckon he has a blood pressure’.

Officer Palmer makes no effort to reassess a blood pressure again.

0340h According to the eARF, at this time, the following vital signs were assessed:

• Pulse (152);

• Respiratory rate (36);

- SPO2 (94%);

- GCS (7/15).

From the Corpuls data, the following heart rates were recorded by the monitor:

• 3.40 am: 142 beats per minute (bpm);

• 3.45 am: 95 bpm; Findings of the inquest into the death of Jamie Brian Campbell Page 12 of 28

• 3.50 am: 86 bpm.

Regarding the SpO2% documented at 3.40 am within the eARF, the monitor’s data revealed the readings were actually 71%, and displayed a ‘!?’ warning to the clinician.

Mr Campbell is certainly GCS 3/15 (deeply unconscious).

0345h The ambulance arrives at Prince Charles Hospital.

Officer Palmer places a mask over Mr Campbell’s face. Mr Campbell’s respirations are notably extremely shallow, at a rate of 35 breaths per minute.

The SpO2 at this point in time is 56% and displayed a warning ‘!?’ to the clinician.

[45] CCP Reus’ evidence at the Inquest was that he did not place an IV line as Jamie was still moving (if involuntarily) when he was placed in the ambulance.

CCP Reus did not travel in the back of the ambulance with Jamie and ACP Palmer as they were concerned Jamie may become agitated again. Senior Constable Lawrenson travelled in the back of the ambulance as a precaution.

His body worn camera footage recorded the actions of ACP Palmer during the transport. CCP Reus drove the ambulance, while ACP Ames followed in the CCP vehicle. During the transport, ACP Palmer was seated in the patient care seat.

[46] CCP Reus was unaware, consistent with the evidence provided by ACP Palmer at the Inquest, that ACP Palmer was vulnerable, had decompensated, and had stopped meaningfully participating in Jamie’s care.

[47] At 03:45am the Ambulance arrived at TPCH Emergency Department. While in triage, Jamie became apnoeic and went into cardiac arrest. Cardiopulmonary Resuscitation (CPR) was initiated and later ceased due to a return of spontaneous circulation. Jamie was intubated, sedated, and admitted to the ICU at TPCH.

[48] On Tuesday 16 March 2021, Jamie was found to have generalised cerebral oedema indicative of the development of diffuse ischaemic encephalopathy with cerebellar tonsillar herniation. While neurosurgical interventions were considered by the treating doctors, a determination was made that such interventions were not indicated. Following discussions with family, due to Jamie’s poor prognosis, life sustaining measures were withdrawn.

[49] On Wednesday 17 March 2021, Jamie was extubated at 4:49pm.31 He died at 5:21pm. 32 31 Exhibit A5, 25-26. Exhibit E6.

32 Exhibit A2.

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Autopsy results and cause of death [50] On 19 March 2021, staff specialist forensic pathologist, Dr Jessica Vidler conducted an autopsy examination. Dr Vidler issued a comprehensive autopsy report on 8 July 2022.33 [51] Dr Vidler concluded that Jamie’s initial cardiac arrest was likely due to a combination of multiple interacting factors. However, the contribution of each to the cardiac arrest cannot be determined. The contributory factors were listed as:

• ‘Excessive physical activity and agitation observed prior to restraint;

• Physical and psychological distress in the setting of restraint;

• Pre-existing natural disease (coronary atherosclerosis);

• Disease identified in the peri-arrest setting (rhabdomyolysis, abnormal electrolytes, metabolic derangement, bacteraemia); and

• The effects of drugs (methylamphetamine, droperidol).’ 34 [52] Toxicological analysis of ante-mortem blood samples confirmed the presence of Amphetamine (Detected <0.05mg/L), Methylamphetamine (1.6 mg/L), Droperidol (0.05 mg/L), and 11-nor-∆9-tetrahydrocannabinol-9-carboxylic acid (Detected). 35 [53] The Court commissioned an expert report from Emergency Physician and Clinical Toxicologist, Dr Katherine Isoardi, to explore the contributory factors that preceded Jamie’s cardiac arrest.

Survivability of the drugs [54] Dr Isoardi was asked to comment on whether Jamie could have survived the drugs found in his system. Her opinion was that the concentration of Droperidol was within the therapeutic range expected following chemical sedation. Dr Isoardi noted that hypotension and respiratory depression may be (rare) side effects. However, for a critically unwell person, these adverse effects would be more relevant. 36 [55] Dr Isoardi opined that the clinical features of life-threatening sympathomimetic toxicity seen in the body worn camera footage supported the view that 1.6mg/L represented a lethal concentration of methamphetamine in Jamie.

[56] It was difficult for Dr Isoardi to comment on the survivability of Jamie’s lifethreatening sympathomimetic toxicity as there is no antidote for the condition and management of it involves ‘good supportive care with aggressive organ support.’ Dr Isoardi opined that: 33 Exhibit A5.

34 Exhibit A5, 28.

35 Exhibit A4.

36 Exhibit G4, 5.

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‘While early ventilatory and cardiovascular support to minimise hypoxia and hypotension usually promote a favourable outcome, even with the best supportive care, Mr Campbell may still have succumbed from severe complications or sympathomimetic toxicity given the degree of physiological derangement prior to QAS arrival.’ 37 Likelihood of cardiac arrest [57] Dr Isoardi considered that the likelihood of Jamie experiencing a cardiac arrest due to drugs of the type and combination listed above was very high due to Jamie’s life-threatening sympathomimetic toxicity. Her opinion was that the body worn camera footage of Jamie in the Eatons Hill Hotel bathroom, showed a man who was peri-arrest or close to cardiac arrest.

[58] Dr Isoardi attributed the main cause for Jamie being critically unwell was severe sympathomimetic toxicity due to a lethal concentration of methamphetamine.38 [59] While Dr Isoardi considered the level of Droperidol detected in the antemortem blood sample was within the therapeutic range, she noted that in a critically unwell patient, like Jamie, ‘Therapeutic concentrations of Droperidol … may have contributed (to a lesser extent) to his cardiac arrest through respiratory depression or hypotension.’ 39 [60] Despite the concentration of Droperidol found in the ante-mortem sample in the therapeutic range, it cannot be said with any certainty whether the Droperidol had any contributory effect in Jamie’s cardiac arrest, particularly given his life-threatening sympathomimetic toxicity when the Droperidol was administered.

37 Exhibit G4, 5.

38 Exhibit G4, 5.

39 Exhibit G4, 6.

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Conclusions on inquest issues Findings required by s 45 of the Coroners Act 2003 [61] I am required to find, as far as possible, the medical cause of death, who the deceased person was and when, where and how he came by his death. As a result of considering all the evidence, including the material contained in the exhibits, I make the following findings: Identity of the deceased: Jamie Brian Campbell How he died: On 14 March 2021, Jamie was restrained by QPS Officers at the Eatons Hill Hotel after he was found naked and agitated, thrashing around on a bathroom floor. Jamie was subsequently administered two doses of Droperidol by QAS officers who did not recognise that he was critically unwell. The second dose of Droperidol was not clinically indicated. At the time, Jamie was experiencing a medical emergency and labouring under the effects of sympathomimetic toxicity. He had a lethal concentration of Methylamphetamine in his system. This was not known to the QAS officers in attendance. It is not possible to separate the various contributors that led to Jamie suffering a cardiac arrest. Jamie died several days after he was transferred to the ICU at The Prince Charles Hospital.

Date of death: 17 March 2021 Place of death: Intensive Care Unit, The Prince Charles Hospital, Rode Road, Chermside QLD, 4032, Australia.

Cause of death: 1(a) Hypoxic ischaemic encephalopathy, due to or as consequence of, 1(b) Cardiac arrest of unknown cause.

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The circumstances surrounding the death including the reasonableness of: The actions of the Queensland Ambulance Service (‘QAS’) officers in administering Droperidol to Mr Campbell.

[62] Jamie was administered two doses of the sedative Droperidol by QAS officers on 14 March 2021.

The first dose of Droperidol [63] The first dose of Droperidol was administered at 03:08am on 14 March 2021.

[64] I accept the submission of counsel assisting that the first dose of Droperidol was clinically indicated noting Jamie’s physical presentation and agitation, as supported by the body worn camera footage and statements of the attending QPS and QAS officers.

[65] I also accept the submission of counsel assisting that the clinical assessment of Jamie performed by ACP Palmer (as the primary treating officer), before the first dose of Droperidol was given was inadequate, and not in keeping with the standard expected of a competent paramedic.

[66] Counsel for Ms Palmer submitted that she accepted that there were failings on her part in relation to the treatment provided to Jamie and that she failed to comply with the QAS policies and procedures then in force.40 [67] I also accept the opinion of Prof. Rashford that while the first administration of Droperidol at 03:08am was clinically indicated, there was no evidence to show that the QAS sedation checklist or an adequate team briefing occurred between the QAS officers in attendance. Prof. Rashford’s evidence was that: ‘The level of assessment was below that expected of professional paramedics. I can neither see or hear evidence on the BWC that CCP Reus and ACP Palmer recognised how critically ill Mr Campbell was, despite significant evidence to the contrary. The pre-sedation checklist was not used and the briefing of the QPS and QAS officers present was inadequate’. 41 [68] I also accept the expert opinion of Dr Isoardi. Dr Isoardi agreed with Prof.

Rashford that the clinical assessment of Jamie, prior to and following the first administration of Droperidol was incomplete. The QAS officers did not recognise that Jamie had life-threatening sympathomimetic toxicity.

40 Submissions on behalf of Kate Palmer at [16].

41 Exhibit G1, 8.

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[69] Jamie appeared ‘acutely distressed’ and was restrained by the QPS. Dr Isoardi agreed that Droperidol was indicated in the circumstances, although it was a high-risk situation: ‘In a patient exhibiting severe acute behavioural disturbance the use of chemical restraint to facilitate safe transport is very appropriate. The initial dose of Droperidol given at 3:08 was appropriate and consistent with guidelines for managing behavioural disturbance.

Giving any form of chemical sedation to a critically unwell patient is a high-risk intervention. In some circumstances it is unavoidable and necessary to facilitate appropriate care. In this instance I believe it was necessary to facilitate safe transport to hospital. However, close observation for anticipated deterioration following sedation should have been performed in this high-risk scenario.’ 42 The second dose of Droperidol [70] The second dose was administered at 03:20am on 14 March 2021.

[71] I accept the submission of counsel assisting that the second administration of Droperidol was not clinically indicated due to Jamie’s physical presentation as set out in the timeline of Prof. Rashford. ACP Palmer and CCP Reus were the primary treating officers when the second dose of Droperidol was administered.

[72] Dr Isoardi’s opinion was that there was no indication that a second dose of Droperidol was required and that the second dose was administered earlier than the recommended dosing interval of 15 minutes.43 Dr Isoardi also commented on the lack of appropriate clinical assessment of Jamie at this time: ‘The decision to provide a second dose was inappropriate particularly in the absence of any meaningful patient assessment following the first dose of Droperidol. In the context of a critically unwell patient, this additional dose of sedation was possibly harmful and contributed to his subsequent deterioration.’ 44 [73] Prof. Rashford’s evidence supported Dr Isoardi’s view: ‘I can see no indication for a second dose of Droperidol being required. I also note it was administered five minutes before indicated. The action of Droperidol requires waiting the full 15 minutes to see the effects before consideration of a second dose.’ 45 42 Exhibit G4, 4.

43 Exhibit G4, 4.

44 Exhibit G4, 5.

45 Exhibit G4, 8.

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[74] I agree with the submission from counsel assisting that I should conclude that ACP Palmer and CCP Reus mistook the involuntary bodily functions exhibited by Jamie such as the gnashing of teeth, clenching of fists, and muscle stiffness as active resistance and aggression, as opposed to Jamie experiencing a medical emergency, namely sympathomimetic toxicity.

[75] Dr Isoardi opined that Jamie: ‘Looked like someone, to me, who was really delirious, and so while he was probably moving around and thrashing around, it was probably part of his toxicity, rather than it being him meaningfully trying to resist...

However, it would be very difficult to distinguish that clinically, looking down at someone, if you don’t realise the person has toxicities, because it certainly looked like he was groaning and moaning and moving around, and so it looked like there was resistance and agitation there. It’s not clear and it’s hard to say from watching the body camera footage exactly how much physical restraint needed to occur to prevent that, but from what I could see, once the paramedics arrived, he didn’t appear to be moving around a huge amount. He was still groaning out and sounded as though he may have been agitated.

It would’ve been a difficult scenario to move someone who was receiving multiple point restraints onto an ambulance trolley and get them into hospital without consideration of some sedation in my opinion. Although, again, it’s very difficult to say, because I don’t think there was a meaningful assessment of Mr Campbell made from the outset from the paramedics to really guide how much he was resisting.’ 46 [76] CCP Reus’ counsel submitted that, with the benefit of hindsight and on all the evidence before the court, CCP Reus accepted that ‘the administration of the second dose of Droperidol to Jamie was not indicated on his presentation at that time, on an application of the relevant QAS policies and procedures then in force.’ 47 [77] CCP Reus accepted that the administration of a second dose of Droperidol was not reasonable and that the monitoring of Jamie’s health by the QAS officers following the administration of two doses of Droperidol was not reasonable.48 CCP Reus also accepted that the timing for the administration of the second dose of Droperidol was truncated.49 [78] It was also submitted on behalf of Ms Palmer that she accepted the second dose of Droperidol was not clinically indicated. However, this had to be considered in context which included Jamie’s unusual and confronting presentation, the limited contextual information they had about how Jamie came to be in the situation, the small space in which the restraint had occurred, and the number of people present. 50 46 20 December 2023, T 2-90, L 35.

47 Submissions on behalf of CCP Darren Reus at [6].

48 Submissions on behalf of CCP Darren Reus at [8].

49 Submissions on behalf of CCP Darren Reus at [12b].

50 Submissions on behalf of Kate Palmer at [16]-[19].

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[79] Ms Palmer’s evidence was that in these circumstances, she was overwhelmed, stressed, and questioning her judgement.

[80] Ms Palmer gave evidence that CCP Reus as the more senior QAS officer on scene grabbed her shirt and physically stopped her from taking Jamie’s temperature, telling her ‘We need to let the police keep doing their job.’ Ms Palmer took this as a signal that CCP Reus was in charge and would dictate the path moving forward.51 ACP Ames observed CCP Reus touch Ms Palmer’s sleeve. The body worn footage recorded Ms Palmer saying: ‘I was just going to do a temperature, that’s all.’ A male voice (believed to be CCP Reus) is then heard to say: ‘No let the guys do their job, that’s the main thing.’ Further comment from the male (CCP Reus) is: ‘it keeps everyone safe.’ Ms Palmer responded: ‘yeah no, no, no, that’s alright, that’s ok.’ 52 During this time police officers can be heard communicating about the way they are restraining Jamie, and making plans to alter that restraint, if Jamie continued to move.

[81] I accept that this conversation, coupled with the alleged contact between CCP Reus and Ms Palmer, had an impact on Ms Palmer’s response in a chaotic and distressing scene. I also accept that the QAS is a hierarchical organisation and that CCP Reus held a degree of clinical primacy in the presence of ACP Palmer and ACP Ames.

[82] Counsel for CCP Reus submitted that CCP Reus did not recall grabbing ACP Palmer’s shirt. However, it was conceded that he may have ‘got her attention by touching her,’ and that CCP Reus had formed the view that police were in control of the scene, and QAS officers should wait for clearance from the police before approaching Jamie to undertake observations.53 The monitoring by QAS officers of Mr Campbells health status following the administration of Droperidol.

[83] Counsel assisting submitted that I should accept the expert opinion of Prof.

Rashford and Dr Isoardi, that there was a failure by ACP Palmer and CCP Reus, as the primary treating officers, to complete an appropriate assessment of Mr Campbell prior to and following the administration of Droperidol. I accept this submission.

[84] Ms Palmer’s submissions accepted there was more that she could have done to treat Jamie once he was placed on the stretcher and taken to the ambulance however, she felt rushed, overwhelmed and incapable of speaking up.54 [85] Counsel for CCP Reus accepted the monitoring of Jamie’s health by the QAS officers following the administration of both doses of Droperidol was not reasonable.

51 Submissions on behalf of Kate Palmer at [21]-[21].

52 Exhibit D3 T17:10:00z – T17:10:18Z.

53 Submissions on behalf of CCP Darren Reus at [13].

54 Submissions on behalf of Kate Palmer at [30].

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[86] However, as submitted by Counsel for CCP Reus, and noted above, CCP Reus was not aware (consistent with the evidence provided by ACP Palmer at the Inquest) that she was vulnerable, decompensated, and had stopped meaningfully participating in Jamie’s care (particularly during the ambulance transport).

Whether the Ambulance officers involved complied with the QAS policies and procedures then in force.

[87] Following Jamie’s death an internal review was completed by the QAS. As a result the QAS notified the Office of the Health Ombudsman (OHO) in respect of the actions of all three QAS officers. Both ACP Palmer55 and CCP Reus56 were subject to internal QAS disciplinary processes. 57 [88] I accept the submission of counsel assisting in respect of ACP Ames and the opinion of Prof. Rashford that while ACP Ames was in attendance, he did not play a central role in the care provided to Jamie. While areas for improvement were identified by Prof. Rashford, there was nothing that amounted to a noncompliant standard of behaviour by ACP Ames.58 [89] I accept the submission of counsel assisting that the actions of ACP Palmer and CCP Reus (as the primary treating officers), did not comply with the QAS policies and procedures then in force.59 [90] I accept the submission of Counsel on behalf of CCP Reus that: ‘There was a profound communication breakdown within the QAS team occasioned by the fact that ACP Palmer quietly decompensated while in the primary patient care role. ACP Palmer did not then step out of that role but did in effect stop doing it. CCP Reus was not aware of the nature or extent of ACP Palmer’s decompensation or the ensuing communication breakdown until the inquest hearing and could have done nothing to manage it differently on the night in question.’60 [91] While it was unfortunate that the circumstances meant there were no clearly designated roles assigned within the sedation team, it cannot be determined with any certainty that this had any effect on the outcome.

55 20 December 2023, T 2-10, L 26. Exhibit G3 at [3].

56 20 December 2023, T 2-65, L 1.

57 Exhibit G1, 7.

58 Exhibit G3 at [4].

59 Exhibit G3 at [2]-[3].

60 Submissions on behalf of CCP Darren Reus at [18].

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Whether the training provided to Ambulance officers to respond to like incidents is appropriate.

[92] I accept the submissions of counsel assisting that appropriate training had been provided to ACP Palmer, ACP Ames and CCP Reus prior to the incident involving Jamie and that the training provided to QAS Officers to allow them to respond to like incidents was appropriate.

[93] The submissions of counsel assisting with respect to this issue were supported by counsel for the QAS, Prof. Rashford and ACP Ames.

[94] ACP Palmer’s evidence was that she had completed a Bachelor of Health Science, Emergency Health Services in 2011. ACP Palmer accepted that during that training she was taught to observe and record the observation of vital signs in an unwell patient, the importance of doing those observations properly and accurately recording them.61 [95] ACP Palmer accepted that vital signs or the observations listed on the eARF form include things such as heart rate, respiratory rate, respiratory pattern, level of consciousness by the Glasgow Coma Score, respiratory rate, temperature, blood sugar, oxygen saturation and the amount of CO2 in a person’s exhalations.62 ACP Palmer accepted that vital signs are markers of the body’s vital functions (cardiovascular and respiratory), and that regardless of whether a patient had suffered an accident or trauma, ‘the core role of the paramedic is to assess and record these vital signs.’ 63 [96] ACP Palmer also accepted that observation of a patient’s vital signs allows a paramedic to make or confirm a diagnosis and guides the provision of treatment to the patient, and whether a patient is responding to treatment or deteriorating. It also facilitates an effective handover between paramedics and hospital staff.64 [97] ACP Palmer confirmed that before the incident involving Jamie, she was compliant with the mandatory training provided by the QAS.65 She accepted that an active ACP undergoes both online training and in-person assessment every year to maintain competence of core skills and must maintain a certificate of clinical competence/clinical practice every two years (and includes assessing patients, taking, and recording vital observations and initiating appropriate treatment).66 [98] ACP Palmer confirmed that the QAS provides clinical practice manuals that were available on an iPad carried by her when she interacted with Jamie, and that she was aware of how to use those manuals, having completed the relevant training.67 61 20 December 2023, T 2-11, L 1.

62 20 December 2023, T 2-11, L 19.

63 20 December 2023, T 2-11, L 29.

64 20 December 2023, T 2-11, L 45.

65 Exhibit C4.

66 20 December 2023, T 2-13, L 25.

67 20 December 2023, T 2-14, L 20.

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[99] ACP Palmer confirmed that she undertook the ‘A5DROPA16, Droperidol for Operational Officers’ training module in February 2017, which included specific training in the management of Acute Behavioural Disturbances

(ABD).68 [100] The training material for ABD Management69 contains the following guidance:

• Patients sedated with intramuscular droperidol…should have an IV inserted once the patient is settled in case intravenous medications or fluids need to be given.70

• Sedation below the level of response of drowsy but rousable to voice is not desired (SAT score-1).71

• The Sedation Check list: ‘The indication for sedation is a SAT score of +2 or +3 post attempts at verbal de-escalation.72

• Guidance on the assembly and briefing of a Sedation Team, with specific note to ensure dedicated clinician to adequacy of airway and breathing.73

• Guidance for Post-sedation care including intervals for observation and recording of vital signs.74

• Consider and manage risks of sudden cardiac collapse and accumulative effects of stressors of the restraint, comorbidities, and sedation.75

• Behavioural Sedation Handover check list.76

• Crisis Resource Management revisited.77

• Information about Droperidol.78 [101] ACP Palmer confirmed she had received training in Crisis Resource Management (CRM) before her treatment of Jamie and recognised the training material shown to her at inquest.79 In reviewing the slide80 ‘what can happen during a crisis’ ACP Palmer confirmed this was the “type of thing” she was describing during her evidence (communication breakdown and tunnel vision).

She accepted she had been trained in relation to managing this type of occurrence.81 68 20 December 2023, T 2-16, L 11. Exhibit C4, 5.

69 Exhibit C7.

70 Exhibit C7, slide 5.

71 Exhibit C7, slide 6.

72 Exhibit C7, slide 7.

73 Exhibit C7, slide 12.

74 Exhibit C7, slide 16, 19, 20.

75 Exhibit C7, slide 21.

76 Exhibit C7, slide 22.

77 Exhibit C7, slide 24.

78 Exhibit C7, slide 25 to 39.

79 20 December 2023, T 2-20, L 38.

80 Exhibit C8, slide 3.

81 20 December 2023, T 2-21, L 9.

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[102] Counsel for Ms Palmer submitted that there was no evidence before the court that Ms Palmer received specific training that was focussed towards managing stress and that this incident has prompted the QAS to provide more training with respect to confidence and speaking up.82 I do not accept that submission.

[103] CCP Reus was also taken through his qualifications and training at the Inquest.

CCP Reus noted in response to training including a sedation checklist: ‘I don’t recall any procedural – training on procedural sedation since my CCP or intensive care paramedic training’.83 CCP Reus could not recall the ‘Droperidol for Operational Officers’ training module.84 [104] Counsel for the QAS submitted that CCP Reus’s training record showed annual training in the digital clinical practice manual, annual CCP core skills training and certification and the ‘Droperidol for Operational Officers’ in 2016.85 [105] Counsel for the QAS submitted that while ACP Ames was not taken to his training record in evidence, the record demonstrates the level of training provided, with equivalent annual assessment of competency in core skills, two yearly certifications in clinical competence /clinical practice and specific training in management of acute behavioural disturbances and the use of Droperidol. ACP Ames also had annual training in the digital clinical practice manual and updates and undertook training in working within challenging situations.86 [106] Counsel for the QAS submitted that I should find that the training provided to QAS Officers both before and after Jamie’s death was appropriate and that matters raised by counsel assisting have been satisfactorily addressed. I accept this submission.

[107] Prior to the Inquest, Prof. Rashford released Medical Circular 28/2021 entitled ‘Reducing safety risk for patients requiring sedation,’ reminding CCPs and ACPs of their training relevant to the key failings in the management of Jamie.

Key points of the publication are:

• Sedation for the management of ABD is a high-risk procedure.

• All restrained patients are to be treated as critically ill patients, including the need for earlier monitoring.

• Paramedics must be able to see the patient’s entire face at all times.

• The use of Droperidol is to be respected and all steps taken to ensure the safety of the patient.

82 Submissions on behalf of Kate Palmer at [33].

83 20 December 2023, T 2-77, L 38.

84 20 December 2023, T 2-77, L 44.

85 Exhibit C6. Submissions on behalf of the QAS and ACP Ames at [5].

86 Exhibit C5. Submissions on behalf of the QAS and ACP Ames at [4].

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[108] Prof. Rashford encouraged cardiac monitoring with the dots or pads on the patient’s back if this was the only available option. A video contained within the circular (available to all QAS staff on the intranet) provided further guidance. 87 [109] On 18 July 2022, Medical Circular 20/2022 was released. That circular announced further online and face-to-face training in ABD and management of emergency sedation.88 [110] On 11 March 2024, Prof. Rashford released Medical Circular 05/2024 and 06/2024 entitled ‘Options for emergency patient deterioration treatment when a Queensland Police Officer is in the rear cabin of the ambulance’ and ‘Assessment and Management of sympathomimetic toxicity.’ Both circulars included updated training on issues relevant to Jamie’s clinical management.

Whether the Police officers involved complied with the Queensland Police Service (‘QPS’) policies and procedures then in force.

[111] Counsel assisting submitted that I should accept the opinion of Detective Sergeant Downey that ‘there is no evidence to indicate any breach of discipline or misconduct by members of the QPS’ and that the QPS officers who interacted with Jamie at the Eatons Hill Hotel, complied with the relevant QPS policies and procedures then in force. 89 [112] This submission was supported by Mr Gnech on behalf of his clients, 90 and Counsel for the Commissioner of Police.91 [113] As I indicated during the Inquest, following oral submissions from Mr Gnech on behalf of his clients, no adverse findings can be made in relation to his clients, nor any QPS officer who attended to Jamie at the Eatons Hill Hotel.92 [114] The QPS Officers who attended to Jamie at the Eatons Hill Hotel complied with the relevant QPS policies and procedures then in force.

[115] Prof. Rashford’s evidence at the Inquest was that the actions of the QPS officers in restraining Jamie before QAS arrival were ‘exemplary’ in the circumstances. 93 [116] I accept this characterisation of the actions of the QPS officers based on the evidence before the court including extensive body worn camera footage and expert medical opinion. During the restraint, the QPS officers displayed an awareness of Jamie’s vulnerable position and the need to ensure their actions in restraining him, to ensure he was not able to injure himself further, did not 87 Exhibit B15. Exhibit B15.1. Exhibit B 15.2.

88 Exhibit B15. Exhibit B15.1 89 Exhibit A6, 23.

90 Submissions on behalf of Mr Gnech’s clients at [3].

91 Submissions on behalf of the Commissioner of Police at [3].

92 20 December 2023, T 2-113, L 13.

93 20 December 2023, T 2-99, L 17.

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inhibit his ability to breathe. Officers maintained respectful communication with Jamie, consistent with the Use of Force model.

Whether any preventative changes to procedures or policies could reduce the likelihood of deaths occurring in similar circumstances or otherwise contribute to public health and safety or the administration of justice.

[117] Counsel assisting submitted that while the training provided by the QAS in relation to ABD is comprehensive, I still may consider a recommendation that a case study be included in training, or that notification be provided to all paramedics based on Jamie’s experience, that specifically references sympathomimetic toxicity, highlighting the medical emergency, as a learning opportunity, to highlight the importance of monitoring patients before, during and following the administration of Droperidol.

[118] Counsel for the QAS noted that on 11 March 2024, Prof. Rashford released Medical Circular 05/2024 and 06/2024 entitled ‘Options for emergency patient deterioration treatment when a Queensland Police Officer is in the rear cabin of the ambulance’ and ‘Assessment and Management of sympathomimetic toxicity.’ [119] Both circulars included updated training on issues relevant to Jamie’s clinical management. The stated intention was to include the training content in the digital clinical practice manual available to ACPs and CCPs in the field on their iPads.

[120] I do not consider that there are any further recommendations that I can make connected with Jamie’s death to prevent deaths from happening in similar circumstances in the future, or would otherwise contribute to public health and safety or the administration of justice.

Further Comments [121] I accept the submission on behalf of Ms Palmer that she was extremely remorseful for her actions on the night, that the events have deeply affected her and that she has taken steps to ensure the failings are not repeated.

[122] I note that Ms Palmer was the subject of an investigation by the Australian Health Practitioner Regulation Agency (AHPRA) and has undergone disciplinary proceedings within the QAS.94 [123] Counsel for Ms Palmer also submitted that while it was accepted that Ms Palmer’s conduct fell below the expected standard for a QAS officer, when placed in their proper context, and in light of the expert evidence before the court, her departures from accepted practice did not cause the death of Jamie, nor did they change the clinical trajectory in any real way such that they were unlikely to have contributed to the death either.95 94 Submissions on behalf of Kate Palmer at [39].

95 Submissions on behalf of Kate Palmer at [41].

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[124] I accept those submissions.

[125] I also note that CCP Reus was subject to the disciplinary process with the QAS following this incident. It was submitted by counsel on behalf of CCP Reus that he accepted responsibility as a team member for shortcomings in communications that may be attributed to him. However it is clear from the evidence of ACP Palmer, that her decompensation on 14 April 2021 was outside the ordinary range of experience in a workplace, and outside what could be described as ineffective team communication.96 I accept those submissions.

[126] I extend my condolences to Jamie’s family and friends for their loss.

[127] I close the inquest.

Terry Ryan State Coroner

BRISBANE 96 Submissions on behalf of CCP Darren Reus at [12c].

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