Michael Peachey inquest finds he died after being pepper sprayed, tasered and held down
This image of Michael Peachey has been used with his family's permission. (Supplied: Aboriginal Legal Service)
In short:
A coronial inquest has found a Gomeroi man died as result of a police operation.
Michael Peachey was pepper sprayed, tasered and held in a prone position after suffering suspected psychosis.
What's next?
The coroner has recommended police and paramedics be given additional training around the use of restraint.
An inquest into the death of a Gomeroi man in North West New South Wales in 2021 has found he died as a result of a police operation in which he was tasered, pepper sprayed and held face-down for 24 minutes.
The Peachey family has granted the ABC permission to use Michael Peachey's name and image.
Michael Peachey died on May 20, 2021 following a struggle with police, who previously stated that they were called to a home in Gunnedah in the New South Wales north-west, where a man became aggressive and a physical struggle ensued.
Mr Peachey, 27, became unconscious following the struggle and was taken to Gunnedah Hospital where medical staff were unable to revive him.
Magistrate Elizabeth Ryan delivered her findings into Mr Peachey's death in Lidcombe Coroner's court.
A NSW coroner finds Michael Peachey died as a result of a police operation on May 20, 2021. (AAP: Dean Lewins)
"Many people's lives have been changed forever because of what happened," she said.
Magistrate Ryan said Mr Peachey was held on the floor in the prone position — face-down — for 24 minutes, after being pepper-sprayed and tasered by two police officers.
"All police officers and paramedics failed to see he had stopped breathing and then it was too late by the time they realised," she noted.
Mr Peachey had stopped moving
The court heard Mr Peachey's condition at the time of the incident was determined as most likely to be a result of an undiagnosed psychosis episode.
Ms Ryan outlined Mr Peachey's death was as a result of cardiac arrest due to cardiac arrhythmia, on a background of prone restraint and the dose of a sedative and a period of exertion in which he suffered the effects of capsicum spray, taser and psychosis.
The inquest found the three police officers who attended the scene had not acted in a consistent manner with NSW Police policy of moving someone from the prone position as soon as possible.
Ms Ryan did not accept the NSW paramedics reasons for not intervening due to risk to themselves, noting Mr Peachey had stopped moving for several minutes before he was released from the prone position.
"I have rejected the claims that Michael continued to actively resist restraint and struggle [in his final minutes].
"During the critical minutes before it was realised Michael was not breathing it does not appear that any monitoring from paramedics was occurring."
She acknowledged that the two police officers who first attended the scene would have been physically and emotionally exhausted from the altercation and waited 40 minutes for backup to arrive.
A Senior Constable arrived on scene to assist his colleagues.
"It is disappointing that he did not take that opportunity to see if Michael could now be moved from the prone position. He fell short of what might have been expected," Ms Ryan said.
Better training
A recommendation was made to the NSW Police Commissioner that she consider forming an independent policy on restraint that provides clear guidance on the risks of the prone position and provide training for officers.
Ms Ryan concluded that NSW paramedics who attended the scene did not take proper steps to advocate that Mr Peachey be moved from the prone position and did not monitor his respiratory situation properly.
The inquest also heard Mr Peachey had encounters with police, medical professionals and the local hospital in the days before his death, but none of those encounters resulted in him receiving a mental health assessment.
Ms Ryan has now recommended hospitals develop policies including follow up for patients who present with mental health but leave without a mental health review.
She made a recommendation for the NSW Ambulance service to better train paramedics in dealing with patients under restraint, but noted this recommendation had already started to be implemented.
Family's heartbreak
The inquest also heard Mr Peachey was much loved by his family and he was a doting father to his young child.
Ms Ryan offered her sympathies to the family.
"They will never forget the heartbreak of his passing and their lives have been forever changed."
Editor's note 29/11/2024: The article has being amended to clarify Mr Peachey did not receive a mental health assessment, not that one wasn't recommended.