Inquest into the death of Omar Mohammad

Case Number: 2020/277315

Findings Date: 19 February 2024

Magistrate: Harriet Grahame

CORONIAL LAW | death in custody; acute cocaine toxicity; first aid by police; adequacy of NSW Police first aid training; CPR; NSW Police access to automatic external defibrillators (AEDs)

Responses

Recommendations

The Commissioner of the NSW Police Force

1. As out-of-hospital cardiac arrests are one of the most common causes of death and because survival prospects are greatly improved where automatic external defibrillators (AEDs) are used, that urgent consideration be given to equipping all police response vehicles with AEDs for use as standard equipment by frontline police.

2. That as an interim measure pending the roll-out of AEDs for all police response vehicles, that urgent consideration be given to AEDs being provided to all mobile supervisor and duty officer vehicles in each Police Area Command.

3. That the NSW Police Force mandatory annual training for CPR include key emphasis upon the following messages:

a. That CPR should be started if the person is unresponsive and not breathing normally (abnormal breathing);

b. To assess breathing – rescuers should look, listen and feel:

i. LOOK for movement of the upper abdomen or lower chest;

ii. LISTEN for the escape of air from nose and mouth; and

iii. FEEL for movement of air at the mouth and nose;

c. That palpation of pulse is unreliable and should not be used to confirm the need for resuscitation;

d. That abnormal breathing can be hard to identify - it is something that is “not normal”. Consider factors such as:

i. Does the breathing look irregular or irregular? Is it very slow (which suggests it may be abnormal)?

ii. Is the breathing noisy? If so, check that the airway is open.

iii. Is there a colour change (for example, is the patient blue around the lips)?

iv. Is there gasping or gulping?

e. If in doubt about whether a person is experiencing cardiac arrest or not, the rescuer should start CPR without concern about causing additional harm (rib fractures and other injuries are common but acceptable consequences of CPR given the alternative of death); that is – “If in doubt, have a go.”

f. That if unsure about ‘abnormal breathing,’ start CPR (even if the person takes occasional gasps or gulps);

g. That agonal breathing is common in the first few minutes after a cardiac arrest – it is sudden, irregular gasps or gulps of breath. This should not be mistaken for normal breathing and CPR should be given straight away;

h. That CPR should be continued until any of the following conditions are met:

i. the person responds or begins breathing normally;

ii. it is impossible to continue (e.g. exhaustion);

iii. a health care professional arrives and takes over CPR;

iv. a health care professional directs that CPR be ceased.

i. That CPR should no be interrupted to check for response or breathing;

j. That the faster the rescuer acts, the higher the chances of survival.

4. That CPR information as set out in (3) above is provided to all members of the NSW Police Force on an urgent basis (noting that the administration of CPR can be a matter of life and death), by way of:

a. A state-wide NEMESIS message; and

b. A module provided to officers who perform frontline general duties delivered via Police Education Training Environment (PETE) that requires the officer to acknowledge their review of the material; and

c. Appropriate scenario training.

5. That having regard to (3) and (4) above, urgent consideration be given to the introduction of an external training course delivered by an appropriate organisation within the next 6 to 12 months, to ensure that there is a baseline level of understanding within the NSW Police Force as to the essentials of CPR and basic life support (after which time, the Commissioner may consider that it is appropriate to revert to an internal training delivery model);

6. That urgent consideration be given to amending the 2023-2024 Session Plan for the CPR/Tourniquet Practical to ensure specific reference to the matters outlined in (3) above, together with inclusion of appropriate scenario training and an appropriate form of assessment to ensure that the content has been understood;

7. That consideration be given to introducing the requirement for police officers at the rank of Senior Constable and above who are involved in first response general duties policing, to be retrained and certified in first-aid every three years.

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