The body of a man who died shortly after police arrested him was left uncovered in front of his family for nearly four hours – or "far too long" – South Australia's deputy coroner has found.
Aboriginal and Torres Strait Islander readers are advised that the following article contains the name of a person who has died. Permission has been granted by the family to use the man's surname.
The man was also deprived of medical attention in the minutes before his death.
Deputy state coroner Ian White on Friday delivered his findings on the death of 50-year-old Aboriginal man Mr Reid, who died from heart disease in May 2017, within 90 minutes of police arresting him at his home in the northern Adelaide suburb of Parafield Gardens.
The findings showed Mr Reid's body was left uncovered at his home for three hours and 50 minutes.
SA Police — also known as SAPOL — said it was "unavoidable" because of requirements to examine the body and scene, but Mr White disagreed.
"Mr Reid's family were present from the moment he collapsed and saw his uncovered body," Mr White found.
"I believe more could have been done by SAPOL to better handle this issue.
"That situation should not be repeated in the future should anything similar in nature happen to any other family."
Confusion about reason for unconsciousness
The inquest was examining the factors that led to Mr Reid's death in police custody.
Mr Reid had long-standing heart problems and was intoxicated when he experienced "an episode of heightened physical and emotional stress with his family and then South Australia Police".
Senior Constable Mark Brookes and Probationary Constable Kieran Ashenden attended the home after Mr Reid's partner called because he was attempting to hit her with a didgeridoo.
The pair arrested Mr Reid for aggravated assault, but within minutes he became unconscious.
Mr White found that all four police officers who ended up at scene thought that was because he was intoxicated.
"It seemed that SAPOL failed to turn their minds to Mr Reid presenting in this manner for any reason other than intoxication," the deputy coroner found.
When police first called for paramedics, Senior Constable Brookes said there was "no rush".
Minutes later, he called back asking the ambulance officers for a location.
"The arrested person has decided to feign unconsciousness," he told the South Australian Ambulance Service.
Two minutes later, he urged paramedics to come more quickly.
"In the minutes following his arrest, there was no particular symptom which should have made it clear to SAPOL that he was having a heart attack or angina presentation, as opposed to being intoxicated," Mr White found.
"However, his presentation at that point was such that medical attention should have been sought immediately under those SAPOL guidelines."
Cardiologist unsure if earlier help would have saved Mr Reid
Mr White said a cardiologist could not conclusively say whether having paramedics arrive earlier would have made a difference.
But Mr Reid was nonetheless "deprived of medical attention for a number of minutes in the lead-up to his fatal cardiac episode", Mr White found.
A spray that Mr Reid used to help his heart condition also became a key point of the inquest.
The deputy coroner also heard evidence from Mr Reid's family, which said he had requested a medical spray to help with his heart condition while police were arresting him.
Mr White found former Constable Ashenden did not communicate to his partner that Mr Reid had a heart condition and there was a spray that could be used.
But he said there was no medical evidence concluding it could have saved his life.
No finding of excessive force
Mr White said Mr Reid's family had urged the court to find the behaviour of SA Police was "unduly rough", but he was "unable to find as they wish".
One of Mr Reid's children gave evidence during the inquest that one of the officers looked like he was elbowing him in the throat, and at one point pushed him against a door frame.
His son alleged the two police officers also laughed when Mr Reid collapsed.
Mr White found because there were "conflicting accounts" about the force the officer used on his neck, the court could not rely on those accounts.
While a post-mortem examination found Mr Reid had a bruise on his neck, it could not be determined if the bruise was from police or if it was there beforehand.
Mr White said there was no doubt there was a physical encounter between Senior Constable Brookes and Mr Reid in the doorway, given evidence from his colleague, but it did not mean that caused the bruise.
