Broadmeadows death exposes the price of a custody system that missed the obvious

A man can be unresponsive in a police cell and still be treated as if the system has all the time in the world. That was the grim impression left on the first day of the inquest into John Makai’s death, after Victoria Police apologised to his family for what happened to the 58-year-old father of 10.

The Victorian coroner’s court heard on Monday that Makai died in 2023 from serious head trauma after spending five hours in a Broadmeadows cell without treatment. Footage shown in court captured him being dragged from a divisional van into police cells, then failing to respond when officers checked on him through the cell door. Counsel assisting Rachel Ellyard told the court that officers twice claimed he had responded, although the CCTV showed no such physical reaction.

A lawyer for Victoria Police chief commissioner Mike Bush said the force apologised for Makai’s death. Andrew Imrie said the care provided was not at the standard any member of the Victorian community was entitled to expect, and offered sincere condolences to the family. He also said there had been failures to complete a medical checklist when Makai arrived at Broadmeadows station, to notice his deteriorating condition, to carry out a risk assessment and to conduct adequate checks.

The sequence began in Sunbury, where police attended a house after one of Makai’s sons punched him twice while they were drinking with another son and a friend. An ambulance was initially called, then cancelled. In footage shown to the court, police could be seen watching as Makai struggled to stand and then collapsed into a bookcase while trying to sit down. They then had to support him to walk to the divisional van, and could be heard telling him to get his legs up.

About 20 minutes later, at Broadmeadows police station, Makai could no longer stand and had to be dragged out of the van by his legs, with his head striking the floor and walls of the vehicle. He was then placed seated on the ground and lifted under the arms into a cell, where he was put in what the inquest heard is known as a coma position. He made no verbal response during the transfer, nor at any other time at the station.

Police requested another ambulance at 1.25am, telling Ambulance Victoria that Makai had a minor facial injury and was in a very deep sleep because of his drunken state, and that they wanted him checked by paramedics. Ambulance Victoria said it was struggling with workload but would dispatch paramedics when available. Ellyard said what was read as deep sleep was in fact the worsening effect of traumatic brain injury and bleeding into the brain.

The delay then became almost absurd in its own way. Because of an issue with Triple Zero Victoria, the job was not actually logged as outstanding. An ambulance was not dispatched until the same police officer called again five hours later, after police entered Makai’s cell and still could not get a verbal response.

In a recording played to the court, the officer said Makai had been in custody for hours, was breathing and had not responded to sternum rubs or other attempts to wake him. He asked for an urgent welfare check, saying the earlier request had been cancelled at the other end. When the operator asked whether the man was unconscious and had not responded for six hours, the sergeant said his officers had been checking on him every 15 minutes. Ellyard said a review of the footage showed that claim was wrong.

When paramedics finally attended, Makai was found to be showing signs of a brain injury. He was taken to hospital and diagnosed with non-survivable brain trauma. He died there two days later.

The first witness, Ryan Goon, director of operations support for Triple Zero Victoria, said the dispatcher had wrongly cancelled the police request because of an issue with multiple associated events. The original ambulance call from the Sunbury house had later been cancelled, and the system had tied the later request to that earlier one.

The inquest before coroner Paresa Spanos is expected to run for two weeks. It will examine the cause and circumstances of Makai’s death, including what treatment he might have received had he been taken to hospital rather than to a police station, and what changes have been made to policy and reviews since then. The question hanging over all of it is not subtle: how many warnings does a system need before it admits it has not merely erred, but failed.

Written by Sandy van Dongen sandy.vandongen@alpineweekly.com