In last evening’s Four Corners Quentin McDermott examined the serial failures of Police services around the country to deal appropriately with the ever-growing number of mentally ill people that they encounter in the course of their duties.

Perhaps McDermott could have looked at the NT, where more traditional policing methods – like the use of the “three point hold” also known as “‘ground stabilisation’ or ‘take-down’ – has been implicated in a number of recent deaths.

Yesterday ABC Darwin reported that NT Police officer Acting Sergeant Bradley Fox had been charged with aggravated assault in relation to an incident at the Royal Darwin Hospital in December 2007 that ended with the death of the well-regarded film-maker Bob Plasto.

Bob Plasto

Bob Plasto

The ABC’s Obituary to Bob Plasto records that:

After leaving the ABC in 1980, Bob founded his own film production company and went on to become an internationally renowned film-maker, making more than 75 films in 35 years. His work included films about Islamic fundamentalism, Pine Gap, the Coniston killings and Aboriginal land rights. Bob was the first independent film producer to enter post-revolution Iran. His exclusive story from this visit, In the Name of God won the United States’ highest award for an independent documentary, the Alfred I Dupont Award in 1986. Iran – Behind the Veil won Best Documentary at the New York Film Festival, the film lauded for capturing a myriad of telling scenes, despite the tight Government control which followed the crew at every turn…Bob was also a poet who wrote more than 500 poems. He retired from film-making in August.

His funeral was held at Darwin’s Uniting Church on December 31. He is survived by three daughters, Jacqueline, Georgina and Rune Al-ith and one son, Tyge.

NT Coroner Greg Cavanagh recently conducted a joint inquiry into two deaths – including Plasto’s – because:

The circumstances of the deaths were investigated at the one inquest because of common factors and an overlap of issues. Both deaths were at least contributed to by injuries sustained after the police used force involving restraining the men in a prone position. Both men were large men who suffered from pre-existing heart conditions. An issue arises in both cases as to whether the deaths were caused by ‘positional asphyxia’,

According to his report into Plasto’s death NT Coroner Greg Cavanagh, on 22 December 2007, NT Police attended at Knuckey Street in central Darwin, where they found Plasto, who was:

“…shaking and sweating and speaking incoherently [and that they] believed…needed urgent medical assistance due to his mental state.”

Plasto was taken to the Royal Darwin Hospital emergency department, where he was examined by a doctor shortly after 4pm, who, according to the Coroner, reported that:

“…he was “pleasant and cooperative.” He was sweaty. She recorded “no insight into current state but does say he will do whatever I think he needs to get better.”

Plasto was then “sectioned” by a Dr Cromarty. At that point, responsibility for, and custody of, Plasto transferred from the NT Police to the Royal Darwin Hospital as an involuntary patient.

Dr Cromarty told Nurse Rebecca Weir that the Deceased was “acutely psychotic and he needed psych reg [psychiatric registrar] assessment”. Dr Cromarty said she spoke to a police officer (Fox) shortly after 4.30pm and told him that she had sectioned the Deceased. She also told him that she was concerned that the Deceased was psychotic.

Plasto remained at the emergency department – as did several NT Police officers including Acting Sergeant Bradley Fox – waiting for the psychiatric registrar to assess him.

During that time:

“The Deceased often talked to himself. The people who heard him speak could not make sense of what the Deceased was saying. He was highly agitated. He was standing up, sitting down and walking in and out of the Oleander room.”

…

“The Deceased, who was a chain smoker, repeatedly asked…for a smoke…The longer the Deceased was waiting at the hospital, the more agitated he became.”

Shortly before 6pm Plasto moved towards the external doors of the emergency ward, repeatedly stating that he wanted to have a smoke and “I want to go and get some air”, “I want to have fresh air.”, “I want to go outside. I want to go outside.”

Some Police officers tried to convince Plasto to stay inside, Acting Sergeant Bradley Fox was more abrupt, telling him to “Get back in the room”, “You’re not free to go just yet. You’re going to have to wait a little bit longer”.

The situation then escalated rapidly with Acting Sergeant Bradley Fox effecting what is known in police parlance as a “takedown”.

“Very shortly, six or seven men including all four police officers became involved in the restraint of the Deceased. Whilst on the ground, Fox and ACPO Eric Morrison applied significant weight to the Deceased’s upper torso. At one point, Fox was using his pectoral area to lie forward on the Deceased’s left shoulder. At some stage, Fox’s right knee was also used to push down the Deceased’s left scapula trying to effect a ‘3 point hold’. The Deceased was resisting and pushing up with his right hand. Acting Sergeant Fox says that he was using all his physical strength and weight. He described the intensity of the struggle as a ten out of ten. He said it was possibly the hardest apprehension in that manner he had ever undertaken. ACPO Morrison was putting his left knee on the Deceased’s right pectoral. Fox also held the Deceased’s head down with his left knee.”

Dr Cromarty attended the scene:

She saw the Deceased restrained face down on the floor with several police members lying across him and others restraining his arms and legs…Dr Cromarty says that as she tried to approach the Deceased, Fox put his knee on the Deceased’s head, and she heard the head smack onto the floor. She and Dr Lai Heng Foong leant down and clustered around the Deceased’s head and told the Deceased to relax, and that she would try to get the police off him. Dr Cromarty was concerned as the Deceased appeared to struggle less and his face was becoming quite red.

Dr Lai Heng Foong, the lead registrar in charge of the emergency ward:

“…heard screaming from the flight deck and came running to the ambulance bay. Dr Foong shouted at the police in a very loud voice to back off a bit and “ease off the pressure”, “let us talk to him”. She remembers very clearly seeing Fox place what appeared to be his whole weight on the Deceased’s head so his face was completely crushed into the floor. Dr Foong saw the Deceased trying to move his body and lift his head, she believed, in order to breathe and talk. She observed that Fox’s knee was on top of his head whilst the Deceased was turning red and later blue.”

“And do you remember now seeing blood come from the Deceased’s nose while he was on the ground?—I’ll never forget it, yes, I do. And why will you never forget it?—Because this is a patient that was scheduled and supposed to be protected by the hospital and he was being restrained with excessive force, compromising his ability to breathe and, despite my pleas, there was no easing of the pressure put on his face.”

Dr Clarissa Oh said that she saw Fox apply a knee to the Deceased’s head when it was about 15 cm above the ground. Dr Oh saw that when Fox put his knee on the Deceased’s head, it hit the ground, and she heard a significant thud.

…

“Dr Cromarty, Dr Foong and Dr Oh all saw the Deceased begin to turn blue, and that shortly after that he stopped struggling. Dr Cromarty and Dr Foong shouted at the police that he was turning blue and that they had to get off him. Dr Foong said nothing happened and she again had to say: “Guys let go of him. He’s getting blue”.

Therese De Groot said she saw a police officer (Fox) with his knee on the Deceased’s head and heard a thump at least once. Nurse Natasha Roberts heard the Deceased say quite loudly words to the effect of: “Can I get up? Sorry, let me get up”.

Plasto was transferred into the Intensive Care Unit but never recovered consciousness and died 6 days later.

NT Coroner Greg Cavanagh was scathing of the conduct of the NT Police officers:

“In my view the conduct of the police in this matter involved a litany of serious errors and misjudgements that led to the tragic and unnecessary death of the Deceased.

The Police Custody Manual and the Police General Order relating to Transport of Persons in Custody require a police officer apprehending a person apparently suffering from a mental illness to notify a hospital Emergency Department that they are attending with the person. This was not done.

More seriously, the Deceased was not taken directly to Royal Darwin hospital. Instead, he was taken to the police station where he was kept in the back of a caged vehicle for 16 minutes. That conduct is unacceptable. The Deceased was not a prisoner. He was not a suspect. He was not, as Fox described the Deceased during his interviews to investigating police a “person of interest”. He was a person who was a potential patient. The only power the police had under section 163 was to apprehend him and take him to a medical practitioner or an authorised psychiatrist for the purposes of an assessment under s 33.

…

In my view the decision to use force against the Deceased was not necessary and the police did not apply the minimum use of force.

I accept that the Deceased said on more than one occasion in a loud voice that he wanted to go outside to get some fresh air or he wanted to have a smoke…All four police officers were in close proximity to the Deceased at that time he said those words. I do not accept that not a single police officer heard the Deceased say those words or words to that effect. It is telling that none of the police asked the Deceased why he wanted to go outside. That is either because the Deceased had told them why he wanted to go outside or it did not occur to the police to engage in any dialogue with him.

There is no cogent evidence that the Deceased was intending to flee or escape or attempt to hurt himself.

…

I also find that if force was required to be used against the Deceased, the force actually used on the Deceased was unnecessary and excessive…I accept the evidence of the civilian witnesses that Fox applied his knee to the Deceased’s head when it was lifted about 15 cm above the ground causing the Deceased’s head to hit the floor. Fox’s conduct was not in accordance with the training provided by the NT police.

…

In making the decision to use force, the police members failed to take into account that the Deceased was mentally ill, that he was in a distressed condition and was in an agitated and anxious state after an unnecessarily prolonged wait at the hospital.”

Coroner Cavanagh also blasted the training provided to NT Police in dealing with the mentally ill:

“The training received by operational police about dealing with the mentally ill was clearly inadequate. Sergeant Hansen…acknowledged that the NT police were not given any specific training on negotiation or ‘tactical disengagement’ or communications with mentally ill people.

Bronwyn Hendry, the Director of Mental Health in the NT, gave evidence of the training received by NT police and security guards in relation to mentally ill people. She regarded that training as inadequate.”

Acting Sergeant Brad Fox remains on duty.

He has been summonsed to appear in the Darwin Magistrates Court on 9 November.

Coroner Cavanagh made the following recommendations:

1 – The NT Police Custody Manual be amended to provide that members must take any apparently mentally ill or disturbed person apprehended under s 163 of the Mental Health and Related Services Act by the most direct practical route and as quickly as possible for the an assessment.

2 – The NT Police Custody Manual, the Police General Orders and the Memorandum of Understanding dated June 2002 offer no clear guidance to operational police in relation to the handover of patients by police to hospital and should be revised.

3 – That Northern Territory Police ensure operational police are trained and retrained using reality based training techniques in relation to: “to the use of the prone restraint; risk factors; warning signs of a rapid onset of serious injury or death which can potentially occur in connection with certain restraint positions when subjects are in the prone position; prevention strategies; the monitoring of a subject person’s health if practical during and certainly immediately after the subjects are in the restraint positions.

4 – The Northern Territory Police should ensure that all members are trained and re-trained in strategies to deal with mentally ill persons.

5 – The Northern Territory Police should amend the General Order on Transport of Persons in Custody, and Part 6 of the Custody Manual – Mentally Ill Persons to include step-by-step instructions for police members on exercising the power of immediate apprehension for the purposes of a mental health assessment.

6 – The Northern Territory Police should amend clause 6.1.2 of the Police Custody Manual…so that Clause reflect that where legal advice is sought by a member and it is not possible to obtain that advice before the end of the member’s shift, the member should be interviewed as soon as reasonably practicable thereafter.

7 – That the legislature consider amending section 34 of the Mental Health and Related Services Act to clarify police powers and responsibilities after a section 34 recommendation has been made.