Police mistook dying man for drunk detainee, inquest into custodial death hears

Key facts

The opening day of the coronial inquiry laid out the initial timeline and visual record surrounding the final hours of John Makai, a 58-year-old man who died while in law enforcement custody. According to reporting by journalist Lachlan Abbott, court evidence presented on September 28 centered on security and body-worn camera footage that captured the moment officers brought Makai into the police facility.

The video footage played for the coroner showed officers physically transporting Makai’s completely limp and unresponsive body into a holding cell. The primary assumption made by the attending personnel was that Makai was severely intoxicated and was simply experiencing a heavy, alcohol-induced sleep. Rather than immediately routing him to a medical facility or requesting emergency clinical assistance, officers placed him inside the cell to sleep off his perceived state of drunkenness.

In reality, Makai was not experiencing ordinary intoxication, but was instead in the grips of a life-threatening physiological collapse. The video evidence presented to the court documented officers handling Makai while failing to identify critical signs of medical trauma or illness. As the initial day of the inquest established, Makai lay dying in the cell while officers operated under the belief that he was merely sleeping. The court proceedings are set to examine the exact chronology of events following his placement in the cell, including how much time elapsed before staff recognized that Makai was not breathing or possessed no vital signs, and what resuscitation efforts were ultimately attempted.

Why it matters

The tragic death of John Makai highlights a long-standing and dangerous systemic vulnerability in law enforcement custody operations: the misidentification of acute medical emergencies as severe alcohol or drug intoxication. In custodial settings, the inability or failure of officers to accurately distinguish between deep unconsciousness caused by substance use and life-threatening conditions—such as traumatic brain injury, stroke, diabetic ketoacidosis, severe hypoxia, or internal bleeding—frequently leads to preventable fatalities.

When police officers take an individual into custody, they assume a legal duty of care. This duty requires that detainees receive appropriate medical evaluation and timely emergency care whenever their physical state is compromised or uncertain. When law enforcement personnel assume that an unresponsive individual is merely drunk, the critical "golden hour" for emergency medical intervention is lost.

Furthermore, this case underscores broader concerns regarding the institutional reliance on police lockups as holding facilities for vulnerable or impaired individuals. Custodial officers typically lack formal clinical training, making them ill-equipped to perform diagnostic assessments on unconscious detainees. When standardized medical screening protocols are bypassed or inadequately enforced, holding cells effectively become high-risk environments for individuals suffering from sudden medical collapse. The legal and operational fallout from this inquest could influence police force policies, mandatory health assessment directives, and accountability mechanisms across police jurisdictions.

Coronial inquests serve as independent judicial inquiries designed to establish the identity of the deceased, the time, place, and cause of death, and the broader circumstances surrounding the fatal event. In cases involving deaths in police custody, inquests hold a statutory responsibility to scrupulously examine whether state authorities fulfilled their common law and statutory duty of care.

Historically, deaths in police cells under similar circumstances have prompted extensive policy debates and judicial inquiries worldwide. A recurring theme in coronial findings across multiple jurisdictions is the phenomenon of "the unconscious detainee." Time and again, inquiries have found that police personnel routinely misinterpret signs of severe medical distress—such as slurred speech, immobility, incontinence, or loss of consciousness—as standard manifestations of extreme drunkenness.

Medical research and custodial management reviews consistently emphasize that alcohol intoxication itself can mask underlying acute conditions. An individual who has consumed alcohol may simultaneously be suffering from a head injury sustained during a fall, an intracranial hemorrhage, drug toxicity, or severe metabolic breakdown. Furthermore, prolonged lying in an improper position while heavily impaired can lead to positional asphyxia, where an individual's airway becomes obstructed due to body placement, preventing normal respiration.

To mitigate these risks, many police services have established standing orders dictating that any individual who is unconscious, unable to stand unassisted, or incapable of answering basic orientation questions must be evaluated by qualified medical personnel or transported directly to a hospital emergency department prior to being processed into a holding cell. Despite these established guidelines, implementation gaps persist, often driven by inadequate training, operational pressure, or subjective assumptions made by frontline officers.

Reaction

During coronial inquests of this nature, formal responses are submitted directly into the judicial record through legal representatives, expert witnesses, and official statements. While the initial report on the opening day did not detail public statements from the involved parties, structured responses from several key entities are an inherent component of the inquest process.

The family of John Makai is represented in court, seeking formal accountability, a comprehensive accounting of his final hours, and systemic reform to prevent similar occurrences. Their legal team is expected to challenge the actions and decision-making of the officers involved, questioning why medical help was not summoned immediately upon observing Makai's total unresponsiveness.

The police officers involved in Makai's arrest and custodial handling, along with their legal counsel and police union representatives, are required to give evidence regarding their observations, training, and adherence to departmental procedures. They are anticipated to detail their state of knowledge at the time, explaining how and why they formed the impression that Makai was merely intoxicated. Senior departmental leadership and policy commanders are also expected to address the court regarding station protocols, custodial guidelines, and the adequacy of officer training programs.

What we don't know yet

Despite the significant details revealed on the opening day of the inquest, several critical factual questions remain unanswered in the available record:

What to watch

As the coronial inquiry into John Makai's death progresses, several key developments and decision points will determine the outcome and systemic impact of the proceedings:

This report is based on original news reporting published by Lachlan Abbott.