Inquest told man died after lying unconscious in police cell for hours

Victoria Police has admitted failures and apologised after a man died from a brain injury following hours spent unconscious in a suburban holding cell.

Mistakes by officers and staff from Triple Zero Victoria were outlined today during an inquest into the death of John Makai, 58.

Barrister Andrew Imrie, representing the chief commissioner of police, said the care in custody offered to Mr Makai "fell short" of standards required under Victoria Police policy.

"On behalf of Victoria Police, my client offers his sincere condolences to John's family, friends and loved ones," he told the Coroners Court of Victoria.

Mr Makai, who had 10 children and a stepchild, was fondly described by one of his sons as "kind and loving".

However, it was an out-of-character act of violence that brought him to police attention on September 9, 2023.

Mr Makai struck another adult son, Terewa, over the head with a mug after becoming angry about a drink being spilled inside an Uber earlier in the night.

Terewa retaliated and punched Mr Makai in the head, the court heard.

Footage from police body-worn cameras, played to the court, showed officers arriving at the Sunbury home where the fight took place.

Mr Makai and Terewa were bleeding and were being questioned by the officers when Mr Makai lost his balance and fell backwards, crashing into a wooden bookshelf.

Officers were told an ambulance was not available and took a groggy Mr Makai to the Broadmeadows Police Station for observation.

During the ride, Mr Makai lost consciousness and slumped forward, falling off his seat.

On arrival, security cameras captured officers carrying a limp Mr Makai to a holding cell, where he was left on a bed.

For more than four hours he was motionless, and nobody entered the cell to check on him, counsel assisting the inquiry Rachel Ellyard told the court.

Ms Ellyard said officers believed Mr Makai was drunk, when in fact it was likely he was suffering the effects of a traumatic brain injury.

Two staff reported that they had checked on Mr Makai through a cell trap door and reported observing him moving. However, footage played to the court suggested otherwise.

A sergeant made repeated requests to Triple Zero Victoria for an ambulance to be sent to the station, but was told paramedics were too busy.

Later, a Triple Zero Victoria staffer made an "inadvertent error" and cancelled the ambulance to the police station, thinking it was no longer needed.

Eventually the sergeant rang Triple Zero and made an emergency request for help.

"This guy's breathing but we can't raise any verbals from him … we were expecting the ambulance here five hours ago,"

he said.

"I've never known anyone not to stir like this."

An ambulance arrived within minutes and took Mr Makai to hospital. A CT scan revealed evidence of oxygen deprivation to the brain, and Mr Makai was diagnosed with a "non-survivable" injury, the court heard.

His life support was switched off days later.

Ms Ellyard said there had been a "significant departure" from Victoria Police policy by officers who failed to actively check on Mr Makai.

Mr Imrie, the police barrister, said disciplinary action had been taken against some employees.

The inquest will probe whether treatment delays contributed to Mr Makai's death, how police responded and why an ambulance was not called sooner to the police station.

This afternoon, Triple Zero Victoria operations support director Ryan Goon said ambulance cancellation errors were "extremely rare".

The staff member who accidentally cancelled the ambulance to the police station received extra training after Mr Makai's death, Mr Goon said.

Updated software was also being designed to reduce confusion for dispatchers, he said.