John Makai was unresponsive when dragged from a Victoria police van. Just one of many ‘shortcomings’ inquest has heard so far

Many mistakes were made in the almost eight hours between John Makai’s son spilling a drink in the back of an Uber, and paramedics arriving at a Melbourne police station to find Makai unresponsive in a cell.

As the Victorian coroner’s court heard this week, it was not clear which – if any – of these mistakes contributed to Makai’s death in September 2023.

What is clear is that police failed to properly care for a 58-year-old father of 10 in their cells, leading to an apology from the state’s most senior police officer, and another inquest into a death in custody.

“It is always a tragedy when a person passes away as John did in connection with their time in police custody, and it’s… a situation that Victoria police and all its members and employees work tirelessly to avoid,” Andrew Imrie, the lawyer for the chief commissioner, Mike Bush, told the court this week.

“My client acknowledges at the outset of this inquest that John’s care while he was in custody fell short of the standards required by Victoria police policy and [Bush]’s expectations of its members.

“As the evidence currently stands, it’s unclear whether these shortcomings would have made any difference to the tragic outcome in this case, but [Bush] acknowledges those shortcomings and offers his apology to John’s family, friends, and loved ones that the care he received in police custody was not of the standard that he or indeed any other member of the Victorian community was entitled to expect.”

Makai died after police visited a house in Sunbury, north-west of Melbourne – after a dispute between him and his son, Terewa, over the spilt drink.

Makai had reacted angrily and struck his son, who told police he punched him back twice in the face in self-defence.

When police arrived, both men were bleeding and remained acrimonious.

Makai was unsteady on his feet, and at one point, collapsed into a bookcasewhile trying to sit down.

A decision was made that he should be given a directive, though not arrested, and transported to the Broadmeadows police station because of his alleged role in a family violence incident, and his level of intoxication.

Police thought an ambulance would meet them there. But he deteriorated during the approximately 20-minute drive, and no ambulance was there when they arrived.

Makai’s condition had deteriorated from struggling to walk from the house to the police van, to being unresponsive upon arrival at the station.

He was dragged from the back of the van by his feet, his head lolling and striking the wall and door on the way out, before he was carried face down into a cell.

Makai was placed in what was known as the coma position, and he stayed there, without moving, for most of the next five hours, until police became concerned and again called for an ambulance.

Paramedics found signs of a brain injury, which were confirmed when Makai arrived at hospital. He was diagnosed with a non-survival brain injury and died in hospital two days later.

The entirety of the police interaction with Makai – from arriving at the house in Sunbury, to the transportation from the house to the van, to arriving at the station and being carried from the van to the cell, and every minute he spent in custody before leaving in an ambulance – was captured on body-worn or CCTV cameras.

The “shortcomings” acknowledged by Imrie started at the point he arrived at the station.

He said police failed to conduct an adequate medical assessment at the station, including receiving a verbal response from Makai to determine his “coma scale” score, a measure used to assess a person’s consciousness.

“A deterioration in John’s conscious state at or around the time he arrived at Broadmeadows police station, and the need for urgent medical attention that represented, should have been identified and acted upon,” Imrie said.

Having been accepted into police custody, there was a failure to conduct and complete a detainee risk assessment and to send that assessment to the custodial health service, Imrie said.

There was also a failure to conduct adequate checks on Makai, with Imrie saying that at a minimum he should have been physically checked and roused every 30 minutes.

Disciplinary action had been taken in relation to the incident, Imrie said, and police would work with the coroner “to improve systems and processes so that such an outcome might be avoided in the future.”

Other errors already outlined in court include the emergency call operator, Triple Zero, admitting it wrongly cancelling an ambulance multiple times in Makai’s case, including when one had been requested by Broadmeadows police.

The police and custody officers – unsworn employees who can legally monitor those in custody at some police stations – who have given evidence at the inquest have acknowledged some of their mistakes, but balked at others.

When Makai collapsed into the bookcase in Sunbury, the four officers in the house did not immediately respond to help him.

The most senior officer present, Sgt Matthew Wilson-Hawe, is seen on camera footage walking away from Makai, admitting in court that he was frustrated Makai had not been listening to him when he insisted he should sit down and required medical care.

He told the court that the appropriate response would have been to go to Makai’s assistance and assess whether he had acquired a further head injury.

“I’m not proud that I didn’t run in and help him,” Wilson-Hawe said.

A postmortem has found that Makai died from a head injury sustained from the assault and possibly the fall, but not from hitting his head while being dragged from the police van.

Constable Taylor Tzouroutis, who was also at the Sunbury house and helped move Makai into a cell after arriving at the station, disputed he was dragged at all.

“The manner in which John was dragged out of the vehicle, hitting his head and carried prone down the hallway, was inappropriate and undignified,” Stella Gold SC, for Makai’s family, said in court this week.

“What do you say to that?”

Tzouroutis responded: “Again, I don’t think he was dragged. I think ‘drag’ can come with different understanding and meaning.

“I think that we did the best that we could to make sure that he was safely put into the holding cell.”

First Constable Abdelrahaman Bakri also disagreed when asked by Gold if he thought dragging Makai in that way from the van was inappropriate and undignified.

“He keeps his dignity,” Bakri said.

“I believe it was necessary at the time.

“It didn’t have anything [to do] with the … dignified or not dignified. It was a physical movement required or physical action required by myself to assist John in getting him out of the van.”

While the footage central to the case was shown in court this week, it may not ever be published – coroner Paresa Spanos has ruled that it should not be released to the media.

Paramedics and the sergeant in charge of the Broadmeadows cells are expected to give evidence when the inquest resumes on Monday.