Coroner's Court of Western Australia

Inquest into the Death of Cherdeena Shaye WYNNE

Inquest into the Death of Cherdeena Shaye WYNNE

Delivered on : 1 April 2022

Delivered at : Perth

Finding of : Coroner Urquhart

Recommendations : Yes

The WAPF should ensure that training in relation to the use of the prone position as a restraint reinforces (i) the increased risk of a potentially fatal health event to the subject person in the prone position and (ii) the need for officers to effectively monitor their breathing.

Further, such training should emphasise that any physical restraint by pressing down on the chest, back or stomach of the subject person in the prone position should only be used in exceptional circumstances.

Orders/Rules : N/A

Suppression Order : N/A

Summary : On 4 April 2019, Ms Wynne was restrained by members of the Western Australia Police Force (WAPF). She suddenly became unresponsive during this restraint. On 9 April 2019, at Royal Perth Hospital, Ms Wynne died from hypoxic ischaemic encephalopathy and bronchopneumonia in a woman with methylamphetamine effect and exertion with restraint. She was 26 years old.

Ms Wynne’s death was subject to an inquest hearing as it appeared her death was caused, or contributed to, by any action of a member of the WAPF.

On the evening of 24 March 2019, Ms Wynne was conveyed by ambulance to the Joondalup Health Campus with her 23-month-old daughter. Ms Wynne’s behaviour at the hospital was documented as erratic and possibly influenced by drug use. Prior to being seen by medical staff, Ms Wynne left with her daughter, and as medical staff had concerns for her welfare and her daughter, police were contacted.  A member of the public who had been awoken by Ms Wynne knocking at their door asking for help, took Ms Wynne to the hospital with her daughter in the early hours of 25 March 2019.  Ms Wynne was assessed and a view was formed that she was in need of an involuntary inpatient admission.

On the afternoon of 26 March 2019, Ms Wynne was able to abscond from the hospital and police were advised.  A high alert police task was created, noting Ms Wynne was a mental health absconder who was a risk to herself and others. On 30 March 2019, a police officer stationed at the State Operations Command Centre, reviewed the police task for Ms Wynne and noted that the Apprehension and Return Order was invalid. Police therefore had no authority to apprehend Ms Wynne unless attending police officers drew their own conclusions that Ms Wynne’s behaviour posed a danger to herself or to others and required a hospital admission.

At about 5.45 am on 4 April 2019, police observed a hooded figure in East Victoria Park but the figure fled on foot before they could be spoken to. The two police officers who gave chase could not locate the person. A short time later, other police attended a nearby unit and located Ms Wynne who appeared to be out of breath as if she had been running. She became quite agitated while being questioned by police officers. After becoming increasingly more agitated, Ms Wynne was handcuffed for her own safety and of those persons present.  She was taken outside where she explained that she had earlier run away because she was scared and nervous. Ms Wynne was then released from the handcuffs as police held no welfare concerns for her and they left the premises.

At about 6.45 am that same morning, a civilian saw Ms Wynne walking along the street holding a stick and repeatedly striking herself to the side of the neck. She then walked onto the roadway and collapsed.  Police and St John Ambulance paramedics attended and found Ms Wynne conscious with abrasions to her neck which were bleeding. She was hyperventilating and said she felt suicidal. Ms Wynne claimed to have taken methylamphetamine and cocaine and requested that the paramedics sedate her. The paramedics advised police that they did not deem Ms Wynne to be a threat and they did not require their assistance in taking her to Royal Perth Hospital.

As the ambulance was about to depart, Ms Wynne became highly agitated. She removed her seatbelts and tried to get out of the ambulance by the rear and then the side door. Ms Wynne was able to exit the ambulance by climbing out of the front driver’s side door while the driver was outside the ambulance. Ms Wynne still had medical intervention equipment attached to her, including a cannula in her arm.  Ms Wynne ran away from the ambulance, removing the cannula from her arm but retaining it in her hand. Paramedics contacted police for assistance and began following Ms Wynne as she ran onto Albany Highway. As Ms Wynne ran along the centre of Albany Highway, passing traffic had to slow down and drive around her.

Police pursued Ms Wynne by vehicle and then on foot before apprehending her on Albany Highway in Bentley. She was then led from the highway onto the grass verge. When Ms Wynne pulled away from police a decision was made to handcuff her to overcome her resistance. She was placed onto the ground on her stomach (the prone position) for the handcuffs to be applied. Once Ms Wynne was handcuffed, police noticed that she was holding the cannula in her fist. They thought it was a syringe and one of them made Ms Wynne release it whilst she was still in the prone position.  As this restraint was taking place, paramedics from the ambulance that Ms Wynne had fled from had arrived on the scene. Police then raised Ms Wynne up as a paramedic tried to speak to her, however, Ms Wynne was limp. She was observed to have glazed eyes which were rolled back and she was unresponsive. Police removed the handcuffs and CPR was commenced and continued until signs of life returned. Ms Wynne was then transported by ambulance to RPH.

A CT scan was undertaken at the hospital which showed Ms Wynne had a severe hypoxic brain injury and she was admitted to the Intensive Care unit. Unfortunately, Ms Wynne never regained consciousness and life support was withdrawn five days later.

The Coroner found that Ms Wynne had a cardiac arrest that led to her death after she was apprehended and then restrained by police. The factors that contributed to this cardiac arrest included Ms Wynne’s methylamphetamine intoxication, her physical exertions before her apprehension and her restraint by police in the prone position. The Coroner also found that (i) a police officer maintained his leg hold across Ms Wynne’s upper back for longer than was necessary, (ii) this resulted in police keeping Ms Wynne in the prone position for an unnecessary length of time and (iii) police failed to adequately monitor Ms Wynne’s breathing whilst she was restrained in the prone position.

The Coroner made a recommendation to improve the training for police officers in relation to the use of the prone position as a restraint. The Coroner found Ms Wynne died by way of accident.

Catch Words : Death in police presence : Methylamphetamine effect and exertion with restraint : Mental Health : Accident

Last updated: 27-Apr-2022

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