Shaun Charles Coolwell was having a violent, drug-induced episode in October 2015 when police were called about 11.30am.
Some 10 minutes later, he was unresponsive. Two hours later, he was dead.
Mr Coolwell was sedated and restrained by Queensland paramedics and police as he went on the rampage in his sister's home in Logan, south of Brisbane.
While he was being restrained, police made a fatal mistake in viewing his sudden non-aggression as compliance. Instead it was a deterioration of his health.
Prior to the arrival of emergency services, the 33-year-old, affected by cannabis and methylamphetamine, banged his head on a bathroom floor and doorframe.
He also kicked a bathroom vanity which resulted in profuse bleeding from his ankle.
When police arrived, they pulled Mr Coolwell by his ankles into the hallway as he thrashed around. Then they handcuffed him with his face to the ground.
He began vomiting and stopped struggling before being injected with the sedative midazolam by paramedics.
Still in a prone position, his breathing became erratic.
When police realised he was unresponsive, he was taken to a couch where resuscitation was performed.
After a three-day inquest in March 2018, Queensland coroner Terry Ryan found that had Mr Coowell been moved from the prone position after he stopped resisting, his chances of survival would have increased.
"The paramedics and police officers who were present interpreted Mr Coolwell's behaviour as compliance with the restraint," Mr Ryan said on Monday.
"There was a basic failure to recognise and respond to his clinical deterioration."
Mr Coolwell struggled for only "a very short time" after he was restrained, the coroner found.
The rest of the time he was restrained, he "required urgent medical attention".
"They (police) should have recognised from their own observations in relation to Mr Coolwell's pulse, breathing and vomiting that restraint was no longer required," Mr Ryan said.
Mr Coolwell was taken to Logan Hospital, where he died.
Mr Ryan found Mr Coolwell, who had existing cardiac issues, died as a result of cardiorespiratory arrest during restraint.
But he stopped short of concluding the restraint alone caused Mr Coolwell's death.
He said it was "inappropriate" that ambulance officers had given him the sedative midazolam because Mr Coolwell was not aggressive when he was injected.
One person at the scene asked, "so he's awake and everything?", moments before he was injected.
Two police officers told the inquest they did everything they could to help Mr Coolwell when they arrived and found him "uncontrollable", bleeding and incoherent.
"I still believe that it was in Mr Coolwell's best interest to be restrained at the time," Constable Tamzin Zarycki said.
Mr Ryan acknowledged responders faced a dynamic and stressful situation.
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