The NSW Coroner has criticised a police officer and recommended his actions be investigated further after an inquest heard he watched a man fall to the floor and have a 20-second fit but failed to provide any medical assistance.
"His responses and lack of responses were extremely concerning," Judge Joan Baptie said.
The coroner found Griffith father Hugo Diaz Knox died of a cocaine overdose while in police custody at Cootamundra in southern NSW on September 30, 2022.
The 25-year-old was arrested at a random traffic stop after testing positive for cocaine earlier that day in Stockinbingal.
He was taken to Cootamundra Police Station, where police discovered a white substance in his underpants during a search.
During the inquest, the court heard that in the time between being arrested and transported to the police station, Mr Knox likely ingested two bags of cocaine.
Judge Baptie found he had been able to do this without police suspecting anything due to the "partial or limited view" police officers had inside the police wagon.
It was noted in the findings that video and audio monitoring were currently being rolled out in NSW police fleet wagons, set to be completed by mid 2028.
Judge Baptie said while CCTV would not have stopped Mr Knox from ingesting the drugs, it would have informed the attending officers of the need for medical assistance.
The inquest also heard police had observed "snorting and sniffing", and it was likely he consumed more cocaine through his nose while in his cell.
Just after 7pm, Senior Constable Cameron Smith, who was charged with observing Mr Knox, watched him fall and suffer a seizure; however, he failed to enter the cell to provide first aid or call for help.
He remained unsupervised until 7:20pm, before another officer noticed blood on his nose and called for medical assistance.
By the time paramedics arrived at 7:45pm, he was unresponsive and he died in hospital around 9pm.
Further investigation of officer recommended
As part of her findings, Judge Baptie said Senior Constable Smith's explanation for his inaction was "perplexing and concerning".
"Evidence showed him looking at the cell, hands in pockets, providing no effort to support him or notify others [while he was having a seizure]," Judge Baptie said while delivering her findings.
Despite recommending his conduct be investigated by the Professional Standards Command, she found no action from police would have prevented Mr Knox's death.
"It is likely, in my view, Mr Knox would have died in whatever body measures were implemented at the police station," she said.
She did, however, recommend a review of the charge room and custody management of prisoners.
An autopsy report showed the amount of cocaine in Mr Knox's blood at the time of his death was 35 mg/L.
An expert had told the inquiry a fatal dose could be as little as 3mg/L, depending on how it is ingested.
Police policies require officers to seek medical attention immediately when a drug or harmful substance is swallowed.
The inquest heard that because police suspected he had snorted cocaine, they suspected smaller quantities were involved, and the risk was lower.
However, Judge Baptie recommended this policy be updated to include broader language where, if it was suspected any harmful substance had been taken, medical assistance should be sought.
While delivering her findings, she acknowledged the anguish of Mr Knox's family, who have been actively involved in proceedings.
The inquest previously heard from his mother, sister and brothers who reflected on their grief and anguish over his death.
"We are facing worse than our worst nightmare. Living without our child, our hearts are shattered," his mother Virginia previously said.
"[He was a] little ray of sunshine that bound our blended family together."
