A coronial inquest into the death of a man in police custody on a busy Sydney motorway has recommended better CPR training for NSW police officers.

Kevin Edwards, from Shellharbour, south of Wollongong, died in Liverpool Hospital on June 5, 2022, about an hour after he was stopped by police on the M5 in Moorebank.

The inquest heard that Mr Edwards suffered from substance abuse and significant deterioration in mental health before his death.

On June 5, police found him on the highway after he was reported walking east on the westbound roadway.

Officers attempted to restrain him and remove him from the road using pepper spray and handcuffs.

CPR was not performed until paramedics arrived about half an hour after Edwards was taken into custody.

The court also heard that the level of methylamphetamine in Mr Edwards’ blood at the time of his death was in the toxic to lethal range.

Reaction on the side of the motorway

As for why the three officers on the scene did not perform CPR, the first said he could not give any explanation as to why he did not begin CPR.

The second said they decided not to perform CPR on him based on his pulse and believing they could see breathing.

A third said that after seeing breathing, although shallow, and a pulse, he decided he wasn’t going to start CPR.

All three felt that their CPR training was inadequate.

They reported that their training lasted between 5 and 15 minutes, mostly annually.

A police training expert testified that mandatory first aid/CPR training for officers included a PowerPoint presentation combined with a hands-on assessment, but as of 2020 the hands-on assessment was removed to minimize risks associated with COVID-19 transmission.

NSW Police told the inquiry it had a requirement under the decision that “all mandatory training must be completed in one day” but the locations were not always ideal.

Coroner’s findings

NSW Coroner Teresa O’Sullivan on Thursday found Mr Edwards died during a mental health episode while being restrained by police who were trying to prevent harm to him and others on the M5.

She found that the cause of his death could not be determined.

While acknowledging that the police actions were “reasonable and appropriate in the circumstances, despite some shortcomings”, she criticized the quality of the CPR training provided.

System failures

Ms O’Sullivan made a number of recommendations to NSW Police, highlighting the need for better training for officers in recognizing when to start CPR.

She recommended annual CPR training be held in facilities equipped for hands-on demonstrations, including videos.

She also recommended that training materials be externally reviewed to ensure they meet Australian Resuscitation Council guidelines.

Ms O’Sullivan said the recommendations aimed to address “systemic failures in police training on mental health crises and CPR response”.

She also acknowledged the mutual compassion shown between Mr Edwards’ family and the officers involved.

In a statement, NSW Police said it acknowledged the coroner’s recommendations and would consider them in due course.

Family Concern for Mental Health Care

Diane and Glen Edwards said their son Kevin, whom they called “boomerang” because he would sometimes leave home but always return, had struggled with addiction his entire adult life.

A statement released by the ABC said he had been discharged from the Elura psychiatric unit at Shellharbour Hospital six days before his death and they remained concerned about the manner of his discharge.

“Now that we have heard Shellharbour Hospital’s evidence into this inquiry, our previous impression that the mentally ill in NSW are doomed to fail has only been strengthened,” they said.

“The mental health system is a revolving door of freeing up beds rather than effectively treating someone.

“They just patch them up and push them out to figure it out on their own.”

They said their son “taught our family not to judge people, but to sympathize with those who are fighting for life.”

Ms O’Sullivan acknowledged her family’s concerns but felt his dismissal was overall appropriate.

The Illawarra Shoalhaven Local Health District has been contacted for comment.