Paramedic care 'below reasonable standard' in death in custody, coroner finds

ABC Coffs Coast

Topic:Courts

Phillip Mark Walton died while in custody at Casino Police Station in March 2023. (Supplied: Ian Walton)

In brief:

Coroner Kasey Pearce has found paramedic care was "below a reasonable standard" in the death of Phillip Mark Walton at Casino Police Station in northern NSW in 2023.

She found police actions in restraining the 48-year-old man were appropriate in the circumstances, although they contributed to his death.

What's next?

The coroner will supply transcripts of the inquest's evidence to the Paramedicine Council of NSW.

A coroner has referred the actions of two paramedics, who treated a man who died in custody, for review by health authorities.

Deputy State Coroner Kasey Pearce said the paramedic examination of Phillip Mark Walton in Casino Police Station lasted just 45 seconds and the patient was not touched to check vital signs.

"In my view, this did not comply with the policy of New South Wales Ambulance Service and fell below the reasonable standard of care," Coroner Pearce said.

Lismore ambulance station officer Tracey Wheeler entered the custody dock to assess Mr Walton, observed by fellow paramedic, Sharon Chapman outside the room.

Given the "reasonable grounds" for a complaint of "unprofessional conduct," the coroner will send a transcript of evidence to the Paramedicine Council of New South Wales.

The coroner found the actions of two NSW Ambulance paramedics "fell below a reasonable standard of care". (ABC News: Timothy Ailwood)

The findings follow the inquest into the death of 48-year-old Phillip Mark Walton at Casino Police Station in March 2023, in hearings in Lismore Court in October 2025.

Police were called to the Casino Showgrounds on March 19, 2023, to reports Mr Walton was assaulting two circus staff members.

During an intense struggle to arrest him, police officers described using pepper spray and two police taser cycles, before being able to handcuff him.

The court heard two of the police officers attending the circus were not wearing body-worn cameras and a third did not activate a camera.

The inquest focused on events at Casino Police Station, where paramedics arrived to assess Mr Walton after the use of pepper spray and taser and his admission to taking cannabis, and having schizophrenia.

Paramedics arrived to assess Phillip Mark Walton at Casino Police Station. (ABC North Coast: Catherine Marciniak)

Coroner Pearce repeated the evidence of Ms Wheeler's observations of a man sitting calmly, not agitated, making eye contact, pupils not dilated, who confirmed the taser barb was removed, no signs of swollen eyes and who said he was not injured.

"Once she stepped back and the door was closed, she made no additional attempt to obtain additional information from Phillip, although she could have asked further questions through the door."

Shortly after paramedics left the station, Phillip Walton repeatedly struck his head on a perspex screen.

Phillip Mark Walton's relatives told the coronial inquest of his love for his family. (Supplied: Ian Walton )

In delivering her findings in Lidcombe Coroners Court on Friday, Coroner Pearce said viewing police station video footage of his behaviour was "confronting".

"Once Phillip Walton began harming himself, police officers had little option but to remove him from the cell, but in view of his continued resistance, were forced to use a method of restraint with inherent risk.

Supervising officer Sergeant Wayne Crotty pinned his head and torso to the floor and paramedics were called back to the station.

"I am not satisfied the restraint was inappropriate or disproportionate to the circumstances."

She determined Mr Walton's sudden death from cardiac arrhythmia was caused by factors including cardiovascular health, physical exertion and hypoxia resulting from his restraint.

Coroner Pearce described the restraint as lasting 1 minute and 40 seconds and when he ceased moving, he was immediately released and turned onto his back for resuscitation, but he could not be revived.

In considering the impact of Mr Walton's schizophrenia, she found expert testimony had persuaded her, that he "understood the importance of his medication and was committed to taking it".

The coroner referenced evidence by Associate Professor Danny Sullivan, a consultant forensic and adult psychiatrist, describing Mr Walton as "exquisitely sensitive to cannabis" and that his taking cannabis that day had led to an "acute onset of psychosis with disorganised, agitated behaviour" at the circus.

Phillip Mark Walton's family: Sharon Olive (front centre) with stepdaughter Jacinda Olive, husband Phillip Olive, daughter Loeen Howse and son Ian Walton. (ABC News)

Several members of Phillip Walton's family viewed the coroner's findings on videolink.

The counsel representing the family had asked for the coroner to consider recommending police protocols in the use of weighted restraint and for transcripts to be provided to health complaint authorities.

"We have heard Phillip Walton was a much-loved member of an extended family, he loved music, was a Parramatta Eels fan and a great darts player," Coroner Pearce said.

New South Wales Ambulance was contacted for comment.

The coronial inquest's hearings were in the Lismore courthouse. (ABC North Coast: David Kirkpatrick)