When Darren Culleton's mental health began deteriorating, his family trusted he would be safe in police custody.
"I got a call from Darren from the police station, we thought we were going to see him in a couple of days," his mother Mary said.
"But we didn't."
The 30-year-old presented at St Vincent's Hospital Melbourne, on February 5, 2021, and asked for help.
He was drug-affected, erratic and tried to self-harm at the hospital, with security and medical staff restraining him and calling police.
Mr Culleton told the officers he was feeling suicidal, they handcuffed him and took him into a room.
He was assessed by a psychiatric nurse and registrar, as police continued to restrain him.
While the health professionals found he was a high risk of deliberate or inadvertent self-harm if taken into custody, they found he did not meet the criteria for involuntary hospital admission.
His actions were diagnosed as "behavioural" rather than consistent with a "psychiatric crisis".
Police continued to keep Mr Culleton under arrest, after discovering he was wanted for theft offences.
They did not tell him the reason for his arrest, which added further distress, and put him in the back of a van to take him to Melbourne West police station.
When they arrived, they kept him in the van for almost 20 minutes and then placed him in a shower.
At the station, police told the custody officers "we can't take our eyes off him", assessed him to be a high risk of suicide in custody and decided he should be transferred to Melbourne Custody Centre.
Mr Culleton was placed into a cell and then put back into a police van about 10 minutes later, after making calls to his family.
He was handcuffed, given a disposable jumpsuit known as a coverall, and a suicide-resistant gown.
He was kept inside the van for 48 minutes, during which police opened the door to check on him twice. But while the van was shut for almost 20 minutes he fatally self-harmed.
Police told an inquest they thought he was "acting up" when they saw him thrashing around on the van's cameras.
After noticing he had not moved, police opened the van's door and began performing CPR on Mr Culleton.
He was taken to hospital, where he died about three days later from a brain injury caused by self-harm.
Coroner David Ryan on Thursday found Mr Culleton's death in custody was a "preventable tragedy" and recommended sweeping changes to Victoria Police policy and guidelines.
Further, he found Mr Culleton may not have intended to take his life in the back of the van.
"Darren required care and treatment, which may well have been better provided in a hospital environment, but once he went into police custody Victoria Police was responsible for his safety, security, health and welfare," he said.
Lack of police training, an absence of policy, communication issues and Mr Culleton's self-harm attempts while in custody "led to an unfortunate confluence of circumstances that ultimately led to Darren’s death", he said.
Mr Culleton's grief-stricken family cried after hearing the coroner's findings.
"The police and the hospital are responsible for him passing because they didn't do their job," his mother said, between tears.
"If they did their job, my son would still be here."
The coroner recommended Victoria Police review its custody transfer arrangements, train officers better in communicating about people in custody, review its use of coveralls and gowns, and improve police information systems.
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