A Western Australian coroner has criticised police offices for their “woefully inadequate” monitoring of an Aboriginal woman’s breathing after she was pinned to the ground and lost consciousness before being allowed to sit up.

Cherdeena Wynne, a 26-year-old Noongar Yamatji woman, died in hospital five days after she was pinned in a prone position by police officers, one of whom had his knee on her shoulder blades and leg across her upper back for almost two minutes.

Her father died in custody 20 years before – also at the age of 26.

The coroner ruled her death accidental, finding she experienced a cardiac arrest which was contributed to by methylamphetamine intoxication, her physical exertions before her apprehension and her restraint in a prone position.

Wynne was restrained by police on 4 April 2019 after she had fled from an ambulance in severe mental distress and had been walking on Albany Highway, a busy arterial road in Perth, in peak-hour traffic, allegedly trying to walk in front of cars.

She was led off the road by police and placed into a prone position, lying on her stomach with her hands behind her back, on a grassy verge beside the highway.

At an inquest into her death, three police officers involved in the restraint said that they placed her in that position because she was resisting and they were worried she would run back onto the highway.

One officer, First Class Const Shaun O’Callaghan, placed one of his legs across Wynne’s hamstrings. Another, Sgt Jace Williams, put a leg over her upper back and kept it there while Wynne was placed in handcuffs.

A cannula Wynne had removed from her hand after fleeing the ambulance – and which police thought was a syringe – was thrown clear.

The coroner investigating her death, Philip Urquhart, did not make any findings of fault or blame against individual police officers.

He said while the decision to handcuff Wynne in the prone position could be justified at the “very upper threshold of what I regard to be a reasonable response”, the time taken by police to remove their weight and sit her up was not justified.

In his 100-page findings, released on Wednesday, Urquhart said it was “unnecessary and not appropriate for Officer Williams to continue to restrain Ms Wynne with his leg across her upper back after the cannula was removed from her hand”.

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Urquhart agreed to a request by Wynne’s family to release CCTV footage of her restraint – which shows Williams kept his leg on her back for almost a minute after she was handcuffed and the cannula was removed.

That process, of handcuffing and removing the cannula, took 45 seconds. The footage shows she was held in a prone position for one minute and 50 seconds.

“It is impossible to say whether the unjustified delay of about one minute to lift Ms Wynne from the prone position contributed to her cardiac arrest,” Urquhart said. “That is because it cannot be established, with any degree of certainty, precisely when she stopped breathing.”

He said the monitoring of Wynne’s breathing while she was in the prone position “was not only woefully inadequate but I am satisfied there was no monitoring during this critical period that was effective in ensuring Ms Wynne had no breathing difficulties”.

He dismissed suggestions by police that Wynne was trying to resist apprehension as inconsistent with the CCTV footage. “Any movement that Ms Wynne may have achieved before she became unconscious was most likely due to her inability to breathe, rather than an attempt to resist or escape,” the coroner said.

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Urquhart criticised the internal police investigation which found police had acted in line with policy and procedures.

“How it could be said that the restraint and handcuffing of Ms Wynne ‘was done in line with policy and procedures’ when no officer had effectively monitored her breathing is, quite frankly, incomprehensible,” he said.

He said that the inconsistency between the statements given by police, which suggested Wynne was sat up as soon as the cannula was removed, and the delay as shown on CCTV, was “very troubling”.

Police said they did not notice Wynne had stopped breathing until they sat her up and noticed she had lost consciousness and her eyes had gone glassy. Paramedics, who were nearby to return Wynne to the ambulance, noted she had no pulse and performed CPR for 12 to 14 minutes to return a pulse before taking her to Royal Perth hospital. She died, without regaining consciousness, on 9 April 2019.

An autopsy listed her cause of death as hypoxic ischemic encephalopathy and bronchopneumonia in a woman with methylamphetamine effect and exertion with restraint. The pathologists told the inquest it was “very difficult to definitively either include or exclude positional asphyxia as having played a role in the death” because there were other factors, notably methylamphetamine use and significant physical exertion, which also contributed.

“When multiple factors have contributed to a death, it is essentially not possible to tease out the exact contribution of each of those factors, other than to say that they have all contributed,” the pathology report concluded.

Urquhart said it was “distinctly possible” that positional asphyxia was a contributing factor in her death. His formal finding was death by accident.

He said if there had been proper monitoring of Wynne’s breathing “then her cardiac arrest may well have been detected earlier”. But he said it was not open to him to find that would have made a material difference in the outcome.

The coroner recommended WA police training on the use of the prone position as a form of restraint should reinforce the need for officers to effectively monitor breathing.

Training should also emphasise that physical restraint by pressing down on the chest, back or stomach of a person in the prone position should only be used in “exceptional circumstances”.

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