An ambulance wasn't called for an Aboriginal woman struggling to speak and moaning on a train despite police guidelines saying it should have been, an inquest has been told.
Tanya Day, 55, died from a brain haemorrhage suffered in police custody in December 2017 after being taken off a train at Castlemaine because she was intoxicated.
Officers called to the train station after being told she was inebriated and unruly decided an ambulance wasn't needed.
Tanya Day died in December 2017 after being arrested for public drunkenness Source: Supplied
"As each minute ticked by her responses were getting better," Senior Constable Stephen Thomas told the inquiry in Melbourne on Wednesday.
This was despite police guidelines requiring people giving unintelligible responses and slurred speech to be taken to hospital or receive urgent medical help.
He also did not consider taking her to the hospital directly, though it was minutes away.
Sen Const Thomas ideally wanted to call someone who knew Ms Day to come and get her and said taking her to the police cells was a last resort.
He told the inquiry he considered leaving her on the train but decided not to.
"I was worried I'd be liable for something that happened if I left her there," he said.
Leaving her at the train station with V/Line staff was another option but he didn't feel it was appropriate.
Sen Const Thomas revealed to the coroner he did not formally caution Ms Day that she was under arrest and said it was "the most low key arrest I've ever done".
"I didn't formally say, 'you are now under arrest', I just expressed I wanted her to come with me and I guess by compelling her to come with me that's a form of arrest," he said.
Police officers did not enter her cell until she was due to be released later that night, despite deciding she should be physically roused every 40 minutes.
CCTV footage showed she hit her head five times while in the cell. She died in hospital 17 days later from brain injuries.
Coroner Caitlin English is examining whether racism contributed to Ms Day's death.
The court was shown CCTV footage collected from the railway platform, which features V/Line staff and police entering the train and re-emerging with Ms Day.
They interact with her as she briefly sits on a bench before the group moves to the car park and she is put in a divisional van.
with AAP...
