A coroner has criticised police and paramedics for failing to recognise the deteriorating condition of an Indigenous man during a drug-induced episode in the hours prior to his death.
Shaun Coolwell, 33, died in custody in 2015 at a Brisbane property after being restrained and sedated by police.
On Monday, Queensland coroner Terry Ryan handed down the findings of an inquest into his death, but Mr Coolwell's family say they weren't notified.
Mr Coolwell's sister, Sonya Coghill, said she was "in shock".
"The family was all gathered and we would have made it an issue to be there," Ms Coghill told NITV News.
"None of my siblings have been contacted or informed to my knowledge.
"There’s so many components with this entire deaths in custody [process] that aren’t adhered to."
'There was a basic failure to recognise and respond to his clinical deterioration.'
The inquest previously heard police and paramedics were called to an address in Kingston, south of Brisbane, after Mr Coolwell injured himself in a "violent", drug-induced episode and locked himself in the bathroom.
Police restrained Mr Coolwell in a hallway, placing him in the prone position for around 10 minutes before administering the sedative, medazolam.
He lost consciousness and died hours later in Logan Hospital.
The coroner said that while the initial restraint was necessary for Mr Coolwell's own safety, he "only struggled for a very short time".
From that point, he said, Mr Coolwell "required urgent medical attention".
"The sudden change in Mr Coolwell’s agitated state should have resulted in a very detailed review of his condition," My Ryan said.
"There was a basic failure to recognise and respond to his clinical deterioration."
He said the administration of medazolam was “clearly inappropriate” given Mr Coolwell's condition at the time, but stopped short of attributing either the physical or chemical restraint as the sole cause of death.
The coroner found Mr Coolwell died as a result of cardiorespiratory arrest during restraint, combined with an existing heart condition, methamphetamine use, injuries and stress.
"It is not possible to separate the various factors that contributed to Mr Coolwell’s death," he said.
He made two recommendations to improve Queensland police and ambulance procedures regarding the use of restraints.
Mr Coolwell's older brother, Bradley, also died in custody in 2011.
Sonya Coghill said the family wanted further action.
"The coronial court determines the cause of the incident, that’s all it does. It does not give anyone justice," she said.