A doctor who was involved in resuscitating an Indigenous man who died in custody has told a NSW coronial inquest he had never performed CPR on a person before.
David Dungay died in Long Bay Prison Hospital on December 29, 2015, just weeks before he was due to be released.
Five correctional officers forcibly transferred him to a camera-monitored cell after Mr Dungay, a diabetic, refused to stop eating a packet of biscuits.
The 26-year-old screamed “I can’t breathe” a dozen times before he was injected with a powerful sedative.
When he became unresponsive, medical staff took over and unsuccessfully attempted to resuscitate him.
A two-week inquest into the death began in July last year and ran behind schedule but resumed at the NSW Coroners Court in Sydney on Monday.
Trevor Ma, the psychiatric registrar on duty at the time of Dungay’s death in custody, described the situation as an “overwhelming experience”.
“If he would’ve cooperated with moving cell - that would have been an ideal outcome,” Dr Ma said.
Dr Ma told the inquest that he wished he “could’ve done better” and that “regrettably”, the delayed response to chest compressions on Mr Dungay minimised the effect of his resuscitation efforts.
“It certainly wasn’t of a high standard,” he said about the CPR.
Mr Dungay's family members left court before a video of his death was shown, telling NITV that it was “distressing” and “felt like a knife in the heart.”
The video showed Mr Dungay being restrained by correctional officers, losing consciousness and going into cardiac arrest.
The footage also showed Dr Ma attempting to perform CPR on Mr Dungay with chest compressions while two registered nurses attempted to clear his airway.
Dr Ma told the inquest that he had the most medical experience at the time of Mr Dungay’s death so he took charge.
“Mr Dungay was my patient, I feel like I had responsibility to lead the resuscitation,” he said.
“In hindsight, I clearly didn’t do that efficiently.”
“It was a pretty frantic situation.”
After he gave evidence on Tuesday, Dr Ma broke down in tears, prompting Coroner Derek Lee to call for a break in court proceedings.
Paul Sonntag, a nurse educator at Long Bay Hospital, told the court there was a “lack of assertiveness” by all medical staff involved.
“The CPR provided by the Justice Health Service was at a very poor standard,” he said.
Meanwhile at a budget estimates hearing, Corrective Services NSW Commissioner Peter Severin admitted just a few staff had recently begun physical training regarding the dangers of positional asphyxia.
"The physical training, where we actually take the staff through the physical aspects of the application of those techniques, has not commenced until very recently," Mr Severin told the legal affairs hearing.
Further quizzed on how many officers had received physical training, Mr Severin took the question on notice.
He said relevant officers had received some written advice concerning positional asphyxia "pretty much straight away" following Mr Dungay's death.
Greens MP and committee member David Shoebridge said the delay in providing adequate training suggests a "systematic failure" in the NSW prisons system.
"It's a matter of life and death and it hasn't been addressed," he said.