Staff at a watch house in south-east Queensland failed to properly check on a woman 11 times the night she died in a cell five years ago, an inquest has heard.
A joint coronial inquiry is underway in the Coroners Court in Brisbane into the deaths of Vlasta Wylucki, 50, and Indigenous woman Shiralee Tilberoo, 49, who both died of natural causes while in custody.
The Deputy State Coroner is probing the adequacy and appropriateness of the supervision and care both women received while they were detained in watch houses.
On the first day of a week-long hearing, the court heard evidence about Ms Wylucki's treatment in the Southport Watchhouse in March 2018 on the night she suffered arrhythmia, which is a fatal irregular heartbeat.
The court heard after being taken into custody, Ms Wylucki told staff she had consumed two bottles of wine and disclosed she had a heart condition for which she was medicated.
'Happy, friendly and talkative'
After surrendering her medicine, she said she did not need to take them that night, the court heard.
Shift supervisor Sergeant Lyle Wiss told the court that before she was placed in a cell with another woman, Ms Wylucki seemed slightly intoxicated but otherwise "happy, friendly [and] talkative".
"She wasn't slurring her speech, she wasn't stumbling … [she was] talking to us like a normal person," he said.
The court heard that during the night, Ms Wylucki became unwell and began throwing up.
At one point, her cellmate asked if she was OK, to which she replied she was sick, but neither raised the alarm with staff through the intercom system, the court heard.
The court was shown CCTV of watch house officers carrying out a number of checks through the door of her cell where Ms Wylucki could be seen positioned behind a concrete wall.
The vision also showed one instance of an officer entering the cell and shining a torch toward her.
When asked what checks would have taken place by staff, Sergeant Wiss testified that "camera checks" were carried out every 30 minutes, where officers would inspect the cells via the live CCTV.
He said they also did hourly "physical checks", and if inmates were asleep, staff would need to sight the "rise and fall in their chest" to determine they were breathing.
Watch house 'understaffed'
Sergeant Wiss, who did not personally conduct any checks that night, told the court he believed the watch house had been understaffed, and that at any given time five officers would have to supervise between 60 to 70 prisoners.
He described the environment at the watch house as "loud", "busy" and "stressful".
"It's dynamic. It could be nothing happening then next minute … all hell could break loose," he said.
Senior watch house officer Daniel Marshall told the court the cell which Ms Wylucki had been placed in was known for being hard to carry out "physical checks" due to its configuration.
"It's been brought up many times," he said.
Mr Marshall said since Ms Wylucki's death, that particular cell, and another that was similar in layout, was now only allowed to hold one person.
"I believe it came about after this incident," he said.
Detective Senior Sergeant Sharon Pickett carried out an internal police investigation into the death and also gave evidence.
She told the court she determined of the 13 physical checks of Ms Wylucki, 11 did not comply with policy, which required officers to "actually see [her]" and ensure people are "breathing comfortably and if they are well".
"[Checks] were not being conducted in compliance with positioning of prisoners," she said.
Detective Senior Sergeant Pickett told the court disciplinary action was taken against officers on the night, but her investigation found there was no evidence of misconduct and no one person caused Ms Wylucki's death.
Officers 'should have done more'
The final witness, Inspector Marcus Cryer, testified as a custody expert and told the court it was clear the officers conducting checks "should have done more".
"In my opinion, it was too quick of an inspection."
Inspector Marcus Cryer also noted that staff should have been watching the CCTV continuously, not every half hour.
"Every other watch house I know does that," he said.
The court also heard no watch house officers had medical training and there were no medical professionals stationed at the watch house around-the-clock.
'It needs to stop'
Outside court, Ms Wylucki's daughter Laura described her mother as a "loving, caring and kind-hearted woman" and said she deserved better.
"No matter who they are, what they are doing … no one should be treated like this at all," she said.
"It needs to stop and something needs to be done about it, otherwise other people are going to die."
Ms Wylucki said seeing the footage of her mother in court was "disgusting".
"Nothing was done to prevent this," she said.
"We need better checks — better everything."
The inquest continues.
