A coroner’s inquest has heard a series of alleged failures preceded the death of a 58-year-old man who was found unresponsive in a Melbourne police station cell in September 2023. The Victorian Coroners Court was told this week that John Makai died two days later in hospital, after being left in the cell for around five hours.
The inquest, which is examining the circumstances surrounding Mr Makai’s death, has heard evidence about the roughly eight hours between an incident in the back of an Uber and paramedics arriving at the police station to find him unresponsive. Counsel assisting the coroner told the court it remains unclear which, if any, of the issues raised so far contributed to his death.
What the court has been told so far #
According to evidence given to the inquest, the sequence of events began after Mr Makai’s son reported a spilled drink during an Uber trip. Court documents and evidence presented this week trace a chain of interactions involving the rideshare trip, an emergency call, and the eventual attendance of Victoria Police officers, before Mr Makai was taken into custody and transported to a suburban police station in a police van.
The inquest was told Mr Makai was unresponsive by the time he was removed from the van. He was then held in a cell for approximately five hours before paramedics were called, the court heard. He died in hospital two days later.
Victoria Police has not been found to have acted unlawfully, and no findings of wrongdoing have yet been made by the coroner. The inquest is ongoing and is specifically tasked with establishing the facts of what occurred, including any systemic issues that may have contributed to the outcome.
‘Shortcomings’ raised in evidence #
Counsel assisting the coroner has outlined to the court a number of alleged shortcomings in how Mr Makai was dealt with across the evening, including in relation to welfare checks, communication between police and paramedics, and decisions made about his transport and detention. These matters were raised as issues for the coroner to consider, rather than as findings of fact.
The court was told that the exact cause of Mr Makai’s death, and whether any of the alleged shortcomings identified so far played a role, is yet to be determined. Medical and expert evidence is expected to be given as the inquest continues, which may assist the coroner in reaching findings on causation.
It is a core function of Victorian coronial inquests to examine not just how a person died, but whether any systems, procedures or decisions by authorities — including Victoria Police and Ambulance Victoria — might have contributed, with a view to preventing similar deaths in future. The coroner is empowered to make recommendations but not to make findings of criminal or civil liability.
How coronial inquests work in Victoria #
Under the Coroners Act 2008 (Vic), any death that occurs while a person is in custody or care — including in a police cell or during transport by police — must be reported to the coroner and is subject to a mandatory inquest. This reflects the heightened public interest in deaths that occur while a person is under the control or supervision of the state.
Inquests differ from criminal trials. There is no prosecution or defence, no charges are laid as part of the process, and no finding of guilt can be made. Instead, the coroner’s role is to determine, where possible, the identity of the deceased, the cause and circumstances of death, and whether any recommendations should be made to prevent similar deaths occurring again. Findings are made on the civil standard of proof — the balance of probabilities — rather than the higher criminal standard.
Family members, Victoria Police, Ambulance Victoria and other relevant parties are typically granted “interested party” status, allowing their legal representatives to question witnesses and make submissions. It is common, as appears to be the case in this matter, for evidence to span several hearing days and for findings to be reserved until all evidence has been heard.
What happens next #
The inquest into Mr Makai’s death is continuing, with further evidence expected from witnesses including police officers, paramedics, and medical experts who may give opinion evidence on the cause of death and any contributing factors. VCN understands the hearing is expected to run over multiple sitting days.
Victoria Police has been contacted for comment. VCN will continue to follow the inquest and report on the coroner’s findings once they are handed down. As with all coronial matters, no conclusions about the conduct of any individual or organisation should be drawn until the coroner delivers final findings.
This masthead is not suggesting any individual officer or paramedic acted unlawfully; the purpose of the inquest is precisely to establish what occurred and whether anything could have been done differently. Deaths in custody carry particular weight in Victoria given the state’s history of coronial scrutiny in this area, including past recommendations around mental health response, welfare checks and inter-agency communication between police and health services.
Why these inquests matter #
Coronial findings into deaths in custody have previously led to changes in Victoria Police procedure, including protocols for medical assessment prior to detention and requirements around welfare checks for people held in cells. Advocacy groups and families of people who have died in custody have long called for stronger independent oversight of these deaths, and inquests such as this one form a key part of the public record on how the system responds when something goes wrong.
VCN has previously reported on coronial findings into other Victorian deaths in custody, and on the broader debate about police mental health response protocols. Readers can find background on the coronial process via the Coroners Court of Victoria.
The matter is currently before the courts. No findings have yet been made and all evidence remains subject to the coroner’s final determination.
Support is available. Anyone affected by issues raised in this story, including family violence, mental health concerns or the loss of a loved one, can contact Lifeline on 13 11 14, Beyond Blue on 1300 22 4636, or the Sexual Assault Crisis Line on 1800 806 292. Aboriginal and Torres Strait Islander readers can contact 13YARN on 13 92 76. Anyone with information relevant to a police investigation is urged to contact Crime Stoppers on 1800 333 000.
