Police continued to keep Culleton under arrest, after discovering he was wanted for theft offences.
They did not tell him the reason for his arrest, which added further distress, and put him in the back of a van to take him to Melbourne West police station.
At the station, police told the custody officers “we can’t take our eyes off him”, assessed him to be a high risk of suicide in custody and decided he should be transferred to Melbourne Custody Centre.
He was handcuffed, given a disposable jumpsuit known as a coverall, and a suicide-resistant gown.
He was kept inside the van for 48 minutes, during which police opened the door to check on him twice. But while the van was shut for almost 20 minutes he fatally self-harmed.
He was taken to hospital, where he later died from a brain injury.
Coroner David Ryan on Thursday found Culleton’s death in custody was a “preventable tragedy” and recommended sweeping changes to Victoria Police policy and guidelines.
Further, he found Culleton may not have intended to take his life in the back of the van.
“Darren required care and treatment, which may well have been better provided in a hospital environment, but once he went into police custody Victoria Police was responsible for his safety, security, health and welfare,” he said.
Lack of police training, an absence of policy, communication issues and Culleton’s self-harm attempts while in custody “led to an unfortunate confluence of circumstances that ultimately led to Darren’s death”, he said.
Culleton’s grief-stricken family cried after hearing the coroner’s findings.
“The police and the hospital are responsible for him passing because they didn’t do their job,” his mother said, between tears.
“If they did their job, my son would still be here.”
In a statement, they said Culleton was taken from them in the most undignified and heartbreaking manner imaginable, alone and inside the confines of a police van.
The family said Culleton begged for help at the hospital but instead of triggering a swift response he was instead released into the care of police who were unequipped to address his mental health crisis.
“Darren was not a threat to others; he was a threat to himself. His fragile mental health should have been treated with the same urgency and care as any physical condition,” they said.
“Instead, he was neglected until he slipped away.”
They’re now calling for justice for the 31-year-old and others who suffer owing to the failures of law enforcement and the mental health system.
“Darren was not just another statistic, another name in the news. He was a human being, a loving member of our family, and he deserved dignity, respect, and, most importantly, the help he so desperately needed,” they said.
“The signs of his anguish were glaring, impossible to ignore, and yet, nobody cared enough to intervene.
“How many more lives must be lost in police custody before we acknowledge the moral destruction of our current approach to mental health?
“We need change. We need empathy.”
The coroner recommended Victoria Police review its custody transfer arrangements, train officers better in communicating about people in custody, review its use of coveralls and gowns, and improve police information systems.
Outside court, Robinson Gill Lawyers principal solicitor Jeremy King said Culleton’s death should never have occurred and was the result of catastrophic mistakes made by police.
He urged Victoria Police to implement the coroner’s recommendations as a matter of urgency.
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