Inquest into the death of Ashley Paull

Case Number: 2019/222760

Date of Findings: 18 August 2025

Magistrate: Deputy State Coroner, David O'Neil

CORONIAL LAW - Collision with truck whilst walking along highway; mental health in custody; release from police custody after detention for secondary drug test; schizophrenia; Community Treatment Order; Kempsey Mental health; mental health treatment and care-interaction between police and mental health service

Responses

Recommendations 

To the Commissioner of NSW Police Force

1. Consider amending the Change Room and Custody Management Standard Operating Procedures (SOPs), and/or the Police Handbook, to clarify the nature and extent of a review of information held on policy systems that should be undertaken by arresting / escorting officers and custody managers where a person is in custody.
2. Consider providing guidance to officers in charge of coronial investigations, where a person has died following a recent period in police custody, to ensure any CCTV footage depicting the person in custody is retained for the investigation.