The inquest highlighted a critical failure among emergency responders, as three police officers and two paramedics did not notice that Peachey had stopped breathing until it was too late.

Coroner Ryan emphasized the lack of monitoring by paramedics during the critical moments leading to Peachey's death.

In light of these findings, Ryan recommended that the NSW police commissioner develop an independent policy addressing the risks associated with prone restraint and the importance of timely repositioning.

Michael Peachey, a 27-year-old Indigenous man, died following a confrontation with police on May 21, 2021, in Gunnedah, NSW, during which he was subjected to Taser use, pepper spray, and prone restraint.

During the incident, Peachey likely suffered from an undiagnosed psychotic episode, which led to violent resistance against the police's attempts to subdue him.

Police responded to the situation around 8:29 PM, and Peachey was placed face down at approximately 8:48 PM, ultimately experiencing a fatal collapse by 9:13 PM.

Despite claims that Peachey remained a threat, the inquest found he had stopped moving by 9:07 PM and should have been repositioned immediately.

The inquest revealed that officers breached training protocols by keeping Peachey in the restraint position longer than necessary.

Ryan also stressed the need for improved training for police officers in handling individuals in severe distress, acknowledging that they are not trained mental health professionals.

Coroner Elizabeth Ryan determined that Peachey's death was caused by several factors, including the prone restraint, which led to cardiac arrest.

The inquest concluded that police officers should have recognized the risks associated with face-down restraint, which contributed to Peachey's tragic death.

Ultimately, the inquest's findings call for systemic changes in how police and emergency responders manage individuals experiencing mental health crises.