Mistakes made by Victoria Police officers and Triple Zero Victoria staff have been outlined at a Melbourne-based coronial inquest into the death of a 58-year-old man in 2023.
Victoria Police has admitted to failures and apologised after John Makai died from a brain injury, having spent hours unconscious in a holding cell at Broadmeadows Police Station.
Barrister Andrew Imrie, representing the chief commissioner of police, said the care in custody offered to Mr Makai "fell short" of standards needed under Victoria Police policy.
Mr Makai, who had 10 children and a stepchild, was fondly described by one of his sons as "kind and loving".
It was an out-of-character act of violence that brought him to police attention on September 9, 2023.
Mr Makai struck another adult son, Terewa, over the head with a mug after becoming angry about a drink being spilled inside an Uber earlier in the night.
Mr Makai and Terewa were bleeding and being questioned by the officers when Mr Makai lost his balance and fell backwards, crashing into a wooden bookshelf.
Officers were told an ambulance was not available and took a groggy Mr Makai to the Broadmeadows Police Station for observation.
During the ride, Mr Makai lost consciousness and slumped forward, falling off his seat.
For more than four hours, he was motionless, and nobody entered the cell to check on him, counsel helping the inquiry Rachel Ellyard told the court.
Ms Ellyard said there had been a "significant departure" from Victoria Police policy by officers who failed to actively check on Mr Makai.