On the first day of the inquest this week, counsel assisting the coroner, R Ellyard, said the inquest into the death of Ricky Broughton was mandatory as he had been in police custody immediately prior to his death.

"But it's not just the particular events of his time in police custody that are going to be considered in the inquest," she said.

"The issues to be considered go well beyond the events of that day, and raise a number of systemic issues about the care and support of those with mental illnesses and the coordination of those supports".

The inquest was told the 47-year-old, who had a long history of mental illness, had been living in Ballarat for 15 months prior to his death.

On the day of his death, on 3 May, 2018, he was being evicted from a boarding house in which he had lived for 10 of those months, but he did not wish to leave.

Clinicians from the Ballarat Mental Health Service were called to assess him and issued an assessment order under section 30 of the Mental Health Act, which would require him to be taken to hospital for a psychiatric assessment.

IN OTHER NEWS:

Police were called to transport him to hospital, but when Mr Broughton was told he needed to go to the hospital he ran away.

He reportedly ran through his room and out of the facility, through grasslands and along a fence that runs alongside the Midland Highway.

The inquest heard Mr Broughton was pursued by police, who caught up to him when he fell on the uneven ground.

The inquest heard that police struggled to "keep him under control and handcuff him".

After the arrival of a second police unit, at some point Mr Broughton was observed to be unconscious. The inquest heard police uncuffed him and performed CPR until an ambulance arrived and took over but he could not be revived.

He was pronounced dead at the scene.

Mr Broughton had a long history of mental illness, including schizophrenia and other health conditions, and throughout his life had been under the care of mental health services, on and off, and had also resided in a number of supported independent living and supported residential service facilities.

The inquest is expected to last for three weeks and in addition to the death, will consider the care that Mr Broughton was given, who was responsible for organising it and if it existed at all.

Ms Ellyard said the inquest would examine the whole period of time Ricky had lived in Ballarat - starting with the transition and transfer from Barwon to Ballarat and then until the time of his death.

"It's important to note that an inquest is not about finding fault. It's not about apportioning blame. It's particularly not about apportioning blame to individuals. It's not a coroner's role to do that. Coroners don't apportion liability whether civil or criminal - that's not their role.

"Coroners don't seek to blame but they do seek to identify and understand the circumstances of a death including identifying where things could have been done differently, where lessons might be learnt, where things might have occurred to make a difference to the outcome, including whether or not a death was preventable."

Our team of local journalists work hard to provide local, up-to-date news to the Ballarat community. This is how you can continue to access our trusted content: