Coronial
NSWcommunity

Inquest into the death of Roberto Laudisio CURTI

Deceased

Roberto Laudisio Curti

Demographics

21y, male

Coroner

Decision ofState Coroner Jerram

Date of death

2012-03-18

Finding date

2012-11-14

Cause of death

undetermined causes, in the course of being restrained by members of the NSW Police Force

AI-generated summary

Roberto Laudisio Curti, a 21-year-old Brazilian, died on 18 March 2012 during police restraint in Sydney after consuming LSD which induced a psychotic state. After a convenience store incident was misclassified as an armed robbery, multiple police officers pursued and restrained him using Tasers (at least 7 drive stuns), OC spray (3 cans), and body weight while he was on the ground and handcuffed. Medical experts found no single cause of death but agreed his death was not coincidental. The coroner found the police use of force was excessive, reckless and abusive, particularly after he was restrained. Key clinical lessons include: recognising drug-induced psychosis requiring de-escalation not force; understanding positional asphyxia risks when multiple officers restrain prone individuals; avoiding multiple Taser applications to handcuffed persons; and implementing communication protocols for mental health presentations to police.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

psychiatrytoxicologyforensic medicinecardiologyemergency medicine

Error types

communicationsystemproceduraldelay

Drugs involved

LSD

Clinical conditions

LSD-induced psychosisparanoiaexcited delirium

Procedures

Taser applicationOC spray deploymentphysical restrainthandcuffing

Contributing factors

  • LSD-induced acute psychosis with paranoia and fear
  • misclassification of convenience store incident as armed robbery leading to pursuit
  • excessive use of Tasers in drive stun mode
  • excessive use of OC spray
  • multiple officers applying body weight during restraint of prone individual
  • failure to recognise mental health presentation
  • junior and inexperienced officers with Tasers
  • poor leadership and failure to de-escalate by senior officer
  • lack of monitoring for positional asphyxia during restraint

Coroner's recommendations

  1. That the conduct of Officers Barling, Cooper, Lim, Edmondson and Ralph in their actions during the pursuit and restraint of Roberto Laudisio Curti be considered for disciplinary charges
  2. That the actions of police during the pursuit and restraint of Roberto Laudisio Curti be referred to the Police Integrity Commission
  3. That there be an immediate review of the contents of the relevant NSW Police Standard Operating Procedures and associated training relating to the use of Taser, OC spray, handcuffing, restraint and positional asphyxia to ensure officers are aware of the dangers of positional asphyxia, multiple use of Tasers and drive stun mode, multiple use of OC spray
  4. Ensure that guidance provided to officers is clear and consistent, in particular removing the term exigent circumstances
  5. Review the criteria for the use of Tasers
  6. Consider imposing limitations on the use of Taser in certain circumstances
  7. Consider prohibiting the use of Tasers drive stun mode, other than where officers are defending themselves from attack
  8. Improve training techniques and education in the appropriate and/or prohibited use of all force options
  9. Consider whether Probationary officers should continue to be authorised to carry Tasers
  10. Ensure that the safe management of risks of asphyxia by crush, restraint or position are included in SOPs wherever use of force must be applied
  11. Review communication procedures to ensure that signs of mental disturbance in any person the subject of a police report be communicated, and officers trained to respond accordingly
  12. Examine NSW Police VKG procedures to ensure accurate categorisation of any incident reported
Full text
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