Coronial
NSWmental health

Inquest into the death of David Dungay

Deceased

David Dungay

Demographics

29y, male

Date of death

2015-12-29

Finding date

2019-11-22

Cause of death

cardiac arrhythmia

AI-generated summary

David Dungay, a 29-year-old Aboriginal man with chronic schizophrenia, type 1 diabetes, and obesity, died on 29 December 2015 in Long Bay Hospital's Mental Health Unit while in custody. The immediate trigger was his refusal to return biscuits he had retrieved; correctional staff unnecessarily called the Immediate Action Team (IAT) to move him to a camera cell, despite no security or medical emergency existing. During the forceful cell transfer, David was repeatedly restrained in the prone position, complained he could not breathe, and was administered midazolam whilst restrained. He collapsed approximately 2-8 minutes later. Multiple systemic failures contributed: the decision to involve IAT lacked proper medical consultation; IAT officers were inadequately trained on positional asphyxia risks; nursing staff failed to monitor David's breathing when he complained of difficulty breathing; and resuscitation attempts were poorly coordinated and ineffective. The coroner concluded David died from cardiac arrhythmia, likely precipitated by the combination of prone restraint-induced hypoxia, poorly controlled diabetes, hyperglycaemia, antipsychotic medications that prolong QT interval, obesity, and extreme stress. Better decision-making, appropriate training, proper medical oversight of the restraint, and attention to David's breathing complaints could potentially have prevented this death.

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

Specialties

psychiatryemergency medicinecardiologyforensic medicineendocrinology

Error types

proceduralcommunicationsystemdelay

Drugs involved

midazolamchlorpromazinezuclopenthixolpaliperidonearipiprazoleinsulin aspartinsulin glargine

Clinical conditions

chronic schizophreniaacute psychosistype-1 diabetes mellitushyperglycaemiaobesitycardiac arrhythmiapositional asphyxiahypoxaemia

Procedures

prone restraintintramuscular injection of midazolamcardiopulmonary resuscitationdefibrillation

Contributing factors

  • prone restraint positioning
  • likely hypoxaemia from prone restraint
  • poorly controlled type 1 diabetes
  • hyperglycaemia
  • antipsychotic medications with QT-prolonging effects
  • elevated body mass index
  • extreme stress and agitation from use of force
  • lack of monitoring of breathing during restraint
  • failure to cease restraint when patient complained of difficulty breathing
  • inadequate resuscitation attempt

Coroner's recommendations

  1. Provide training on Joint Planned Interventions procedures to all CSNSW and Justice Health staff at Long Bay Hospital
  2. Audit compliance with Joint Planned Interventions and Enforced Medications Local Operating Procedures
  3. Amend Section 4.6 of Enforced Medications policy to mandate psychiatrist/medical officer attendance for enforced medication assessment
  4. Amend Joint Planned Medication Checklist to include positional asphyxia risk factors
  5. Amend Joint Planned Interventions and Enforced Medications policies to allow Justice Health medical personnel to direct CSNSW officers regarding patient positioning
  6. Make Aboriginal Welfare Officer or Aboriginal Inmate Delegate available in Mental Health Unit for Aboriginal/Torres Strait Islander inmates
  7. Review proclamation process by Immediate Action Teams in Long Bay Hospital for mentally ill patients
  8. Continue Positional Asphyxia Awareness online training for custodial staff and audit completion rates
  9. Continue specialist practical training on positional asphyxia for IAT and Special Operations Group officers
  10. Provide training to all CSNSW officers in Mental Health Unit on restraint techniques, positional asphyxia and risks of sudden death
  11. Audit at least one-third of all IAT use-of-force video recordings to verify compliance with Custodial Operations Policy sections 13.7.8 and 13.7.9
  12. Complete trial of soft restraint system for Mental Health Unit as alternative to metal handcuffs
  13. Create and implement revised use-of-force training package for Mental Health Unit staff with 50% weighting on de-escalation techniques
  14. Review and clarify Custodial Operations Policy to require retention of all potentially relevant video footage in death in custody incidents
  15. Implement training for all Justice Health clinical staff on NSW Health Policy Directive on Aggression, Seclusion and Restraint (PD2012_035)
  16. Consider use of supine rather than prone position for enforced medication and emergency sedation administration
  17. Amend Medical Emergency Response procedure to clarify Medical Emergency Response Team Leader assigns roles and directs but does not actively participate
  18. Specify roles to be assigned by Medical Emergency Response Team Leader
  19. Audit Justice Health staff performance under Medical Emergency Response Procedure and Checklist
  20. Forward evidence transcript of Registered Nurse Charles Xu to Nursing and Midwifery Board of Australia for professional conduct review
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