Inquest into the death of Tristan Naudi

Contributing factors

• MDMA drug intoxication
• physiological stress from sympathetic overdrive
• physical restraint including prone restraint
• confinement in poorly ventilated police vehicle for approximately 54 minutes
• delay in ambulance dispatch
• uncoordinated transfer from police vehicle to isolation room
• lack of cardiac monitoring prior to arrest
• possible positional asphyxia contributing to respiratory compromise

Coroner's recommendations

1. That the NSW Police Force Guidelines on the Management of People Affected by Methylamphetamine and Other Stimulant Drugs be reviewed to ensure consistency with other NSW Police Force policies and training regarding the use of prone restraint.
2. To the extent that there is any change to the Guidelines, that consideration be given to providing a training module on the amended Guidelines, including by reference to the risk factors presently included at Appendix A.
3. That consideration be given to removing the 'Excited Delirium' module from NSW Police training resources given that 'excited delirium' is not recognised in the DSM-V nor ICD-10 and the advice appears inconsistent with the NSW Health – NSW Police Force Memorandum of Understanding 2018 regarding transportation of persons detained under the Mental Health Act 2007 in police vehicles.
4. That consideration be given to improving the conditions under which mentally ill or disordered persons might be transported using police vehicles, including through modifications such as: improved air-conditioning or other ventilation; and installation of padding in caged vehicles.