Coronial
NSWcommunity

Inquest into the death of Keith Titmuss

Deceased

Keith Titmuss

Demographics

20y, male

Coroner

Decision ofDeputy State Coroner Lee

Date of death

2020-11-23

Finding date

2024-05-03

Cause of death

exertional heat stroke

AI-generated summary

A 20-year-old professional rugby league player collapsed and died from exertional heat stroke after his first pre-season training session following an extended off-season break. Keith had the lowest aerobic fitness of his cohort (Yo-Yo test score 680m vs 1600-1800m expected), weighed 4.6kg more than end of previous season, had BMI 35.3, and low blood volume limiting heat dissipation. After 90-100 minutes outdoor training in moderate temperature/high humidity, he underwent intense indoor training in a hot, humid, poorly ventilated facility (Dojo) while dehydrated. He developed seizures, hyperthermia (41.9°C), and multi-organ failure. The coroner found the training was inappropriate given his fitness level, without heat stress index measurement, without medical oversight, and without graduated return to training. Prior incident in 2017 (Lloyd Perrett) had yielded recommendations that were not effectively communicated when medical staff changed. The coroner made extensive recommendations regarding heat policy mandates, player screening, acclimatisation periods, and medical oversight.

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

Specialties

sports medicineemergency medicineparamedicinecardiologyintensive careneurology

Error types

systemdelayprocedural

Drugs involved

midazolam

Clinical conditions

exertional heat strokehyperthermiaseizuresmulti-organ failuremetabolic acidosisrhabdomyolysisrenal failurecardiac arrestcoronary artery stenosis

Procedures

extracorporeal membrane oxygenation (ECMO)

Contributing factors

  • low aerobic fitness (lowest in training cohort)
  • elevated body mass index (35.3)
  • weight gain during off-season (4.6 kg increase)
  • prolonged outdoor training (90-100 minutes) in heat
  • intense indoor training in Dojo
  • hot and humid environment in Dojo with poor ventilation
  • involuntary dehydration prior to indoor training
  • first training session after extended off-season break
  • high metabolic heat production due to body size
  • lack of heat stress index measurement
  • absence of medical oversight during training
  • no graduated return to training program

Coroner's recommendations

  1. Provide findings to Professor Ollie Jay and Dr Douglas Casa for review of NRL Heat Policy
  2. Mandate reporting by NRL Clubs of every instance of exertional heat illness in games and training
  3. Mandate NRL Clubs comply with Heat Policy during all outdoor and indoor training sessions
  4. Provide greater guidance on circumstances for measuring environmental conditions in training settings and frequency of measurements
  5. Identify cooling and heat management strategies for training settings based on Heat Stress Index
  6. Identify and mandate adjustments to indoor and outdoor training sessions based on Heat Stress Index
  7. Mandate screening and classification of players according to risk factors for exertional heat illness (aerobic fitness, size, BMI, training history)
  8. Mandate individual player training program adjustments based on risk factors
  9. Mandate 14-day period of controlled training load (acclimatisation) for players returning after extended breaks
  10. Identify circumstances when medical officer attendance at training is mandatory
  11. Mandate medical officer approval of strength and conditioning plans for players returning after off-season breaks
  12. Mandate medical officer approval of screening for players returning after off-season breaks
  13. Use Keith Titmuss death as case study for ongoing NRL education on exertional heat illness risk factors, signs, symptoms, and management
  14. Manly to review record-keeping procedures to ensure effective communication of serious adverse health incidents and lessons to coaching staff, high performance unit, and medical staff with annual briefings
Full text
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