Coronial
NTcommunity

Inquest into the death of Robert Plasto-Lehner and David Gurralpa aka Moscow

Deceased

David Gurralpa and Robert Plasto-Lehner

Demographics

male

Date of death

2007-12-28

Finding date

2009-06-10

Cause of death

David Gurralpa: sudden heart attack (coronary atherosclerosis with long-standing coronary artery disease); Robert Plasto-Lehner: combined effects of restraint asphyxia, obesity-associated heart disease and chronic airways disease

AI-generated summary

Two deaths resulted from police restraint in prone positions. David Gurralpa, a 39-year-old Aboriginal man with pre-existing coronary artery disease, died of sudden cardiac arrest following police restraint during a domestic disturbance call. Robert Plasto-Lehner, a 57-year-old with chronic airways disease and heart disease, died of restraint asphyxia following police restraint in hospital while awaiting psychiatric assessment. Both men became acutely agitated during restraint and ceased struggling suddenly, which should have triggered immediate medical intervention. The coroner found police failed to recognise these critical warning signs, use alternative de-escalation strategies, or respond to medical staff warnings. Inadequate training on positional asphyxia, mental illness management, and handover procedures between police and hospitals were identified as systemic failures. Police used unnecessary force when other options existed.

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

Specialties

emergency medicinepsychiatryintensive careforensic medicinecorrectional health

Error types

diagnosticcommunicationsystemdelay

Drugs involved

olanzapinemidazolamadrenaline

Clinical conditions

coronary artery diseasesudden cardiac arrestpositional asphyxiaacute heart failureobesitychronic obstructive airways diseasebronchiectasisbipolar depressive disorderacute psychosisaspiration pneumoniaacute cerebral hypoxiaacute renal failurerespiratory failurecardiomyopathyhepatosteatosis

Procedures

prone restraintthree-point holdhandcuffingOC spray applicationintubationcardiopulmonary resuscitationmechanical ventilation

Contributing factors

  • Police restraint in prone position
  • Failure to recognise warning signs of cardiac distress
  • Sudden cessation of struggle (sudden tranquility) not recognised as critical warning sign
  • Pre-existing coronary artery disease (Gurralpa)
  • Obesity (both cases)
  • Chronic airways disease (Plasto-Lehner)
  • Inadequate police training on positional asphyxia risk factors
  • Failure to provide urgent medical attention after restraint
  • Multiple police applying weight to torso during restraint
  • Knee applied to head during restraint (Plasto-Lehner)
  • Failure to respond to medical staff warnings (Plasto-Lehner)
  • Excessive force use when alternative options available (Plasto-Lehner)
  • Inadequate handover procedures from police to hospital
  • Alcohol intoxication (Gurralpa)
  • Mental health crisis and psychosis (Plasto-Lehner)

Coroner's recommendations

  1. Amend NT Police Custody Manual to require mentally ill persons apprehended under s163 to be taken by most direct practical route as quickly as possible to hospital
  2. Revise NT Police Custody Manual, Police General Orders and Memorandum of Understanding to provide clear guidance on handover of patients from police to hospital
  3. Implement reality-based training on dangers of sudden cardiac arrest and positional restraint asphyxia covering: prone restraint use, risk factors, warning signs, prevention strategies, monitoring of subject health during and after restraint
  4. Train and retrain all members in strategies to deal with mentally ill persons including: communication strategies, rapport building, de-escalation tactics, verbal restraint, containment strategies, recognising symptoms and behavioural changes
  5. Amend General Order on Transport of Persons in Custody and Custody Manual Part 6 to include step-by-step instructions for mental health apprehensions covering: assessing s32A requirements, communication strategies, contacting Mental Health Services, locating appropriate treatment facilities, identifying transport options, advising place of treatment, completing appropriate forms, guidance on police presence at treatment facility
  6. Amend clause 6.1.2 of Police Custody Manual to provide that where legal advice is sought and unavailable before end of shift, member should be interviewed as soon as reasonably practicable thereafter
  7. Amend Mental Health and Related Services Act section 34 to clarify police powers and responsibilities after section 34 recommendation
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