Coronial
NThospital

Inquest into the death of Gottlieb Rubuntja

Deceased

Gottlieb Rubuntja

Demographics

39y, male

Date of death

2009-04-16

Finding date

2010-08-11

Cause of death

coronary atherosclerosis

AI-generated summary

A 39-year-old Aboriginal man died from coronary atherosclerosis after police responded to reports of strange and agitated behaviour. His mother and family had requested police assistance; he appeared to be experiencing a mental health crisis with hallucinations and disorganized speech. Police determined apprehension was necessary under mental health legislation. After initially declining to take him to hospital, police returned when his behaviour escalated later that evening. A physical altercation ensued during attempted apprehension; police deployed Taser twice and OC spray twice before subduing him. He collapsed and died at hospital shortly after. Autopsy revealed severe underlying coronary atherosclerosis (70% stenosis in worst vessel). The coroner found use of force premature and inappropriate in hindsight, but acknowledged the speed and confusion of events and the officer's inexperience. Key lessons: Taser policies needed tightening to restrict use to high-risk situations; better mental health training for officers; consideration of tactical disengagement and de-escalation strategies in mentally unwell individuals.

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

Specialties

emergency medicineforensic medicinepsychiatryintensive care

Error types

proceduralcommunication

Clinical conditions

coronary atherosclerosisacute myocardial infarctionmental health crisispsychosispossible deliriumhypoxia

Procedures

Taser deploymentOC spray administrationphysical restraint and holdhandcuffingCPR

Contributing factors

  • acute stress from police interaction
  • acute stress from physical altercation
  • underlying severe coronary atherosclerosis (70% stenosis)
  • possible acute myocardial infarction at time of police attendance
  • mental health crisis or delirium
  • possible hypoxia from altered mental status

Coroner's recommendations

  1. Police training in relation to Tasers should clearly convey that Tasers should not be used simply as a compliance tool and should only be considered in the most serious of circumstances
  2. Amendments proposed to the ECD Good Practice Guide to clarify that use should be reserved for situations where there is a real and imminent risk of serious harm and no other less forceful option would bring about safe resolution
  3. Amendment to include clear provision that ECD should not be used as a compliance measure
  4. Increase the threshold for Taser use from 'real and imminent risk of violence' to 'real and imminent risk of serious harm'
  5. Continue review of Taser use policies to ensure no abuse of this device
  6. Consider inclusion of guidance on 'target areas' in ECD Good Practice Guide, including recommendation that point of aim be to the back when practical, and lower centre of mass for front shots
  7. Encourage rapid completion of amendments to NT Police Custody Manual regarding transport of mentally ill persons apprehended under Mental Health and Related Services Act (from prior coronial recommendation)
  8. Improve training of police officers regarding obligations and responsibilities toward mentally ill persons in their care, custody or control
  9. Consider improved protocols for calling mental health practitioners to scene when circumstances permit, rather than immediate apprehension
Full text
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