Rangi, Taare Tamakehu
Deceased
Taare Tamakehu Rangi
Demographics
44y, male
Date of death
2018-07-07
Finding date
2020-06-29
Cause of death
Cardiac arrhythmia during physical restraint
AI-generated summary
Taare Rangi, a 44-year-old man with bipolar affective disorder, died from cardiac arrhythmia during physical restraint in a mental health unit. Critical failures occurred at multiple levels: (1) the decision to acutely sedate him with intramuscular lorazepam was not clinically warranted—he was calm and not aggressive; (2) the restraint was poorly planned with no designated team leader to protect his airway; (3) unauthorised restraint techniques were used including a knee pin to the head and a chokehold-style neck restraint by a security officer with no training in such techniques; (4) staff failed to stop the restraint despite observable signs of severe distress including gasping and colour changes. Systemic failures included inadequate briefing, absence of clinical leadership during the restraint, and failure of multiple trained staff to intervene. The coroner found the decision to sedate was made for convenience rather than clinical necessity, contrary to all relevant guidelines.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- Physical restraint without clinical indication
- Unauthorised knee pin to head by security officer
- Unauthorised neck restraint (chokehold) by security officer
- Neck compression during restraint
- Fear and stress experienced during restraint
- Obesity (BMI 55.1)
- Enlarged heart
- Coronary artery disease
- Lack of designated team leader to monitor airway
- Absence of senior clinical staff during restraint
- Failure to cease restraint despite visible distress
- Patient left in prone position post-restraint
- Lack of direct monitoring immediately post-restraint
Coroner's recommendations
- Consideration of MAYBO versus MAPA occupational violence prevention training standardisation in consultation with Queensland Occupational Violence Strategy Unit
- Development of guidelines by a working group to ensure staff debriefings do not compromise potential police investigations while protecting staff wellbeing
- Incident reports should be completed by staff directly involved in critical incidents rather than supervisors with peripheral involvement, with contemporaneous reporting by witnesses
- Incident reporting documentation should include specific fields to record what use of force techniques or tactics were attempted or applied, with meaningful descriptions to allow clear understanding of events upon review
- Ensure replacement techniques for figure 4 leg lock do not carry similar risks of injury to patients
Full text
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