Coronial
QLDother

Inquest into the death of Selesa Tafaifa

Deceased

Selesa Tafaifa

Demographics

44y, female

Coroner

Gallagher

Date of death

2021-11-30

Finding date

2025-10-29

Cause of death

Cardiac arrest in the context of several contributory factors (physical exertion, restraint, safety hood application with hair across face) in setting of significant pre-existing natural disease (obesity, cardiomyopathy, coronary atherosclerosis). Cause listed as 'not determined' as relative contribution of factors could not be determined.

AI-generated summary

Selesa Tafaifa, a 44-year-old woman with Samoan heritage, died in custody at Townsville Women's Correctional Centre on 30 November 2021 during physical restraint by correctional officers, including application of a safety hood. She suffered cardiac arrest attributed to multiple contributory factors: significant pre-existing heart disease (cardiomyopathy, coronary atherosclerosis, obesity), physical exertion during restraint, psychological distress from being denied phone calls, and possible intermittent asphyxia. The coroner found the cause 'not determined' as relative contributions could not be established. Clinical lessons include: recognising signs of medical deterioration during restraint in vulnerable prisoners with comorbidities; removing safety hoods when distress is evident; training officers to recognise respiratory distress beyond baseline; considering system-wide factors (phone access, mental health support) affecting prisoner wellbeing; and reviewing continued use of safety hoods where alternatives exist.

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

Specialties

forensic medicineemergency medicinecardiologypsychiatrycorrectional healthparamedicine

Error types

proceduralsystem

Drugs involved

mixtard 30/70 insulinmetformin xratorvastatinquetiapinezuclopenthixolibuprofenparacetamolbudesonide/formoterolsalbutamol

Clinical conditions

cardiac arrestcardiomyopathycoronary atherosclerosisobesitytype 2 diabetes mellitusbipolar disorderasthmamental health comorbiditypolysubstance abuserespiratory distress

Procedures

physical restraintsafety hood applicationhandcuffingprone positioningcell extraction

Contributing factors

  • Significant pre-existing cardiomyopathy and coronary atherosclerosis
  • Severe obesity
  • Physical exertion during restraint
  • Psychological distress related to inability to contact family
  • Possible intermittent mechanical asphyxia from restraint positioning
  • Safety hood application with hair held across face
  • Rapid cycling bipolar disorder with polysubstance abuse history
  • Type 2 diabetes mellitus
  • Poor fitness level

Coroner's recommendations

  1. QCS review the use of terms such as 'excited delirium' and 'positional asphyxia' in QCS training manuals in consultation with QAS to ensure terminology is accurate and reflective of best medical practice
  2. QCS consider implementing a phone system that allows prisoners to make free phone calls to loved ones, acknowledging that operational aspects (timing, frequency) remain QCS discretion
  3. QCS consider undertaking a review of training provided to officers regarding deployment of safety hoods and monitoring of persons subject to use of safety hoods, in consultation with QAS, with particular focus on recognising signs of medical distress in vulnerable prisoners with comorbidities
Full text

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