Finding into death of Adam Justin White
Deceased
Justin John Fraser
Demographics
35y, male
Coroner
Coroner Peter White
Date of death
2007-10-26
Finding date
2013-03-13
Cause of death
Sudden death during restraint in an agitated obese man with coronary artery atherosclerosis
AI-generated summary
Justin Fraser, a 35-year-old male with first-episode psychosis, died in restraint at Frankston Hospital psychiatric ward on 26 October 2007. He was found attempting suicide by hanging, became agitated and threatening, leading to a code grey alert. Security staff and AMT members restrained him on the floor in chaotic, disorganized manner in a confined space, with multiple staff applying pressure to his torso and body. He lost consciousness during restraint and died despite resuscitation attempts. The pathologist concluded death resulted from sudden death during restraint in an agitated obese man with coronary artery atherosclerosis. Clinical lessons: senior clinical leadership was absent; the CSM failed to obtain briefing or maintain control; restraint protocols were not followed; staff were poorly trained in positional asphyxia risks; the restraint became unnecessarily prolonged and disorganized in confined space. The coroner found the death preventable, concluding better clinical management, de-escalation, and adherence to protocols could have avoided this tragedy.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- physical restraint in prone position
- multiple staff applying disorganized pressure
- restraint in confined space
- underlying coronary artery atherosclerosis
- failure of clinical leadership
- absence of senior medical officer response
- poor adherence to restraint protocols
- inadequate training in positional asphyxia recognition
Coroner's recommendations
- Inclusion of seven principles for safe physical restraint in Mental Health Act regulation: (1) restraint only as last resort; (2) no pressure on trunk; (3) joint training of all staff; (4) specific training on positional asphyxia dangers; (5) senior clinical staff to lead restraint; (6) clinical monitoring during restraint; (7) minimal time on ground with continuous respiratory monitoring
- Development of single practice guideline for physical restraint across hospitals, with particular consideration of MOVAIT Techniques Manual
- Clarification of respective duties and responsibilities of clinical, nursing, PSA, and security staff
- Standardized training across hospitals to avoid confusion from differing approaches
- Specific training for agency and bank staff on local protocols before deployment
- Australia-wide standards for security industry training and licensing in hospital psychiatric settings
Full text
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction — report an inaccuracy here.