Finding into death of Justin John Fraser

Contributing factors

• physical restraint in prone position
• failure of clinical leadership by CSM
• premature security intervention without de-escalation
• chaotic restraint with multiple staff falling on patient
• lack of proper briefing of responding staff
• absence of duty medical officer
• insufficient space in patient room
• non-adherence to RiSCE restraint protocols
• inadequate supervision and team control

Coroner's recommendations

1. Include regulation in Mental Health Act endorsing seven principles for safe physical restraint: (1) restraint only as last resort after all options exhausted; (2) approved techniques should never apply pressure to trunk or take patient to prone position; (3) all staff involved in restraint should be trained together by hospital personnel in approved techniques including specific direction on positional asphyxia; (4) aggression management must be led by senior clinical staff member; (5) clinical staff member must remain present during entire restraint to monitor patient breathing and well-being; (6) approved restraint should not involve taking patient to floor unless unavoidable, and if so should be minimal duration only while respiratory condition uncompromised; (7) senior clinician must have exclusive control and direction of restraint determination before and during
2. Office of the Chief Psychiatrist should issue practice guideline directing adoption of single manner of physical restraint guideline for hospital consideration, with particular consideration of MOVAIT Techniques Manual