Finding into death of Anthony William Dunning
Deceased
Anthony William Dunning
Demographics
40y, male
Date of death
2011-07-07
Finding date
2015-03-27
Cause of death
Global ischaemic brain injury following cardiorespiratory arrest during prone restraint (including pressure on the neck) of an obese male with cardiomegaly
AI-generated summary
Anthony Dunning, a 40-year-old male, suffered cardiac arrest while being restrained prone on the floor at Crown Casino with pressure applied to his neck. He was held in this position for approximately 4 minutes before losing consciousness. He developed global ischaemic brain injury due to cardiorespiratory arrest during this restraint and died at The Alfred Hospital. The autopsy identified cardiomegaly and obesity as contributing factors. The coroner found that security staff failed to comply with their training, which specifically prohibited neck restraint and prolonged prone positioning. Critical lessons include the need for continuous vital signs monitoring during restraint, immediate repositioning to side positioning, strict adherence to training protocols despite perceived permissiveness, and prompt escalation procedures when injuries occur.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- prone positioning during restraint
- pressure applied to neck by security officer
- obesity with prominent protuberant abdomen
- cardiomegaly
- alcohol intoxication (0.19g/100mL)
- failure to reposition from prone position
- prolonged restraint duration (4 minutes)
- lack of immediate vital signs monitoring
- non-compliance with training protocols
Coroner's recommendations
- Crown should routinely reinforce in training the risk of positional asphyxia and the appropriate means of mitigating that risk (rolling patrons onto their side if they are on the floor)
- Training of security staff should be clear and focus on the safety, welfare and risk of injury to those involved in incidents and other patrons, with this safety focus overriding any concern for the employer's legal position
Full text
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