Finding into death of Hizir Ferman

Contributing factors

• Prolonged prone restraint with hands cuffed behind back
• Shield applied to back with downward pressure applied at times
• Inhalation of CS gas (tear gas)
• Prior violent struggle leading to exhaustion and increased respiratory demand
• Being positioned upright when already critically compromised
• Fractured ribs (likely from struggle/restraint)
• Possible excess mucous secretions from gas exposure
• Lack of objective monitoring of restraint necessity and degree by team leader
• Failure of nurses to recognise unconscious state and call ambulance

Coroner's recommendations

1. Corrections Victoria should update SESG cell extraction training and manuals to incorporate matters raised in the coroner's comments regarding restraint asphyxia and operational safety
2. Corrections Victoria should update its Critical Incident and Safety Management online training module on positional asphyxia to: use the term 'restraint related positional asphyxia'; include CS gas as a risk factor; provide clear guidance to place restrained person in recovery position as soon as safe; make clear it is dangerous to sit on or apply prolonged pressure to back or chest
3. Corrections Victoria should review bedroom configuration at Middleton to assess means of allowing prison officers to view or enter bedrooms in emergencies, and modify one or more doors to insert a trap
4. Corrections Victoria should ensure all SESG and medical staff receive enhanced training on dangers of prone restraint, particularly when combined with handcuffs, shields, or chest pressure
5. Corrections Victoria should ensure all SESG and medical staff receive enhanced training on signs and symptoms of restraint related positional asphyxia, recognising it may develop insidiously without obvious signs of breathing difficulty
6. Corrections Victoria should implement procedures requiring: logs of all communication attempts with prisoner before extraction; contemporaneous recording of reasons if proclamation is dispensed with; inclusion of medical staff in extraction planning; clear handover from SESG to medical staff documenting force, method, and duration of restraint; and monitoring by team leader of extraction and prisoner condition
7. Corrections Victoria should nominate an alternate SESG team leader in advance of extraction and have process for replacing fatigued team members
8. Corrections Victoria should ensure team leader actively monitors extraction and restraint, ensures prisoner placed in recovery position as soon as safe, and ensures prisoner medically reviewed as soon as possible after extraction
9. Corrections Victoria should ensure all cell extractions have an emergency exit plan, particularly for use of chemical agents
10. Corrections Victoria should implement policy that video operator for cell extractions be designated and assertive about obtaining clear views, including instructing others to step away if necessary
11. Correct Care Australia should ensure medical staff are included in pre-extraction planning or fully briefed prior to extraction occurring
12. Correct Care Australia should ensure medical staff allocate clear roles and devise plan of response including when to call ambulance; seek additional medical help before extraction if expertise may be needed
13. Correct Care Australia should ensure medical staff undertake clinical assessments in accordance with Medical and Nursing Response Record form, which includes recording oxygen saturations and neurological observations
14. Correct Care Australia should have the RESTRAINT AND POSITIONAL ASPHYXIA fact sheet reviewed by appropriately qualified medical practitioner, including: clarifying that inadequate ventilation leads to elevated CO2 which impairs conscious state; adding defaecation to list of signs; and reconsidering recommendation to place patient in upright position with head elevated as this appears contraindicated