Finding into death of Spiros Boursinos
Deceased
Spiros Boursinos
Demographics
45y, male
Date of death
2018-10-20
Finding date
2021-04-29
Cause of death
coronary artery disease and mechanical asphyxia in a man using cocaine
AI-generated summary
A 45-year-old man with a history of drug-induced psychosis, cocaine use, and underlying coronary artery disease died in police custody following physical restraint at a licensed bar. After consuming cocaine, he experienced acute paranoia and agitation, screaming that people were attacking him. Bar staff and patrons restrained him on the ground for approximately two minutes before police arrived. He lost consciousness and could not be resuscitated despite extensive CPR. Medical cause of death was coronary artery disease and mechanical asphyxia in a cocaine user. The coroner found that bar staff, police, and paramedics acted appropriately and in good faith, though staff lacked training in recognizing mental health crises and the dangers of physical restraint. Key lessons: early recognition of drug-induced psychosis is critical; physical restraint poses serious asphyxia risks; trained security should be available in high-risk venues; liquor service staff need training in mental health recognition and restraint dangers.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Contributing factors
- cocaine-induced psychosis
- underlying coronary artery disease
- physical restraint in prone position
- lack of training for bar staff on mental health crises
- lack of awareness of mechanical asphyxia risks
- extended restraint period (approximately 2 minutes)
- high intoxication environment at late-night venue
Coroner's recommendations
- Chief Executive Officer of Victorian Commission for Gambling and Liquor Regulation should arrange production of a Safety Alert/Guidance Note explaining the risks and dangers associated with managing people who experience mental health episodes and aggressive behaviours, and risks associated with physical restraint and apprehension of these people, and distribute to all licensed bar owners
- Secretary of the Department of Justice and Community Safety should arrange to amend Responsible Service of Alcohol Training to include information about how to recognize and manage a person experiencing mental health or drug-related episode and the dangers and risks associated with physical restraint
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