Coronial
VICcommunity

Finding into death of David Perry

Deceased

David Philip Walter Perry

Demographics

35y, male

Coroner

Coroner Katherine Lorenz

Date of death

2019-01-11

Finding date

2021-08-18

Cause of death

unascertained - multifactorial: underlying ischaemic heart disease, drug intoxication (synthetic cannabinoids and other illicit drugs), and excited delirium syndrome with physical restraint

AI-generated summary

David Perry, aged 35, died from unascertained causes during police arrest at Bellbrae on 11 January 2019. He presented to The Alfred with acute paranoia, hallucinations and agitation following synthetic cannabis use, and was discharged after assessment as substance-intoxicated rather than mentally ill. Less than 24 hours later, after allegedly attempting murder, he was arrested by police and developed cardiac arrest while in prone restraint. Autopsy revealed significant early-onset atherosclerotic heart disease. The coroner found the police use of force was reasonable and proportionate, the Alfred's discharge was appropriate, and paramedics acted reasonably. The death was likely multifactorial: underlying cardiac disease, illicit drug use (particularly synthetic cannabinoids), and excited delirium syndrome combined with physical restraint. No clinical or operational failures were identified. This case illustrates the dangerous intersection of untreated excited delirium, restraint and underlying cardiac pathology.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

emergency medicinepsychiatryparamedicineforensic medicinecardiology

Drugs involved

synthetic cannabinoidsibuprofenparacetamoldiazepamtemazepamoxazepamcannabismethamphetaminecocaineketamineoc spray

Clinical conditions

acute drug-induced psychosissynthetic cannabis intoxicationexcited delirium syndromeischaemic heart diseaseearly-onset atherosclerotic diseasecardiac arrhythmiaasystolepneumothoraces

Procedures

cardiopulmonary resuscitationdefibrillation

Contributing factors

  • synthetic cannabis intoxication
  • early-onset atherosclerotic heart disease
  • excited delirium syndrome
  • prone restraint during arrest
  • underlying illicit drug use
  • resistance to police control
  • cardiac arrhythmias secondary to underlying disease and drug effects

Coroner's recommendations

  1. No formal recommendations made. The coroner found no preventable contributing factors and that the management by The Alfred, police and Ambulance Victoria was reasonable and appropriate in the circumstances.
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.