Finding into death of Daniel Charles Richards

Contributing factors

• underlying cardiovascular disease with coronary artery narrowing and left ventricular hypertrophy
• strenuous physical exertion and resistance during restraint
• acute agitation and mental health crisis
• possible anxiety and stress from police presence
• use of OC foam which may have had aggravating effect
• restraint procedures including handcuffs
• potential impaired respiration during struggle

Coroner's recommendations

1. That recommendations 8, 9 and 10 from the Royal Commission into Victoria's Mental Health System be prioritised and implemented in their entirety as recommended
2. That in implementing RCVMHS Recommendation 10, where a person is being assessed in the community by a mental health service with police and paramedics involved, specific consideration be given to: (a) circumstances of police and paramedics involvement; (b) inter-service planning ensuring mutual understanding; (c) trauma-informed care principles; (d) identification of best practice; (e) practical guidance to all onsite services
3. That the Chief Psychiatrist alert Area Mental Health Services to risks of restraint in people with mental illness and cardiovascular/respiratory/metabolic diseases, and assume physical disease may be present
4. That mental health services include identification of physical health risks as part of collateral information gathering from family and other sources
5. That identified physical health risks be communicated to police and paramedics prior to engagement
6. That consideration be given to mitigating strategies by all onsite services if physical health risks are identified or remain unknown