Finding into death of Ricky James Broughton
Deceased
Ricky James Broughton
Demographics
47y, male
Date of death
2018-05-03
Finding date
2023-12-08
Cause of death
Complications of acute agitation in the setting of a prolonged struggle in an acutely psychotic man with a history of chronic schizophrenia
AI-generated summary
Ricky Broughton, a 47-year-old man with chronic treatment-resistant schizophrenia, died during police restraint while being transferred for involuntary psychiatric assessment. After moving from Geelong to Ballarat in February 2017, Ricky's mental health and housing needs were not adequately coordinated across services. His placement at boarding house Merindah (unsuitable for his complex needs) became unstable by May 2018. When psychiatric assessment led to an Assessment Order on 3 May 2018, police pursued and restrained him. During restraint, he rapidly deteriorated but CPR was not commenced until 9 minutes after becoming unconscious. He died from complications of acute agitation during prolonged struggle while acutely psychotic. Key failures included: lack of communication between mental health services and private psychiatrist; absence of appropriate accommodation despite NDIS funding; inadequate police protocols for transporting mentally unwell persons; and delayed recognition of life-threatening deterioration during restraint, with handcuffs hampering vital sign assessment.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
Contributing factors
- Inadequate coordination between Barwon Mental Health Service and Ballarat Mental Health Service upon relocation
- Failure to establish appropriate housing given complex support needs
- Multiple unplanned relocations with minimal notice to support coordinators
- Loss of assertive care from GP following move from Kallara
- Communication breakdown between private psychiatrist and broader care team
- Lack of clarity and guidance on transport protocols for mentally unwell persons
- Delayed initiation of CPR during police restraint
- Use of handcuffs while unconscious, hampering vital sign assessment
- Absence of clear coordination and leadership among multiple responding police members
Coroner's recommendations
- Department of Health to revise Protocol for transport of people with mental illness in consultation with Victoria Police and Ambulance Victoria, clarifying distinction between police involvement and police transport, and ensuring guidance aligns with least restrictive practice principles
- Chief Commissioner of Victoria Police to clarify, reinforce or enhance guidance and training for members responding to life-threatening emergencies in persons in their care/custody, including: recognition and response to deterioration in state; management of unconscious persons; timing of CPR commencement; and coordination of effort by multiple responding members
Full text
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