Coronial
VICcommunity

COUPER Gregory

Deceased

Gregory David Couper

Demographics

43y, male

Date of death

1998-12-06

Finding date

2002-06-07

Cause of death

Hypoxic/ischaemic encephalopathy resulting from asystolic cardiac arrest due to restraint asphyxia

AI-generated summary

Gregory David Couper, 43, with chronic schizophrenia, experienced a psychiatric crisis at a supported residential care facility on 2 December 1998 and died the next day from restraint asphyxia. Police responded to calls about aggressive behavior toward staff and attempted to apprehend him while seated calmly in his room. Police used asp batons and punches, then restrained him prone on the wooden floor with full body weight applied to his back for an extended period. The coroner found he died from asystolic cardiac arrest caused by restraint asphyxia in excited delirium. Key preventable factors: police should have used de-escalation, waited for the psychiatric crisis team, or contained him rather than using physical restraint. Police had training in mental health crisis response and safety-first principles but failed to apply them. Coroner recommended enhanced training on positional asphyxia dangers, review of restraint techniques, and better coordination between police and mental health services.

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

Specialties

psychiatrypathologyparamedicine

Error types

proceduralcommunicationsystemdelay

Clinical conditions

schizophreniaexcited delirium

Contributing factors

  • Police restraint using three-point hold with full body weight applied to back
  • Prone position on hard wooden floor
  • Excited delirium in context of acute schizophrenic relapse
  • Failure to wait for psychiatric crisis assessment and treatment team
  • Use of excessive force including asp baton strikes and facial punches
  • Inadequate monitoring of vital signs during prolonged restraint
  • Failure to adopt de-escalation tactics despite police training in mental health crisis response

Coroner's recommendations

  1. Victoria Police ensure that all operational police are trained and retrained to a sufficient degree to ensure a proper understanding of the dangers of positional asphyxia, in particular ensuring that any new or updated techniques are drawn to the attention of police members
  2. Victoria Police in conjunction with the appropriate medical experts undertake a review of the restraint technique known as the three point hold
  3. The Office of Chief Psychiatrist, in conjunction with Victoria Police, review the emergency response role of the CAT team to ensure police have the necessary support when dealing with the mentally ill
Full text
Official source Archived copy

Related cases

SAhospital2026-05-28

Coroner's Finding: Sargeant, Gary Dale

36y · Male·Drowning

Gary Dale Sargeant, a 36-year-old Royal Australian Air Force member, died by drowning after absconding from Edinburgh Health Centre during an acute mental health crisis. Critical clinical failures included: a clinical ps…

general medicinepsychiatrydiagnosticprocedural
ACTcommunity2026-05-26

Inquest into the death of Donald Morley

93y · Male·Complications of invasive squamous cell carcinoma of the scalp

Donald Morley, aged 93, died at Claire Holland House hospice on 12 July 2024 while serving a nine-year sentence for murder. He was under 24/7 custodial supervision. The cause of death was complications of invasive squamo…

palliative carepsychiatry
NSWcommunity2026-05-19

Inquest into the death of Dion White-Cotterell

45y · Male·Multiple stab wounds

Dion White-Cotterell, 45, was stabbed to death (83 wounds) on 28 February 2019 by his neighbour Benjamin Moore in an unprovoked attack outside their townhouse in Parramatta. Moore, suffering acute schizophrenia relapse w…

psychiatrysystemcommunication

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. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. 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 —