Inquest into the Death of Roderick Malcolm NARRIER
Deceased
Roderick Malcolm NARRIER
Demographics
38y, male
Date of death
2019-10-30
Finding date
2022-08-22
Cause of death
Multiorgan failure following out of hospital cardiac arrest in a man with methylamphetamine effect, restraint and focal moderate coronary artery arteriosclerosis
AI-generated summary
A 38-year-old Noongar man died from multiorgan failure following out-of-hospital cardiac arrest after being restrained in prone position by police. He had injected methylamphetamine and developed excited delirium, becoming violently agitated. Police restrained him for approximately 22-27 minutes in prone position until ambulance arrived. SJA administered midazolam which did not contribute to death. The coroner found cardiac arrest was primary event, likely due to methylamphetamine-induced excited delirium combined with physical exertion and possible coronary artery disease. Police complied with training regarding monitoring breathing and minimising back pressure. Key clinical lessons: excited delirium carries high cardiac arrest risk; physical restraint intensifies physiological stress; indicators of positional asphyxia overlap with delirium signs, creating diagnostic difficulty; midazolam was appropriately indicated. Coroner made recommendations to strengthen police training on prone restraint risks and introduce fast strap leg restraints as safer alternative to prolonged prone positioning.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Drugs involved
Clinical conditions
Contributing factors
- methylamphetamine intoxication causing excited/agitated delirium
- violent physical exertion and resistance during prolonged prone restraint
- focal moderate coronary artery atherosclerosis
- protracted restraint in prone position for approximately 22-27 minutes
- underlying cardiac arrhythmia risk from stimulant intoxication and exertion
Coroner's recommendations
- The restraint of a subject in the prone position should always avoid the application of downward force directly to the subject's back, chest or stomach. If such an application of downward force is required, it should only be used for the purpose of applying handcuffs and should immediately cease once police have gained control of the subject.
- The WAPF should ensure that training in relation to the indicators of positional asphyxia reinforces that evidence of struggling and/or rapidly escalating body temperature by the restrained person may be due to positional asphyxia and not excited delirium.
- As soon as practicable, the WAPF should consider making fast strap leg restraints available to operational police officers and should provide training as to the appropriate use of these devices.
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