WAhospital

Inquest into the Death of Roderick Malcolm NARRIER

Deceased

Roderick Malcolm NARRIER

Demographics

38y, male

Coroner

Coroner P J Urquhart

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. Report an inaccuracy.

Specialties

emergency medicineintensive careforensic medicinetoxicologyparamedicine

Drugs involved

methamphetaminemidazolam

Clinical conditions

methylamphetamine-induced excited deliriumdrug-induced psychosiscardiac arresthyperthermiacoronary artery atherosclerosishypoxic brain injurymulti-organ failurerhabdomyolysismyocardial infarctionhepatic ischaemiarenal failure

Procedures

intramuscular midazolam injectioncardiopulmonary resuscitationdefibrillationintravenous cannulationendotracheal intubationmechanical ventilation

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.

Full text

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