WAcommunity

Inquest into the Death of Joshua Fredrik VAN MALSSEN

Deceased

Joshua Fredrik Van Malssen

Demographics

24y, male

Date of death

2023-06-16

Finding date

2026-02-02

Cause of death

Cardiac arrest in a man with Sotos syndrome and multiple comorbidities, including, complex heart disease, asthma, early bronchopneumonia and obesity, while being restrained in a prone position, with alcohol effect

AI-generated summary

Joshua Fredrik Van Malssen, 24, with Sotos syndrome, dilated cardiomyopathy, asthma, and WHO class III obesity (BMI 40.6) died from cardiac arrest on 16 June 2023 after being restrained in prone position by PTA transit officers at Perth Underground Train Station. Following disorderly conduct and alcohol intoxication, officers used a harness takedown and handcuffs to detain him. While restrained, Josh experienced cardiac arrest and despite CPR resuscitation, could not be revived at Royal Perth Hospital. The coroner found the arrest was lawful and justified, but the monitoring standard was poor. Officers failed to notice Josh had stopped breathing until his face changed colour. The coroner could not establish earlier CPR would have changed the outcome, but made five recommendations: enhance officer training on positional asphyxia risks and monitoring procedures, provide contextualised life support training, reassess handcuff fit for larger individuals, consult police on alternative restraints, and establish formal critical incident review and lessons-sharing protocols.

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

Error types

communication procedural system

Drugs involved

alcohol

Clinical conditions

Sotos syndrome dilated cardiomyopathy coronary artery atherosclerosis asthma obstructive lung disease early bronchopneumonia obesity obstructive sleep apnoea moderate intellectual disability autism spectrum disorder anxiety depression early psychosis

Contributing factors

Restraint in prone position
Pre-existing dilated cardiomyopathy and coronary artery atherosclerosis
Pre-existing asthma and obstructive lung disease with early bronchopneumonia
Obesity (BMI 40.6)
Alcohol intoxication (blood alcohol 0.174%)
Physical exertion and stress during altercation
Sotos syndrome
Poor monitoring while restrained

Coroner's recommendations

The PTA should take immediate steps to ensure transit officers are keenly aware that persons being detained in the prone position are at grave risk of experiencing positional asphyxia and the need to minimise the time people spend in that position, including: liaising with WAPOL to determine applicable resources and policies; revising the Defensive Tactics Manual to be more detailed and prescriptive with concrete examples of risk factors and signs/symptoms; including information about Josh's case and lessons learned; and emphasising persons must only be restrained in prone position for as short a time as possible
The PTA should consider providing contextualised life support training to transit officers during the Transit Officer Recruit Training program and during annual refresher courses
The PTA should reassess ASP Hinged Ultra-Cuff handcuffs to determine whether they are fit for purpose when detaining persons of large build, and if not, whether an alternative type of restraint device should be made available
The PTA should liaise with WAPOL to determine whether the type of leg strap restraint used by WAPOL would be suitable for use by PTA transit officers
The PTA should ensure that a formal review is conducted following any critical incident involving transit guards where death or serious injury occurs, and that lessons learned from such reviews are provided to all PTA transit officers

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