Coronial
WAother

Inquest into the Death of Joshua Fredrik VAN MALSSEN

Deceased

Joshua Fredrik VAN MALSSEN

Demographics

24y, male

Coroner

Acting Deputy State Coroner Jenkin

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, a 24-year-old man with Sotos syndrome, complex cardiac disease, asthma, and obesity, died from cardiac arrest after being restrained in the prone position during a lawful arrest by Public Transit Authority officers. While the arrest was justified due to disorderly conduct, the coroner found the standard of monitoring during restraint was poor. Officers failed to promptly recognize signs of respiratory distress, displaying inadequate understanding of positional asphyxia risks despite training. The prone position, combined with Josh's pre-existing conditions, alcohol intoxication, and exertion, created a fatal cascade. While the coroner could not conclude earlier CPR would have saved him, the case highlights critical gaps in officer training about monitoring restrained persons, particularly those at high risk. Key recommendations include enhanced awareness of positional asphyxia risks, improved defensive tactics training, and reassessment of restraint equipment for large individuals.

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

Specialties

cardiologyrespiratory medicinepsychiatryemergency medicineforensic medicine

Error types

communicationsystemdelay

Drugs involved

loratadineparoxetinequetiapinealcohol

Clinical conditions

Sotos syndromedilated cardiomyopathymild ventricular systolic dysfunctioncoronary artery atherosclerosisobstructive sleep apnoeaasthmaobstructive lung diseasemoderately severe airways obstructionearly bronchopneumoniaobesitymoderate intellectual disabilityautism spectrum disorderanxietydepressionhepatic steatosiscardiac arrestpositional asphyxia

Procedures

physical restrainthandcuffingprone positioningharness takedowncardiopulmonary resuscitation

Contributing factors

  • Pre-existing dilated cardiomyopathy with mild ventricular systolic dysfunction
  • Obstructive sleep apnoea and asthma with moderately severe airways obstruction
  • Obesity (BMI 40.6)
  • Early stage bronchopneumonia
  • Alcohol intoxication (blood alcohol 0.174%, urine 0.215%)
  • Physical exertion and agitation during arrest
  • Restraint in prone position for prolonged period
  • Poor monitoring of restrained person
  • Delayed recognition of respiratory distress

Coroner's recommendations

  1. 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 liaison with WAPOL, revision of the Defensive Tactics manual with more detailed guidance, concrete examples of risk factors, inclusion of Josh's case circumstances and lessons learned, emphasis that prone position time must be minimized, and provision of regular refresher training with practical scenarios
  2. The PTA should consider providing contextualised life support training to transit officers during their Transit Officer Recruit Training program and annual refresher courses
  3. The PTA should reassess ASP Hinged Ultra-Cuff handcuffs currently issued to transit officers 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
  4. 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
  5. 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
Full text
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