Finding into death of David Perry

35y · Male·unascertained - multifactorial: underlying ischaemic heart disease, drug intoxication (synthetic cannabinoids and other illicit drugs), and excited delirium syndrome with physical restraint

David Perry, aged 35, died from unascertained causes during police arrest at Bellbrae on 11 January 2019. He presented to The Alfred with acute paranoia, hallucinations and agitation following synthetic cannabis use, and was discharged after assessment as substance-intoxicated rather than mentally ill. Less than 24 hours later, after allegedly attempting murder, he was arrested by police and developed cardiac arrest while in prone restraint. Autopsy revealed significant early-onset atherosclerotic heart disease. The coroner found the police use of force was reasonable and proportionate, the Alfred's discharge was appropriate, and paramedics acted reasonably. The death was likely multifactorial: underlying cardiac disease, illicit drug use (particularly synthetic cannabinoids), and excited delirium syndrome combined with physical restraint. No clinical or operational failures were identified. This case illustrates the dangerous intersection of untreated excited delirium, restraint and underlying cardiac pathology.