Inquest into the death of Robert Plasto-Lehner and David Gurralpa aka Moscow

Male·David Gurralpa: sudden heart attack (coronary atherosclerosis with long-standing coronary artery disease); Robert Plasto-Lehner: combined effects of restraint asphyxia, obesity-associated heart disease and chronic airways disease

Two deaths resulted from police restraint in prone positions. David Gurralpa, a 39-year-old Aboriginal man with pre-existing coronary artery disease, died of sudden cardiac arrest following police restraint during a domestic disturbance call. Robert Plasto-Lehner, a 57-year-old with chronic airways disease and heart disease, died of restraint asphyxia following police restraint in hospital while awaiting psychiatric assessment. Both men became acutely agitated during restraint and ceased struggling suddenly, which should have triggered immediate medical intervention. The coroner found police failed to recognise these critical warning signs, use alternative de-escalation strategies, or respond to medical staff warnings. Inadequate training on positional asphyxia, mental illness management, and handover procedures between police and hospitals were identified as systemic failures. Police used unnecessary force when other options existed.