Finding into death of Anthony William Dunning

40y · Male·Global ischaemic brain injury following cardiorespiratory arrest during prone restraint (including pressure on the neck) of an obese male with cardiomegaly

Anthony Dunning, a 40-year-old male, suffered cardiac arrest while being restrained prone on the floor at Crown Casino with pressure applied to his neck. He was held in this position for approximately 4 minutes before losing consciousness. He developed global ischaemic brain injury due to cardiorespiratory arrest during this restraint and died at The Alfred Hospital. The autopsy identified cardiomegaly and obesity as contributing factors. The coroner found that security staff failed to comply with their training, which specifically prohibited neck restraint and prolonged prone positioning. Critical lessons include the need for continuous vital signs monitoring during restraint, immediate repositioning to side positioning, strict adherence to training protocols despite perceived permissiveness, and prompt escalation procedures when injuries occur.