Rangi, Taare Tamakehu

44y · Male·Cardiac arrhythmia during physical restraint

Taare Rangi, a 44-year-old man with bipolar affective disorder, died from cardiac arrhythmia during physical restraint in a mental health unit. Critical failures occurred at multiple levels: (1) the decision to acutely sedate him with intramuscular lorazepam was not clinically warranted—he was calm and not aggressive; (2) the restraint was poorly planned with no designated team leader to protect his airway; (3) unauthorised restraint techniques were used including a knee pin to the head and a chokehold-style neck restraint by a security officer with no training in such techniques; (4) staff failed to stop the restraint despite observable signs of severe distress including gasping and colour changes. Systemic failures included inadequate briefing, absence of clinical leadership during the restraint, and failure of multiple trained staff to intervene. The coroner found the decision to sedate was made for convenience rather than clinical necessity, contrary to all relevant guidelines.