Coronial

40 results for police restraint procedures

VIC2022-06-03

Finding into death of Micky Craig Revera

40y · Male·Unascertained; opioid withdrawal-related seizure or cardiac arrhythmia could not…

…8 February 2019 from unascertained causes. He was arrested on 12 February after erratic driving, underwent police restraint with baton strikes and OC spray, then was sedated with ketamine and midazolam at Dandenong Hospi…

emergency medicineforensic medicinediagnosticcommunicationheroin
QLDhospital2025-03-31

Inquest into the death of Jamie Brian Campbell

43y · Male·Hypoxic ischaemic encephalopathy, due to or as consequence of, cardiac arrest of…

A 43-year-old man with methamphetamine toxicity was restrained by police and given two doses of droperidol by paramedics who failed to recognize he was critically unwell. The firs…

emergency medicinetoxicologydiagnosticmedicationmethamphetamine
WAcommunity2026-02-02

Inquest into the Death of Joshua Fredrik VAN MALSSEN

24y · Male·Cardiac arrest in a man with Sotos syndrome and multiple comorbidities, includin…

…ome, but made five recommendations: enhance officer training on positional asphyxia risks and monitoring procedures, provide contextualised life support training, reassess handcuff fit for larger individuals, consult pol…

communicationproceduralalcohol
SAcommunity2004-09-03

Coroner's Finding: EUSTICE Dean Stanley

73y · Male·ischaemic heart disease due to coronary atherosclerosis

…n. The coroner concluded the emotional stress of false accusation combined with physical exertion during restraint precipitated fatal cardiac ischaemia. Security staff with first aid training failed to initiate resuscit…

cardiologyemergency medicineproceduralcommunication
NSW2013-05-16

Inquest into the death of Jason Lee PLUM

37y · Male·Single gunshot wound deliberately self-inflicted while in police custody

Jason Lee Plum, a 37-year-old man with bipolar disorder, died from a self-inflicted gunshot wound while in police custody at Wagga Wagga. Arrested for domestic violence, he was not searched before being placed in a polic…

psychiatryemergency medicineproceduralsystem
VIChospital2017-06-07

Finding into death of Samer Rony Damouni

21y · Male·Compression of the neck consequent upon hanging

…ing to conduct proper risk assessment given his absconding history; not considering chemical or physical restraint despite aggressive behaviour; inadequate communication between emergency and mental health teams; and in…

psychiatryemergency medicinecommunicationsystemmethamphetamine
VICcommunity2021-06-28

Finding into death of Sestilio Malaspina

74; 30y · Male; male·Sestilio Malaspina: stab wound to the chest. Hassan Khalif Shire Ali: gunshot wo…

…le followed by a knife assault. He fatally stabbed 74-year-old Sestilio Malaspina, and injured two others. Police responded appropriately with restraint and tactical options; Police Officer A1 shot Hassan, who died from …

psychiatryemergency medicinesystemcommunicationcannabis
NSWcommunity2024-05-31

Inquest into the death of BC

78y · Male·multiple blunt force injuries

…78-year-old man with no prior mental health history died by suicide after jumping from a cliff following a police response to a welfare concern. He had recently undergone cardiac surgery and was managing physical rehabil…

cardiothoracic surgerycardiology
QLDcommunity2010-07-16

Bornen, Andrew John

16y · Male·Internal injuries received when struck by a motor vehicle

A 16-year-old intoxicated boy was handcuffed on a major roadway at night after police responded to a report of an armed person. While officers activated emergency lights, one officer attempted…

diagnosticprocedural
VIChospital2022-02-22

Finding into death of Matthew Lee Dongelmans

30y · Male·Complications of methylamphetamine toxicity

… a family violence intervention order. He consumed methylamphetamine prior to arrest, likely in panic when police arrived. At Horsham Police Station, officers appropriately recognized his deterioration (agitation, eye tw…

emergency medicineintensive caredelaysystemmethamphetamine
QLD2024-02-26

13 year old boy

13y · Unknown·Drowning

…coroner found that the youth worker Mr La's decision-making was reasonable, including not using physical restraint when the boys ignored directions not to swim in dangerous turbulent conditions. The death was found to b…

paediatricsoccupational and environmental healthsystem
QLDcommunity2021-06-10

McCoy, Damon Edward

20y · Male·Multiple injuries due to motor vehicle accident

…ies in trauma cases, as incomplete photography potentially missed valuable forensic evidence of seatbelt restraint patterns.

trauma surgerypathologyproceduralsystemalcohol
QLD2017-10-20

Anthony William Young, Shaun Basil Kumeroa, Edward Wayne Logan, Laval Donovan Zimmer and Troy Martin Foster

Male·Police use of lethal force; coroner found in each case the officers acted approp…

This multi-death inquest examined five police shootings in Queensland (2013-2014) where all deceased had mental health histories. The coroner found offi…

emergency medicinepsychiatrysystemcommunicationmethamphetamine
NSWcommunity2018-12-13

Inquest into the death of H P

52y · Male·Multiple blunt force injuries from a fall from height

…tained after jumping from a third-floor balcony during enforcement of the order. Mental health workers and police attended his unit to administer depot antipsychotic medication following breach of the CTO. The deceased h…

psychiatrycommunicationsystempaliperidone
NSWhome2022-09-13

Inquest into the death of Ian Fackender

47y · Male·Multiple gunshot wounds; discharged by police officer during enforcement of Comm…

…tic during the incident. Critical failures occurred throughout: inadequate risk assessment and planning by police before and during the operation; miscommunication between mental health services and police about the swor…

psychiatryforensic medicinecommunicationsystemaripiprazole
QLDcommunity2020-08-27

Master Carr and Jaylen

17y · Male·multiple injuries due to motor vehicle collision

… powerful vehicle at night on unfamiliar terrain. Key preventable failures included: absence of seatbelt restraint (seatbelts engaged but occupants sitting on them), inexperienced juvenile driving a stolen high-powered …

forensic medicineproceduralsystemmethamphetamine
WAmental health

Inquest into the Death of Vincent Tavita Tolai SCHWENKE

24y · Male·complications of ligature compression of the neck (hanging)

Vincent Schwenke, a 24-year-old male of Maori descent, developed acute psychotic symptoms after ceasing cannabis use and was admitted to a secure mental health unit as an involuntary patient. Despite initial improvement …

psychiatryneurologyescitalopram
WAmental health2004-09

Inquest into the Death of Peter Daniel Mahoney

55y · Male·Immersion (Drowning) arising by way of suicide

…was an involuntary patient with potential for deception and self-harm. The hospital failed to fully inform police of his potential for harm when he absconded.

psychiatrypsychiatrycommunicationsystemtemazepam
VIChospital2023-05-16

Finding into death of Mathew James Luttrell

43y · Male·Hanging

…ur at lunchtime. He was discharged the following afternoon with limited discharge planning and a note that police may need to be called if he returned. He died by hanging 19 hours later. The coroner found the hospital fa…

psychiatryemergency medicinecommunicationdelayolanzapine
VIChospital2014-04-24

Finding into death of Stacey Jade Smith

20y · Female·Multiple injuries sustained when struck by train at Lalor Railway Station

…nd explicit threats to throw herself in front of a train. Initial assessment appropriately placed her in restraints in resuscitation cubicle with one-to-one nursing. However, restraints were removed after approximately …

emergency medicinepsychiatrycommunicationsystemdiazepam

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