Finding into death of Daniel Charles Richards

48y · Male·Ischaemic heart disease complicating restraint of an acutely agitated male

Daniel Richards, 48, died from ischaemic heart disease precipitated by restraint during a mental health assessment at home. He had underlying significant coronary artery disease with left ventricular hypertrophy and old myocardial infarction. A CAT team assessment order was initiated after his family contacted mental health services. When police assisted with the order, Danny resisted vigorously during a 4-6 minute struggle in his kitchen while being handcuffed. OC foam was deployed twice without effect. Danny developed respiratory distress and cardiac arrest during restraint. Clinically, the case highlights: (1) the need for collateral physical health risk identification in mental health crisis responses; (2) the importance of assuming underlying cardiovascular disease in those with mental illness; (3) de-escalation and communication training for police (PRIME training); and (4) paramedic-led emergency response models. The coroner found actions of police and CAT team were reasonable, though planning and inter-service coordination could be improved.