COUPER Gregory

43y · Male·Hypoxic/ischaemic encephalopathy resulting from asystolic cardiac arrest due to restraint asphyxia

Gregory David Couper, 43, with chronic schizophrenia, experienced a psychiatric crisis at a supported residential care facility on 2 December 1998 and died the next day from restraint asphyxia. Police responded to calls about aggressive behavior toward staff and attempted to apprehend him while seated calmly in his room. Police used asp batons and punches, then restrained him prone on the wooden floor with full body weight applied to his back for an extended period. The coroner found he died from asystolic cardiac arrest caused by restraint asphyxia in excited delirium. Key preventable factors: police should have used de-escalation, waited for the psychiatric crisis team, or contained him rather than using physical restraint. Police had training in mental health crisis response and safety-first principles but failed to apply them. Coroner recommended enhanced training on positional asphyxia dangers, review of restraint techniques, and better coordination between police and mental health services.