76y · Male·Bronchopneumonia with multiple organ failure in the setting of advanced metastat…
John Henry Waterfall, a 76-year-old prisoner at Acacia Prison, died from bronchopneumonia with multiple organ failure secondary to advanced metastatic…
29y · Male·Hypoxic ischaemic encephalopathy and multi-organ failure due to out of hospital …
…cking four correctional officers, Mr Morrison was restrained using handcuffs, plastic flexi-cuffs as leg restraints, and a spit mask. He was then carried (not walked) to a van without body supports and transported to G …
32y · Male·Cardiac arrest as a result of the combined effects of severe coronary atheroscle…
…aia, a 32-year-old male with schizophrenia, died in custody at Capricornia Correctional Centre following restraint after assaulting officers. He collapsed during a 2-minute prone restraint by five officers. The autopsy …
35y · Male·Cardiorespiratory arrest in the setting of acute agitation and physical and chem…
… Middleton Prison following forcible extraction from his room by SESG officers using CS gas and physical restraint. He was held prone with hands cuffed behind him, a shield on his back, and additional downward pressure …
56y · Male·Complications, including sepsis, of left leg infection (operated), in a man with…
Matthew John Pickin, a 56-year-old prisoner with metastatic lung adenocarcinoma, died from sepsis complicating a left leg infection. His lung cancer …
46y · Male·Methylamphetamine toxicity and coronary atherosclerosis
… of methylamphetamine toxicity, significant coronary artery disease, and physical exertion during police restraint and transport. Critical clinical lessons include: (1) failure to recognise signs of rapid clinical deter…
89y · Male·Complications in association with a gastrointestinal illness in an elderly man w…
Raymond Sydney Cheek, an 89-year-old prisoner with multiple comorbidities including insulin-dependent diabetes, died from complications of gastrointest…
40y · Male·Unascertained; opioid withdrawal-related seizure or cardiac arrhythmia could not…
…y 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 Hospital. Des…
66y · Male·infectious complications of plasmablastic myeloma
…ed to his hospital bed throughout multiple admissions despite having low security rating—policy required restraints only for high/medium security prisoners unless elevated risk justified it; (2) hospital journal mainten…
42y · Male·Combined effects of moderately severe physical exertion; a lateral vascular neck…
… a foot chase in Spring Hill, Brisbane. Following an initial wrestling struggle, a lateral vascular neck restraint was applied by Senior Constable Jakes for approximately three 10-second intervals. The coroner found Mr …
53y · Male·aspiration pneumonia on a background of oesophageal cancer and ischaemic heart d…
…mmunication failures between correctional services and hospital staff, and demonstrates that appropriate restraint review protocols were lacking. The coroner endorsed subsequent policy improvements made by correctional …
66y · Male·Cardiac arrhythmia in a man with arteriosclerotic cardiovascular disease, pulmon…
Bradley Stinson, a 66-year-old prisoner with a long history of heavy smoking and alcohol use, died from cardiac arrhythmia in the setting of arte…
44y · Female·Cardiac arrest in the context of several contributory factors (physical exertion…
… heritage, died in custody at Townsville Women's Correctional Centre on 30 November 2021 during physical restraint by correctional officers, including application of a safety hood. She suffered cardiac arrest attributed…
64y · Male·bronchopneumonia and sepsis with chronic obstructive pulmonary disease in a man …
Edward Ivan Africh, a 64-year-old sentenced prisoner, died from bronchopneumonia and sepsis with chronic obstructive pulmonary disease (emphysema) in the sett…
38y · Male·Combined effects of methylamphetamine toxicity, violent struggle, and positional…
Kevin Norris, 38, died in police custody after methamphetamine intoxication, violent police restraint at McDonald's, and positional asphyxia at Bowral Police Station. He had schizophrenia and was on a Commu…
48y · Male·Complications of human immunodeficiency virus infection with terminal palliative…
…f appropriately escalated care when delirium suggested temporary incapacity. A secondary issue concerned restraint use during emergency transfers—policies required EMRAs for prisoners with significant medical issues, bu…
65y · Male·complications of intracranial haemorrhage (hypertensive haemorrhage), with termi…
Alan David Ratcliff, a 65-year-old prisoner at Acacia Prison, died from complications of intracranial haemorrhage (hypertensive haemorrhage) on 20 Ju…
77y · Male·cardiac failure in an elderly man with valvular heart disease and other co-morbi…
Brian Attwell, a 77-year-old sentenced prisoner with multiple chronic conditions including diabetes, chronic renal failure, peripheral vascular disease, …
43y · Male·Gunshot wound to the chest and abdomen
…ding escape risk to escort officers; insufficient training in medical escort scenarios involving shackled prisoners; limited non-lethal weapons available; and legal uncertainty about whether firearm discharge under regul…
29y · Male·Unascertained causes on a background of agitated delirium state
…stabbed a member of the public, leading to police arrest involving oleoresin capsicum spray and physical restraint. Ambulance paramedics cleared him for transport to the police station. During the drive, officers notice…
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