Inquest into the Death of Levi Shane Clement CONGDON

27y · Male·methylamphetamine toxicity

Levi Shane Clement Congdon, a 27-year-old male, died from methylamphetamine toxicity on 13 November 2017 at Royal Perth Hospital during a police search warrant execution. He ingested a fatal dose of methylamphetamine, reportedly to avoid police discovery. He exhibited symptoms consistent with excited delirium (agitation, sweating, altered consciousness), but police incorrectly communicated this term to St John Ambulance paramedics, resulting in miscategorisation of priority. The ambulance was triaged as Priority 3 (non-urgent) and later Priority 2 (urgent) rather than Priority 1 (life-threatening). Police officers provided appropriate initial care and CPR; paramedics arrived at 8:05 pm but could not revive him due to severe trismus (locked jaw) complicating airway management. The coroner found police and paramedic care exemplary but identified a critical communication gap: 'excited delirium' was not recognised by SJA as indicating medical emergency, likely delaying response. The death was classified as misadventure. The coroner recommended implementing liaison between police and ambulance services regarding medical terminology and emergency protocols to prevent similar miscommunication.