Coroner's Court of Western Australia

Inquest into the Death of Chad RILEY

Inquest into the Death of Chad RILEY

Delivered on :30 July 2021

Delivered at : Perth

Finding of : Coroner Jenkin

Recommendations :Yes

Recommendation No. 1

In order to promote a patient-centred care approach, the East Metropolitan Health Service should consider introducing a policy to deal with patients who do not wait for treatment, similar to the WA Country Health Service policy entitled: Management and Review of ‘Did Not Wait’ Patients that Present to Emergency Services Policy.

Recommendation No. 2

To enhance the standard of care provided to Aboriginal people, the East Metropolitan Health Service should consider recruiting additional Aboriginal Liaison Officers (ALOs) so as to ensure that ALOs are available outside of business hours on any day of the week.

Recommendation No. 3

As soon as practicable, and assuming the trial currently underway is positive, the Western Australian Police Force should consider making fastrap leg restraints widely available to police officers and should provide training as to the appropriate use of these devices.

Recommendation No. 4

The Western Australian Police Force should consider expanding the number of Mental Health Operational Response Teams, so that these specialists can respond to situations involving mental health issues, including those caused or exacerbated by illicit drug use, (e.g.:drug induced psychosis) at any time of the day or night.

Recommendation No. 5

The Western Australian Police Force should ensure that training in relation to Tasers emphasises the importance of avoiding activations to the subject’s chest and heart.  Further, such training should emphasise the risks involved with repeated Taser activations and remind officers of the very real possibility that prolonged resistance and physical exertion may create an increased risk of the subject experiencing a potentially fatal health event.

Recommendation No.6

The Western Australian Police Force should ensure that officers confronting a person exhibiting signs of drug-induced psychosis or related conditions are reminded to treat the situation as a medical emergency and ensure that an ambulance is requested on a priority one basis.  Further, all relevant information about the subjects’ presentation must be communicated in a timely manner to attending ambulance officers.

Orders/Rules : N/A

Suppression Order : Yes

Summary :

Mr Chad Riley (Mr Riley) was 39 years of age when he died at Royal Perth Hospital (RPH) on 12 May 2017 following an interaction with police.  His death was consistent with a cardiac arrythmia and he became unresponsive whilst he was being restrained by police.  Attempts to resuscitate him were unsuccessful.

On the 11 May 2017, Mr Riley was apprehended by police on the Graham Farmer Freeway.  A vehicle matching the description of his car had seen driving erratically.  Whilst he was being questioned, Mr Riley became aggressive and although a breath test was negative for alcohol, attending police fel he may be affected by illicit drugs.  For that reason, Mr Riley was arrested and taken to the Perth Watch House.  A blood test confirmed that Mr Riley was intoxicated by methylamphetamine at the time of his apprehension.  Mr Riley was released from custody, but because he said he might want to talk to someone, police took Mr Riley to RPH for further assessment.  Mr Riley refused to engage with staff and declined offers of assistance from police.  He left RPH in the early hours of 12 May 2107.

Mr Riley was observed acting strangely outside of RPH shortly before7.00 am and later that morning he attended the Aboriginal Alcohol and Drug Service in East Perth and asked to speak to someone, although he did not wait to be seen.  Mr Riley was subsequently seen by a member of the public and by staff at a Tyre and Auto Centre in the East Perth, all of whom thought Mr Riley’s behaviour suggested he was either affected by illicit drugs or mentally ill.

At about 11.35 am, a member of the public saw Mr Riley banging his head on a wall outside of Officeworks in East Perth and approached two police officers who were on the scene investigating an unrelated robbery.  The officers felt Mr Riley was either affected by illicit drugs or cognitively impaired and called an ambulance.  Although Mr Riley was initially unresponsive, as the officers tried to engage with him, Mr Riley suddenly stood up and advanced towards the officers whilst threatening to kill them.  In fear for their lives, one of the officers discharged his Taser at Mr Riley who was temporarily incapacitated.  However, as police attempted to handcuff Mr Riley, the effects of the Taser appeared to wear off and he began to violently struggle.

Subsequent Taser discharges appeared to have no effect on Mr Riley who began trying to remove the officer’s pistol from its holster.  The officers eventually managed to apply handcuffs to Mr Riley and urgent police back-up was requested.  Additional police arrived and took over attempts to subdue Mr Riley.  Ambulance officers attended and as they were treating Mr Riley, he suddenly stopped breathing.  Resuscitation was immediately commenced and Mr Riley was taken to RPH but he could not be revived.

The coroner concluded that Mr Riley’s intoxication with methylamphetamine led him to exhibit irrational behaviour and threaten to kill police officers who had organised medical assistance for him.  Despite repeated Taser activations, Mr Riley engaged in a desperate struggle with police during which he repeatedly attempted to gain control of an officer’s pistol, before suddenly collapsing.

The coroner made six recommendations aimed at expanding the services available to people affected by illicit drugs and/or mental health issues.  Further recommendations included the provision of leg restraints to police officers and increased training regarding the use of Tasers and the provision of information to ambulance officers.  An expansion of mental health response teams (where specialist police officers and a mental health professional respond to incidents involving mental health issues) was also recommended.

The coroner found the cause of Mr Riley’s death was consistent with cardiac arrhythmia following violent exertion necessitating physical restraint in a man with methylamphetamine effect, known systemic hypertension and morbid obesity.  The coroner found that his death occurred by way of misadventure.

Catch Words : Death in police presence, Tasers, methylamphetamine, restraints, actions of police : Misadventure


Last updated: 20-Sep-2021

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