Coroner's Court of Western Australia

Inquest into the Death of Roderick Malcolm NARRIER

Inquest into the Death of Roderick Malcolm NARRIER

Delivered on : 22 August 2022

Delivered at : Perth

Finding of : Coroner P J Urquhart

Recommendations : Yes

Recommendation No. 1

The following sentence currently appears in the WAPF Operational Safety and Tactics Training Unit Empty Hand Tactics and Handcuffing Training Manuals with respect to the use of a restraint of a subject in the prone position by police:

          ” (REDACTED)

To reduce the danger of positional asphyxia to a subject in the prone position, that sentence should be replaced with the following:

The restraint of a subject in the prone position should always avoid the application of downward force directly to the subject’s back, chest or stomach. If such an application of downward force is required, it should only be used for the purpose of applying handcuffs. It should immediately cease once police have gained control of the subject.

Recommendation No. 2

The WAPF should ensure that training in relation to the indicators of positional asphyxia reinforces that evidence of struggling and/or rapidly escalating body temperature by the restrained person may be due to positional asphyxia and not excited delirium.

Recommendation No. 3

As soon as practicable, the WAPF should consider making fast strap leg restraints available to operational police officers and should provide training as to the appropriate use of these devices. 

Orders/Rules : No

Suppression Order : Yes

That there be no reporting or publication of any document or evidence that would reveal police policies and standard operating procedures, tactics, or training methods in relation to the use of force.

Summary:  Roderick Malcolm Narrier (Roderick) was a 39 year old Noongar man who died on 30 October 2019, at Royal Perth Hospital (RPH) from multiorgan failure following an out of hospital cardiac arrest in a man with methylamphetamine effect, restraint and focal moderate coronary artery arteriosclerosis. Days earlier, on the morning of 27th October 2019, Roderick went into cardiac arrest as he was being restrained by members of the Western Australia Police Force (WAPF), following the administration of a sedative by St John ambulance officers. Pursuant to section 22(1)(b) of the Coroners Act 1996 (WA), his death was subject to a mandatory inquest to examine the conduct of police in their interactions with Roderick.

In the early hours of 27 October 2019, Roderick was at his home in Kewdale with his partner, when he injected methylamphetamine, before going to sleep in the bedroom of their home. Roderick’s partner awoke hours later and when she attempted to leave the bedroom to go to the bathroom, Roderick became distressed and grabbed onto her. His partner’s concerns grew as she noted Roderick was sweating heavily, had a very fast heartbeat and refused to let her go. The commotion from this interaction woke the other occupants of the house.

Roderick’s partner directed the occupants to break down the locked door in order to give her assistance. Upon gaining entry to the bedroom, the occupants saw that Roderick was choking his partner, and that he was not responding to anything that was being said to him. The occupants were able to separate Roderick from Ms Forrest, but only after he bit her on the chest. Two of the occupants were then able to restrain Roderick, who was now face down on the bed, with pressure placed on his arms and legs.

Another occupant called emergency services requesting police attendance. When two police officers arrived, they took over the restraint of Roderick on the bed and were able to eventually handcuff him behind his back. The officers were informed Roderick had recently injected methylamphetamine, and given his significant resistance to his restraint, profuse sweating and high body temperature, they suspected he was experiencing an episode of excited delirium. One of the officers made a radio call to WAPF Police Operations Centre, which resulted in an ambulance and two more police officers being dispatched. With the arrival of the other two police officers, the four officers were able to establish a degree of control over Roderick who was displaying incredible strength.  

As the restraint continued, ambulance officers arrived and conducted a visual examination of Roderick, which noted that given the noises he was making and the position he was in, he was not in respiratory distress. The ambulance officers concluded that Roderick was experiencing drug-induced psychosis and a decision was made to inject a sedative. Shortly after the injection, Roderick suddenly went limp, and it became evident that he was in cardiac arrest.

Ambulance officers requested that the police officers cease their restraint of Roderick and uncuff him. Resuscitation efforts then commenced and Roderick was admitted to RPH where he was placed on life support systems, without regaining consciousness. On 30 October 2019, life support was withdrawn and Roderick died.

The Coroner found that Roderick’s death occurred by way of misadventure, after he went into cardiac arrest while being restrained by four police officers. Several hours earlier, he had injected methylamphetamine which was the primary contributing factor in his death as it caused him to have an episode of excited delirium.

The Coroner found that the police officers involved in the restraint of Roderick acted appropriately in their conduct. The Coroner made three recommendations aimed at enhancing training and better equipping police officers to respond to cases involving excited delirium, positional asphyxia and the use of force.

Catchwords: restraint – positional asphyxia – excited delirium

Last updated: 2-Oct-2023

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