A West Australian coroner remains "concerned" and "troubled" about police use of a physical restraint that has been linked to deaths in custody, recommending even stricter limits as part of findings into the death of Noongar man Roderick Narrier in Perth.
WARNING: Aboriginal and Torres Strait Islander readers are advised that the following article contains images of people who have died.
Mr Narrier died after going into cardiac arrest while being restrained face down on his stomach after he took methamphetamine at his Kewdale home in October 2019.
His family had called police to the home after he became aggressive towards his partner.
Known as the "prone" restraint, the face-down position used on the 39-year-old is an effective form of control for police, but can be dangerous due to the risk of asphyxiation.
The use of the restraint was either a contributing factor or the cause of death in at least 10 deaths across Australia, including Perth woman Cherdeena Wynne in 2019.
As part of an inquest into Mr Narrier's death, West Australian coroner Philip Urquhart considered the role of the prone position and found that it was not the cause of his death.
He said police acted appropriately when they held Mr Narrier face down for 22 minutes because they had no safe alternative to restrain him.
Coroner 'troubled' by wording of training manuals
But Mr Urquhart, who earlier this year recommended changes to police training around the use of the restraint, said he remained "troubled by the present wording" in officer training manuals.
He said WA Police should update their training material to assert that officers should not apply downward pressure to a person's back, chest or stomach.
"If … required, it should only be used for the purpose of applying handcuffs," wrote Mr Urquhart, adding that it should stop immediately after police gain control of the subject.
He also recommended training should reinforce that a person who is struggling against police may be doing so because they are experiencing asphyxia from the restraint.
Asked how it would respond to the recommendations and criticisms, WA Police said its officers were found to have acted appropriately and that it would review the coroner's findings.
Family believes prone position played role in death
Mr Narrier's sister, Monica, still believes the restraint played a part in her brother's death.
"I believe there was too much force put on him," Ms Narrier said of her brother's death.
Ms Narrier said her family heard Mr Narrier say "I can't breathe" in an audio recording of the incident that was played at the inquest hearings.
"When we heard it, it just lit us right up because we can hear it clear," Ms Narrier said.
Mr Urquhart said the audio recording quality was too poor to determine what Mr Narrier said but the evidence suggested he likely said something that was not "I can't breathe", but sounded similar to it.
Coroner recommends better training for second time
The National Justice Project, which represents Mr Narrier's family, says the recommendations show the coroner remains unsatisfied with the WA Police response.
"Legal advocates for the family are disappointed that despite the coroner's repeated warnings against excessive use of the prone position, he did not acknowledge the role that WA Police may have played in Mr Narrier's death by holding him in the prone position for 22 minutes," the National Justice Project said in a statement.
Mr Urquhart's report is his second this year that recommends better training for police to reduce the risk of death linked to the prone restraint, after he concluded it was a factor in the death of Noongar woman Cherdeena Wynne in 2019.
He said police had failed to check her breathing according to procedure and was critical of the WA Police internal investigation that found the officers' conduct was in line with procedures.
But he found the use of the restraint in Mr Narrier's case "contrasts sharply" with its use in the case of Ms Wynne.
Prone restraint linked to other deaths in custody
The role of the prone restraint is also being considered in the case of a Queensland man who died in 2019.
Of the other nine cases of deaths in custody identified by the ABC, three were in the past four years.
The Wynne and Narrier families are among those calling for the restraint to be banned, and for greater police transparency around how officer training has improved since their deaths.
"Why isn't there more being done in Australia to combat this? Why isn't it on the front page of everybody's [paper]?" said Ms Wynne's great aunt, Barbara Stoeckel-Clayton.
The risk associated with the prone restraint relates to a condition called positional asphyxia.
Determining role of prone restraint in death 'complex'
David Ranson, a forensic pathologist at the Victorian Institute of Forensic Medicine, said there were multiple factors that could increase a person's risk of dying when they were restrained in the prone position.
The use of certain drugs and pre-existing physical conditions are possible risk factors, and deaths where prone restraint is the sole cause are rare.
"What is certainly appearing in the literature now, is this view that what's happening here is it's actually more of a cardiac arrest association, rather than an asphyxia or restriction of breathing," said Mr Ranson.
"However, there is a bit of overlap.
"In other words, if you decrease someone's oxygen levels, you can actually put increased stress on their heart, and you can change their metabolic status to make them more likely to suffer a cardiac arrest."
He said the signs of this type of death were often not detectable through an autopsy.
"You're then forced to go back to look at the circumstances and investigate in more detail — the background and medical conditions that the victim may have suffered from," he said.
Restraint used by police across Australia
Police across Australia use the restraint and most acknowledge the risk of death, while offering varying advice to their officers on how to mitigate it and in what circumstances the restraint should be used.
WA Police said it updated its policies in response to the initial recommendations from the Cherdeena Wynne inquest.
It said the inherent risks of restraining a person in the prone position were now included in a "use of force" training package which included a specific reference to positional asphyxia.
It has also updated its training manuals to encourage greater consideration of the risks, but the coroner wants the police force to go further.
Ms Wynne's great aunt Barbara Stoeckel-Clayton and grandmother Jennifer Clayton said police did not notify them directly of any changes, and called for more transparency about the nature of the training improvements.
"Anybody can say that but you need to show us — what does that look like?" Ms Stoeckel-Clayton said.
"And is that just for the officers that are coming through now? Or has the whole force been put through that training?"
Methamphetamine a factor in both cases
Karina Hawtrey from the National Justice Project said continuing deaths showed the restraint was s still being used too frequently and in dangerous circumstances.
"We are concerned … in terms of restraining people that have mental health issues or are drug affected — [they] are often even more vulnerable in that state to positional asphyxia," Ms Hawtrey said.
"Their body is already kind of processing panic and the physical exhaustion, the exertion of the drugs or the mental health crisis or anxiety attacks that they're having."
Ms Wynne had methamphetamine in her system when she died and Mr Narrier had become violent after using the drug, with police forced to restrain him as he was kicking, growling, thrashing and trying to bite them.
He went into cardiac arrest about 10 seconds after he was injected with a sedative but Mr Urquhart found that did not contribute to his death.
"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," reads a summary on the website for the Coroner's Court of Western Australia.
"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."
Families want to raise awareness, bridge gap
Despite their frustrations, the families of Ms Wynne and Mr Narrier say they are motivated by peace and reconciliation.
They want to raise awareness about what happened to their loved ones, and help save lives.
Ms Stoeckel-Clayton, who now cares for Cherdeena's young daughter Shirley-Rose, said it was exhausting to relive her losses, but she wanted to speak up for future generations.
"Now she's going to grow up with the fear of her mother's life and her grandfather's life, so we now need to undo that damage," Ms Stoeckel-Clayton said.
"It's that intergenerational thing.
"And so to help undo that, police need to communicate with us [as well as] legislation.
"Yeah, we are making change. We don't need to chase this information, though. You should be coming to us to bridge this gap of reconciliation with society, not only Aboriginal people but society and the police force."
The 10 cases where prone position was deemed to be a contributing factor to a death in custody were:
- Cherdeena Wynne – 2019 — WA
- Pasquale Giorgio – 2018 – QLD
- Jack Kokaua – 2018 NSW
- Tristan Naudi – 2016 — NSW
- David Dungay Jr – 2015 — NSW
- Styles Isaac King – 2013 — NT
- Carl Antony Grillo – 2009 — QLD
- Robert William Plasto-Lehner – 2007 — NT
- Tofia Josen Mataia – 2008 – QLD
- Michael John Eddy – 2004 – QLD
