Inquest Finds Prone Restraint Likely Contributed to Death at Perth Station

A coronial inquest into the death of 24-year-old Joshua Van Malssen at Perth Underground Station in June 2023 has concluded that being restrained in a face-down (prone) position likely contributed to his death.

Mr. Van Malssen was arrested by Public Transport Authority (PTA) Officers after allegedly being verbally abusive towards staff. Officers handcuffed him while he was in the prone position, and it took time for them to notice he had stopped breathing. He was transported to Royal Perth Hospital but was declared dead shortly after.

Inquest Findings

The inquest heard the cause of death was cardiac arrest. Mr. Van Malssen had several pre-existing medical conditions, including complex heart disease, asthma, early bronchopneumonia, and obesity.

Acting Deputy State Coroner Michael Jenkin described the monitoring by PTA Officers while Mr. Van Malssen was restrained in the prone position as "poor." CCTV footage presented during the inquest showed officers struggling to apply handcuffs due to the size of his wrists.

Surveillance footage further indicated that Mr. Van Malssen took several short, deep breaths before becoming unconscious. An officer eventually noticed he was unresponsive and his face had changed color, at which point handcuffs were removed, and an ambulance was called.

Two doctors who performed a post-mortem concluded that the physical stress of the altercation, combined with his significant heart and lung conditions, obesity, and alcohol consumption, overwhelmed his physiological reserve, leading to cardiac arrest.

Coroner Jenkin ultimately found that the arrest itself was justified and appropriate. He stated:

"A cascade of events led to Josh's death, and the evidence establishes he developed a fatal cardiac arrhythmia due to a combination of factors including: his pre-existing medical conditions; his exertion; his intoxication with alcohol; and his restraint in the prone position."

Recommendations and Response

Coroner Jenkin made several key recommendations to the PTA:

• Improved training on monitoring individuals detained in the prone position.
• An assessment of whether handcuffs issued to transit officers are fit for purpose for individuals of a larger build.
• Updating the PTA Defensive Tactics Manual to emphasize the increased risk of death with every second spent in the prone position.
• Liaising with WA Police to determine if their policies on positional asphyxia are applicable to PTA operations.

The PTA has accepted all recommendations.

Mr. Van Malssen's mother spoke out, stating that his death devastated their family and affected everyone involved, emphasizing that it should not have happened. She expressed her belief that with proper funding, support, and training, particularly for those with disabilities, mental health issues, obesity, or substance abuse, her son would still be alive.

"Our son deserved better. Our family deserved better. The system must do better."