A SWAN Hill man died after being put in a restraint position after a fight outside a Swan Hill nightclub five years ago, a Victorian coroner has found.
The 20-year-old man, who The Guardian has chosen not to name due to cultural sensitivity, died on the footpath near Barrells Nightclub on Campbell Street on January 19, 2019.
During the altercation, the man was restrained by a security officer and owner of the venue for “upwards of four minutes”.
In a Coroners Court of Victoria finding into the death without inquest, Coroner Leveasque Peterson determined the man died from prone-restraint asphyxia in the setting of alcohol intoxication and centripetal obesity.
Prone-restraint asphyxia occurs when someone’s position prevents their breathing.
Ms Peterson said there was differing, and sometimes conflicting, evidence over the circumstances of the incident.
The court heard that in the hours leading up to the incident the dead man spent the evening with his brother and two friends before they went to the nightclub and nearby hotel.
There was a brief verbal exchange between a group of patrons and the dead man outside the venue.
The two groups met on the footpath between Voyage Fitness and Syd Wilson Electrics and, following a brief verbal exchange, there was a fight.
Ms Peterson said while details of the fight differed in various accounts, there had been subsequent criminal convictions.
One offender struck the dead man in the face, causing him to fall backwards to the ground.
After a few seconds, he regained his feet with the assistance of a passer-by and continued to fight.
The venue owner intervened and attempted to separate the parties.
At 1.15am, the owner restrained the man by placing his arm around his upper body from behind.
The deceased lent forwards and went to ground, where the owner continued to restrain him face down.
While the deceased was being held in a prone position, a member of the other party approached and kicked him in the upper body or stomach.
The kick was described as “a big football kick that connected with (the) stomach” and “looked like it took the wind out of him”.
As the man and his brother were held in position, the fight ended and an employee of the nightclub was asked to call 000.
CCTV footage showed that for about two minutes, the man continued to kick back and forth before becoming still and stopped moving at about 1.17am.
The owner attempted to lift the man but noticed he was still and not breathing.
CPR began with assistance from another security officer before emergency services arrived. He was pronounced dead a short time later.
Victorian Institute of Forensic Medicine pathologist Dr Linda Iles conducted an autopsy and found it did not demonstrate an anatomical cause of death.
“There is no evidence of head injury, abdominal or chest haemorrhage or underlying natural disease process to account for (the deceased’s) death,” Dr Iles said in her report.
Dr Iles considered two possibilities, including blunt head trauma in the setting of alcohol intoxication.
Dr Iles said this was a condition in which the central nervous system depressant effects of alcohol magnifies any concussive effects to the brain stem consequent to blunt trauma, which could result in prolonged apnoea or respiratory and cardiorespiratory arrest.
The second possible scenario was that of prone-restraint asphyxia in the setting of alcohol intoxication and centripetal obesity.
However, taking into account the information which was available to her at the time, Dr Iles was unable to elevate one cause above the other and provided an opinion that a reasonable formulation for the medical cause of death was “1(a) Unascertained”.
Ms Peterson said that based on autopsy findings, witness statements and video footage, prone restraint asphyxia in the setting of alcohol intoxication and centripetal obesity appeared to be the most likely cause of death.
The Barrells Nightclub owner was charged with one count of negligent manslaughter before he was discharged after three days of evidence in a contested committal.
The dead man’s family raised concerns that the owner had not undertaken adequate training in the safe use of restraint techniques or the risks of positional asphyxia.
“At the relevant time of the incident, (the owner) had maintained a crowd controller, security guard and unarmed guard licence since 2007. His most recent renewal was in March 2019,” Ms Peterson said.
“Taking into account my finding that (the deceased’s) passing was caused by prone-restraint asphyxia in the setting of alcohol intoxication and centripetal obesity, I am satisfied that restraint was one factor which contributed.
“Further, I am satisfied that there is a sufficient causal link to warrant investigation and comment with regard to the appropriateness of training requirements for security personnel in relation to safe use of restraint techniques.
“Nonetheless, I consider that the circumstances of (the deceased’s) passing may provide an opportunity to improve public safety.”
Ms Peterson recommended Victoria Police’s licensing and regulation division establish a requirement that before licence renewal, existing security licence holders must undertake refresher training with an LRD-approved registered training organisation, including with regard to the safe use of restraint techniques and the risks of positional asphyxia.
