Original communication
Restraint related deaths and excited delirium syndrome in Ontario
(2004e2011)
Alain Michaud, MD
675 Rang 1 Sud Roberval, Quebec, G8H 2M9, Canada
a r t i c l e i n f o
Article history:
Received 30 December 2015
Received in revised form
20 March 2016
Accepted 1 April 2016
Available online 9 April 2016
Keywords:
Excited delirium syndrome
Physical exertion
Prone position
Restraints
Sudden death
Unexpected death
a b s t r a c t
Restraint related death in individuals in excited delirium syndrome (ExDS) is a rare event that has been
the subject of controversies for more than 3 decades. The purpose of this retrospective study was to
retrieve data on all restraint related deaths (RRD) that occurred in Ontario during an 8-year period and
compare them with an earlier study on RRD in ExDS covering the period 1988e1995 in Ontario. The
Office of the Chief Coroner of Ontario website was consulted under verdicts and recommendations. The
Canadian Legal Information Institute website was used to consult verdict explanations and coroner's
summary of evidence. During the period 2004e2011, RRD occurred in 14 individuals in ExDS, a 33%
reduction. Psychiatric illness as a cause of ExDS decreased from 57% to 14%. Cocaine was the cause of
ExDS in 11 (79%) individuals. The number of RRD following a violent encounter in cocaine-induced ExDS
(8) was identical in the 2 periods. RRD occurred in 6 individuals without ExDS following a violent
encounter. Final restraint position preceding cardiorespiratory arrest was available in 36% of individuals
with ExDS and 83% of individuals without ExDS. In both groups, cardiorespiratory arrests could be
classified as immediate or delayed. All 4 individuals without ExDS who had immediate cardiorespiratory
arrests were restrained in the prone position. Delayed cardiorespiratory arrest occurred in the non-prone
position in both groups. Although many hypotheses may be put forward to explain changes in the
epidemiology of RRD in ExDS in Ontario, multiple warnings and recommendations from coroners' inquests
cannot be ignored. There is probably not a unique pathophysiological pathway leading to
cardiorespiratory arrest in RRD. The death rate in RRD in ExDS is so low that drawing any conclusions
based on statistical studies or on isolated case report could be hazardous.
© 2016 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
1. Introduction
Since the publication of Reay et al.,1
the cause of sudden and
unexpected death of individuals restrained for excited delirium
syndrome has been a subject of controversy.2,3
While respiratory
compromise in the prone position has been proposed, suggesting
that restraints could play a significant role in these deaths,4,5,6
others believed that these deaths were the result of fatal autonomic
dysfunction caused by abnormalities in dopamine
signaling.7,8
Now recognized as a condition requiring rapid medical
diagnosis and treatment, it has been suggested that the mortality in
ExDS could be lowered if police officers had a pocket card
describing the signs and symptoms of ExDS.9
Recently, Hall et al.10
published a study based on multiple data
collected in 4 Canadian cities from August 2006 until March 2013.
One of these data was the documentation of “the final resting position
of the subject, once physical control had been achieved and
while awaiting disposition at the end of the police-public interaction”.
As the only death occurred in the non-prone position in an
individual presenting “all 10 features of excited delirium”, the authors
explained that their results echoed “the earlier findings of
Pollanen and other authors that sudden in custody death has more
to do with the features of the individual”.
The goal of this study was to re-examine deaths in custody
related to restraints in Ontario since the period 1988e1995 used by
Pollanen et al.11
2. Methods
Because verdicts and recommendations of coroners' inquests in
Ontario are information available to the public, no ethics committee
approval was necessary. Through the website of the Office of the
Chief Coroner of Ontario (OCCO),12
verdicts and recommendationsE-mail address: g.a.michaud@hotmail.com.
Contents lists available at ScienceDirect
Journal of Forensic and Legal Medicine
journal homepage: www.elsevier.com/locate/jflm
http://dx.doi.org/10.1016/j.jflm.2016.04.010
1752-928X/© 2016 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
Journal of Forensic and Legal Medicine 41 (2016) 30e35
were consulted. Going backward from the date of the last inquest
held in 2014, the names of the deceased were retrieved if the
following key words “restraints”, “accident.custody”, “undetermined.custody.police”,
“restraint asphyxia”, “accident.police”, “positional
asphyxia”, “accident.jail”, “accident.detention center” were
found in “Summary”. Then, through the Canadian Legal Institute
Information (CanLII) website,13
the first name and the last name of
the deceased followed by “coroner inquest” was used to have access
to verdict explanations and the coroner's summary of evidence. If
verdict explanations and summary of evidence were not found, the
OCCO was contacted. The year considered to be the study starting
point was the year when the first individual died following the use
of restraints. Then, all individuals who died following the use of
restraints during an 8 year-span were considered for the study.
3. Results
Between 2004 and 2011, 20 coroner inquests were held
following the use of restraints in Ontario. All individuals were men.
The mean age was 35 years (SD 8.6). All deaths occurred in custody.
Signs and symptoms of ExDS resulting from drug-induced psychosis
or psychiatric illness were present in 14 (70%) individuals.
Six (6) individuals were not in ExDS (Fig. 1, Fig. 2, Fig. 3).
In 11 (79%) individuals with ExDS, a violent physical encounter
occurred with police officers. Loss of consciousness followed by
cardiorespiratory arrest was immediately noticed in 5 individuals
once handcuffs were in place. The other 6 individuals were still
conscious after the application of handcuffs and unexpected
cardiorespiratory arrest occurred following a bout of continuous
fighting and struggling against restraints. In 3 (21%) individuals
with cocaine-induced ExDS, minimal use of force was reported. One
was a “body packer” who died from an acute cocaine overdose. In
the other 2 individuals, “acute cocaine intoxication” or “cocaine
poisoning” was mentioned in the summary but cocaine blood levels
were not available. In individuals with ExDS, cardiovascular disease
was mentioned in 4 individuals (29%). Conducted electrical weapon
(CEW) was used in 5 individuals. Stun mode was briefly effective in
20
No ExDS ExDS
6 14
Immediate cardiorespiratory arrest
*
Still conscious once handcuffed
†
4 2
Violent altercation Minimal use of force
11 3
Immediate cardiorespiratory arrest
*
Still conscious and struggling once handcuffed
5 6
* Unconsciousness observed immediately following the application of handcuffs.
†
Still conscious but immediate breathing difficulties leading very rapidly to cardiorespiratory arrest.
Fig. 1. Sudden and unexpected deaths following restraints in Ontario (2004e2011).
0
1
2
3
4
5
6
2004 2005 2006 2007 2008 2009 2010 2011
Fig. 2. Restraint related deaths associated with ExDS in Ontario (2004e2011).
0
1
2
3
4
5
6
2004 2005 2006 2007 2008 2009 2010 2011
Fig. 3. Restraint related deaths in individuals without ExDS in Ontario (2004e2011).
A. Michaud / Journal of Forensic and Legal Medicine 41 (2016) 30e35 31
3 out of 4 individuals with cocaine-induced ExDS, allowing the use
of handcuffs. In an aggressive schizophrenic, sudden collapse and
cardiorespiratory arrest occurred almost immediately when darts
hit the anterior chest area from a distance of 4 feet. Final position
and type of restraint used when the individuals lost consciousness
was mentioned in 5 (36%) individuals with ExDS.
In the 6 individuals without ExDS, all deaths occurred following
a violent altercation with police officers. In 4 individuals, loss of
consciousness and cardiorespiratory arrest was noticed immediately
once wrists were secured by handcuffs. Those individuals
were all restrained in the prone position and in at least 3 cases,
pressure was applied on the chest with a knee or the police officer(s)
body (ies). In the case of an 18 years old healthy individual,
chest compression by 2 police officers was preceded by a 2e3 min
foot race. In the 2 individuals still conscious once handcuffed,
“breathing difficulties” were observed in 1 individual and verbalized
by the other. In both individuals, cardiorespiratory arrest
occurred very rapidly thereafter. According to police officers, prone
position was not used in 1 of those 2 individuals. The position used
to restrain and handcuff the other individual who had submitted
himself to a prolonged foot race was not mentioned. Final position
and type of restraints were mentioned in 5 (83%) individuals
without ExDS. Cardiovascular disease was mentioned in 2 (33%)
individuals. Fig. 4 and Table 1 compare different data from this
study with the period 1988e1995.
4. Discussion
Restraint related deaths (RRD) in ExDS are rare in Canada. In
2004, the death rate was estimated to be around 0.25 death/
million/year.14
In the absence of a national registry on RRD, the
OCCO and CanLII websites remain a valuable source of information
as Ontario accounts for nearly 40% of the total Canadian population.
By including all RRD for the period 2004e2011 and by taking
advantage of the Pollanen et al. study,11
this study shows that the
epidemiology of RRD in ExDS has changed in Ontario and that RRD
are not exclusive to individuals in ExDS.
4.1. Evolution of restraint related deaths associated to excited
delirium syndrome in Ontario
Compared to the period 1988e1995, RRD in ExDS decreased
from 21 to 14, a 33% reduction, and psychiatric disorders, as the
cause of ExDS, decreased from 57% (12) to 14% (2). After 2005, only 1
death per year occurred on average (0.08 death/million/year). This
decrease is not related to an increase rate of institutionalization
as reintegration of individuals with mental illness is still the trend.
Better social and health care of individuals with psychiatric disorders
may have reduced the total number of police interventions
during the period 2004e2011. Warnings from the OCCO concerning
the association between restraints and fatal ExDS came in February
1995. Since 1995, the Pollanen et al. study11
has been published and
there have been repetitive recommendations from different coroners'
inquiries held in Ontario. In November 2007, a jury recommended
that a “policy be implemented that forbids first responders
who are attending to a medical emergency from putting a patient in
the prone position particularly with patients exhibiting the set of
symptoms commonly referred to as excited delirium”. Since, there
has not been a single death reported in a physically restrained
psychiatric individual in Ontario. In 2006, paramedics patient
standards on prone position in agitated psychiatric patients were
changed from “not recommended” to “not be used”.15
In Toronto,
Mobile Crisis Intervention Teams consisting of a specially trained
police officer and a mental-health nurse have been created during
the period 2004e2011. During the period 2004e2011, no death was
associated with neck pressure and hog-tied was mentioned only
once. Summaries reveal that police officers were aware of the association
between restraints in the prone position and fatal ExDS
but thought that “the risks of prone restraint” applied “only within
the context of excited delirium.” That information suggested that
restraints in the prone position were probably discarded as an option
during interventions in individuals with ExDS and may
possibly explain why, in the last 3 years of this study, there were
more RRD in individuals without ExDS than in individuals with
ExDS. There is indirect evidence that restraint techniques and
training may have also evolved elsewhere in Canada. The only death
reported in the Hall et al. study10
occurred between August 2006
and August 2009.16
In the Hall et al. study,10
hog-tying was not
allowed and “significantly more individuals with any comorbidity
detected at the scene were placed in a not-prone position”. However,
within 6 weeks during the same period, 2 individuals died in
custody while restrained in the prone position in Western Canada.
Both deaths resulted in special inquiries.17,18
4.2. Cocaine-induced fatal ExDS
Cocaine can cause multiple adverse effects other than acute
psychosis. Based on findings in cocaine-induced fatal ExDS, some
0
2
4
6
8
10
12
14
1 2 3
psychiatric illness cocaine-induced other drug-induced
2004-2011
1988-1995
Fig. 4. Cause of excited delirium syndrome in restraint related deaths in Ontario.
Table 1
Restraint related death in excited delirium syndrome in Ontario.
2004e2011 1988e1995
Number 14 21
Mean age (SD) 35.7 (8) 33 (10)
In custody 14 (100%) 18 (86%)
Psychiatric illness 2 (14%) 12 (57%)
Drug induced 12a
(86%) 9 (43%)
Cocaine (lethal range) 3/11 (27%)b
0/6
Violent encounter 11/14 (79%) 21 (100%)
Neck pressure 0 3 (14%)
Prone position 3c
18 (86%)
Supine 1d
0
Hog-tied ǁ 1 2
Seizure preceding death 3 (21%)e
0
Cardiovascular disease 4 (29%) 4 (21%)
a
Cocaine in 11 cases, methamphetamine in 1 case.
b
No blood levels available (See Limitations).
c
No information available for 9/14 individuals; includes fatal collapse following
CEW.
d
Very combative with police officers-was put in police wagon with handcuffs and
ankle restraints only-was struggling side to side in police wagon-still combative at
hospital arrival-unexpected death occurred when restrained supine at hospital
arrival-no detail on restraint technique. ǁ Hog-tied and left as such in prone position.
e
2 cocaine-induced ExDS and 1 methamphetamine-induced ExDS.
A. Michaud / Journal of Forensic and Legal Medicine 41 (2016) 30e3532
have argued that fatal ExDS resulted from central nervous alterations
leading to fatal autonomic dysfunction similar to the
neuroleptic malignant syndrome7,19
or from an uncontrolled and
severe metabolic acidosis. In this study, minimal use of force was
reported in 3 (21%) individuals with cocaine-induced ExDS and the
number of RRD in cocaine-induced ExDS following violent physical
encounters (8) did not change between the 2 periods. At least 1
individual, possibly 3, died apparently from cocaine overdose. The
total number of cocaine users was probably higher during period
2004e2011. Estimated prevalence of cocaine consumption in Canada
was around 0.9% for period 1988e199520
and 1.9% in 2004,21
1.6% in 200822
and 0.9% in 201122
and Ontario population
increased by more than 2 million. The total number of police interventions
in these circumstances and whether individuals with
recreational blood levels of cocaine were less inclined to develop
cocaine-induced ExDS is unknown. The majority of RRD in individuals
with cocaine-induced ExDS following a violent encounter,
63% (5/8), occurred in the first 2 years of this study (2004e2005).
Following a violent encounter in the last 4 years (2008e2011), there
were more RRD in individuals without ExDS (3) than in individuals
with cocaine-induced ExDS (2). The hypothesis that fatal ExDS results
from central nervous system alterations leading to fatal
autonomic dysfunction originates from reports and studies from
Florida in individuals with cocaine-induced ExDS.7,19,23
Those authors
also showed that police custody was the most important
factor determining sudden death (odds ratio 22.3) and that summer
season (odds ratio 2.5) increased the risk of fatal cocaineinduced
ExDS.23
Physical exertion associated with ExDS and the
fact that cocaine can increase intracellular calcium24,25
should raise
the possibility that the multiorgan failure syndrome (MOF) associated
to cocaine may have more in common with hypermetabolic
syndromes such exertional heat illness, exertional rhabdomyolysis
or malignant hyperthermia which are characterized by an uncontrolled
increase in intracellular calcium.26
The dramatic temperature
drop and clinical improvement following use of dantrolene
also suggests that the MOF described in cocaine users may have a
relation with mitochondrial dysfunction.27
The notion that severe
metabolic acidosis could be a significant factor in RRD in cocaineinduced
ExDS was introduced in 1999 by Hick et al.28
They outlined
the importance of police officers collaboration and, with the
application of certain principles gained from past experiences, they
described the successful reanimation of 5 individuals in cocaineinduced
ExDS who never went into cardiac arrest in spite of pH
as low as 6.76.28
4.3. The prone position controversy in fatal ExDS
The prone position controversy in fatal ExDS is the core of a
larger debate on whether law enforcement restraint techniques are
the direct cause of cardiorespiratory arrest in RRD. In RRD, handcuffs
can be used as a marker to distinguish the “control phase”
from the “restrained phase”. This study shows that handcuffs can
also be used as a marker to classify RRD as sudden (immediate) or
unexpected (delayed). In this study, all sudden deaths (4) in individuals
without ExDS occurred in the prone position with chest
compression in at least 3 cases. In 2 of those 4 individuals, postmortem
did not reveal any potential factors that could be used to
explain those deaths. This finding should question methods, results
interpretations and any conclusions drawn from studies in healthy
subjects designed to simulate the same circumstances. No clear
distinction between the “control phase” and the “restrained phase”
was made in the 5 case series articles where 70/71 cardiorespiratory
arrests were reported in the prone position.4,5,6,11,29
In the
Pollanen et al. study,11
handcuffs were not mentioned in the 3 individuals
“with pressure applied to the neck” and in 4 individuals
“with chest compression” in the prone position suggesting that at
least 7 RRD occurred during the “control stage” during period
1988e1995. Isolated case reports of RRD in the non-prone position
have been reported during the “restrained phase”.30,31
Recovery
rates after exercise with chest compression in the prone position32
or “hobble restraints”33
have been used as arguments that the
prone position is not a predisposing factor in RRD in ExDS. Paterson
et al.34
have criticized both studies and have questioned their
“ecological validity”. Moreover, in the phase 2 of Schmidt and
Snowden's study,33
subjects, once “placed in maximal restraint”,
were immediately rolled “onto a side”. Their technique differed
from early hog-tying and was developed by a local San Diego police
department in 1992.33
O'Halloran et al. explained that San Diego
police department had “banned the practice of transporting subjects
hogtied and proned” following death of 5 men restrained in
prone position.5
Among the 6 individuals in ExDS who kept on
struggling once handcuffed in this study, at least 2 individuals were
tightly restrained in the prone position, 1 on a gurney, the other
hogtied. At least 1 individual “went vital signs absent” very rapidly
after being forcefully “strapped onto the restraint gurney in a supine
(face-up) position”. Whether restraints resulted in abdomen
compression in that case is unknown.
In this study, breathing difficulties and shortness of breath
during the “restrained phase” were reported as the only complaint
from the 2 individuals without ExDS. Shortness of breath is a
subjective sensation reported in acute coronary insufficiency and
acute diastolic dysfunction as well as in anxious individuals. Being
restrained in the prone position may be uncomfortable even in
healthy volunteers.35
Psychotic individuals in ExDS are unable to
communicate verbally. Struggling against restraints may be the
only warning sign that they feel “short of breath”, that they are not
comfortable or that a major event is occurring. An expected reaction
of a psychotic and paranoid individual tightly restrained
should be increased struggling and forcing desperately to change
position. Hick et al. explained that “continued combativeness
despite restraints, especially in the setting of sympathomimetic
agents such as cocaine, seems to be a marker for a patient at high
risk of sudden death”.28
Struggling continuously against restraints
or forcing desperately against tight restraints are 2 forms of static
exercise that may have different hemodynamic consequences.
Forcing desperately against tight restraints is an exercise similar to
weight lifting. By severely increasing intrathoracic pressure, weight
lifting can induce a Valsalva maneuver resulting in syncope.36
By
increasing significantly diastolic blood pressure, static exercise
such as continuous struggling will increases myocardial oxygen
demands.37,38
Unexpected cardiac events are likely to occur in hypermetabolic
individuals in a clinical situation of sudden decrease
in cardiac output or acute increase in myocardial oxygen demands.
In medicine, potential deleterious consequences of prone position
are recognized in critical care,39
in anesthesiology,40
in sudden
unexpected death in epilepsy.41
Compared to the supine position,
the prone position decreased the cardiac output by 14% in healthy
subjects.42
Prone position impedes adequate observation and
monitoring of individuals in ExDS who are at risk of unexpected
cardiorespiratory arrest. There is probably not a unique pathophysiology
leading to cardiorespiratory arrest in RRD. The finding
that RRD occurred in the non-prone position in at least 1 individual
without ExDS indicates that there is a risk associated with restraints
but this should not be interpreted as if the prone position
cannot increase that risk in ExDS.
4.4. Use and abuse of the expression excited delirium syndrome
Identifying individuals in ExDS is a subjective exercise based on
non specific clinical features and it has a low specificity in
A. Michaud / Journal of Forensic and Legal Medicine 41 (2016) 30e35 33
predicting fatal ExDS.43
In public coroner inquests in Ontario, an
expert is invited to explain issues related to ExDS to a jury. In regard
to the schizophrenic individual, known in the past for “aggressive
and unpredictable behaviour”, who collapsed immediately
following the deployment of CEW in the chest, the use of ExDS
should be questioned. The vast majority of the clinical features of
ExDS were absent. The individual appeared quiet and was seated at
police officers arrival. They were able to have a conversation with
him. Situation deteriorated 5 min later when police officers
explained that he was going to be arrested. This individual was
discovered at autopsy to have SCN5A polymorphism of class III, a
normal variant not likely to cause cardiac arrhythmia. An objective
finding in this inquiry was the result of a blood sample, taken in the
emergency department. As it showed a severe metabolic acidosis
with pH of 6.85 and an anion gap of 27, this was considered as an
evidence in favor of fatal ExDS. In this case, response time in the
field (time between cardiac arrest and CPR start) was very high
(roughly between 10 and 15 min) and toxicology was negative for
cocaine. The jury was not aware that the mean initial pH and anion
gap value in individuals sustaining an out-of-hospital cardiac arrest
is 6.90 and 20 respectively.44
Clinically, this individual had more in
common with the 17 years old teenager who became upset when
he learned that he had lost his job.45
Individuals with cocaine-induced ExDS appear to be at higher
risk of cardiorespiratory arrest during physical interventions.
However, the violence and the length of the struggle during law
enforcement encounters implies that the majority of those individuals
had similar cardiovascular and physiological reserve than
individuals without ExDS who died from RRD. In that regard, the
possibility that heat shock protein 70 could be a non specific
marker46
would require more studies.
There are probably more cases of “near misses” in individuals
restrained in the prone position than the 2 recently reported.47,48
The limiting factor during severe exercise is cardiovascular, not
respiratory.49
The ACEPW mentions that “the majority of lethal
ExDS die shortly after a violent struggle”, “suddenly, typically
following physical control measures”.50
If the goal of the pocket
card is to identify individuals in ExDS and to transfer them alive to
appropriate medical care,9
understanding the potential impact of
restraints on cardiovascular physiological adaptations to exercise is
important considering the acute level of exhaustion occurring
during violent encounters.51,52
5. Limitations
This study has many limitations. It is retrospective. In Ontario,
coroner inquest summary is a “document solely to assist interested
parties to understand jury's verdict”. In some summaries, the
amount of information was extensive. In others on cocaine-induced
fatal ExDS, information was sometimes minimal. Information
concerning restraint positions used in some cocaine-induced fatal
ExDS was lacking. It is possible that some individuals with cocaineinduced
ExDS may have been classified erroneously in the sudden
cardiorespiratory arrests category. Moreover, as no cocaine blood
levels were available, it is impossible to know objectively if expressions
such as “cocaine intoxication” and “cocaine poisoning”
corresponded to individuals with cocaine blood levels such as in
the 6 individuals in Pollanen et al. study.11
The expressions “cocaine
level well within a fatal range”, “potential lethal cocaine intoxication”
and the presence of a body packer strongly suggest that 3
individuals may have had cocaine blood levels well over those
found in the Pollanen et al. study.11
Some of the information relies
on testimony of events that occurred months or years earlier and
witnesses' testimonies may have been influenced by earlier meetings
with their legal advisors. However, summary information
concerning the period studied was reliable for the number of
deaths, the year of death, the cause of ExDS associated to RRD, the
fact that RRD occurred in individuals with and without ExDS and
that in both groups, cardiorespiratory arrests occurred rapidly or
following a variable delay.
6. Summary
Epidemiology of RRD in ExDS has changed significantly in
Ontario since the period 1988e1995 and impact of warnings and
recommendations from coroners' inquest on police officers'
training cannot be ignored. The fact that 30% of RRD occurred in
individuals without ExDS suggests that ExDS may be an incidental
finding in certain cases of RRD. Although some RRD in cocaineinduced
ExDS appear inevitable, the violence and the length of
the struggle suggest that the majority of those individuals had good
cardiovascular reserve before law enforcement officers' interventions.
The death rate of individuals restrained for ExDS is so
low that drawing any conclusions based on statistical studies or on
isolated case report could be hazardous.
Conflict of interest
The author does not have any conflict of interest.
Funding
There is no funding related to this study.
Ethical approval
As explained in Methods, verdicts and recommendations of
coroners' inquests in Ontario are information available to the public
through the website of the Office of the Chief Coroner of Ontario
(OCCO)12
. Therefore, no ethics committee approval was necessary.
Moreover, verdict explanations and coroner's summary of evidence
are also available to the public through the Canadian Legal
Institute Information (CanLII) website13
.
All the data used in the present study are from those 2 websites
which are available to the public.
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