Findings have been handed down in the inquest into the death of Tristan Francis Naudi, 23.
Findings have been handed down in the inquest into the death of Tristan Francis Naudi, 23.

'His life mattered': Hospital death findings handed down

THE State Coroner has handed down four key recommendations to police in the wake of inquest into the death of a Bangalow man at Lismore Base Hospital. 


Tristan Francis Naudi, 23, had taken what he believed was LSD before he suffered a "severe behavioural disturbance" and was taken to Lismore Base Hospital on January 18, 2016.

The apprentice chef passed away as police restrained him facedown in an emergency department isolation room, as medical staff attempted to sedate him.

While an ambulance was called to Mr Naudi's Bangalow home as a result of his uncharacteristic behaviour, it was police who transported him to hospital.

The inquest previously heard he spent about 18 minutes in the rear of the police vehicle after arriving at the hospital.

In handing down her findings before Byron Bay Coroner's Court today, State Coroner Teresa O'Sullivan said Mr Naudi's cause of death was "acute cardiac arrhythmia", associated with MDMA toxicity and the prone physical restraint he was subject to at the time.

Ms O'Sullivan's lengthy 75-page report which states the reasons behind her findings were yet to be made public.
She handed down four recommendations to NSW Police, which included consideration be given to improving airconditioning or other ventilation and installing padding and in the cages of police vehicles used to transport people.

She also recommended a review of the NSW Police Force guidelines on managing people affected by MDMA and other stimulant drugs, and that any changes to guidelines be reflected in police training.

And the condition "excited delirium" be removed from NSW Police guidelines as the condition is not recommended in key diagnostic medical manuals.

Mr Naudi's sister, Angela Tallon, said it would be difficult for any recommendations to be enough for any family who'd suffered a loss but welcomed the outcome of the inquest.

"It has gone on a long time, I think a lot longer than we ever expected," she said.

"We've learnt to manage our expectations along the way but I think the outcome today is probably a good one in that there have been acknowledgments and recommendations handed down that I think will make things safer for people in the future (and will) hopefully prevent this from happening again.

"If they are upheld and the powers that be listen, then I believe this will make it safer, potentially, for other people and to prevent this from happening from anyone else.

"Because we would really not want anyone else's family to have to go through this."

She said Tristan would be remembered as a "very charismatic, very happy lad".

"He was loved by a mountain of people," she said.

"And I think that we have tried to fight as hard as we can for him.

"We just wanted everybody to know that his life mattered and that he was loved."

Barrister Sebastian De Brennan, who represented Mr Naudi's father, Vincent, at the inquest, said his client was "particularly pleased" with the recommendation regarding police vehicles.

The inquest had heard evidence Mr Naudi was overheated and sweating profusely at the time leading up to his death.

"My client welcomes all of the recommendations and is grateful to counsel assisting and the coroner for their hard work and for the findings and recommendations generally," Mr De Brennan said.

"Of course in matters such as these there are always lessons that can be learned.

"My client is particularly concerned about the nature of the vehicle that was used on the night in question.

"The vehicle had within it what can only be described as a very small cage, evidence was received as to the very poor ventilation.

"From my client's perspective, he had real concerns as to whether putting Tristan in a cage of that sort was consistent with his human rights and Australia's human rights obligations more generally.

"He took particular comfort in the fact that recommendations have been made to review the use of that vehicle."


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