An inquest into the death of Tristan Francis Naudi, 23, at Lismore Base Hospital in January, 2016 is being held this week.
An inquest into the death of Tristan Francis Naudi, 23, at Lismore Base Hospital in January, 2016 is being held this week. Facebook.

'Perfect storm' led to chef's sudden death

THE inquest into the death of a young drug-affected man who was being restrained at Lismore Base Hospital has heard that a "perfect storm" of circumstances contributed to the tragedy.

Bangalow man Tristan Francis Naudi, 23, had MDMA in his system when he died of a sudden cardiac arrhythmia on January 18, 2016.

After taking the drug, which the court heard he'd believed was LSD, Mr Naudi spiralled into a state of "severe behavioural disturbance" and police took him to the hospital after being told ambulance would not attend due to his "aggressive" behaviour.

Mr Naudi became unresponsive after being given anti-psychotic and sedative medication in the emergency department's isolation room.

He was being restrained by four police officers on a mattress on the floor of the room.

Emergency medicine expert, Associate Professor Anna Holdgate, told the court "blue or purple" discolouration on Mr Naudi's chest and neck after he stopped moving suggested he "hadn't been getting adequate oxidation".

The court heard she believed Mr Naudi, who was suffering "significant physiological stress" as a result of the MDMA and other factors, had probably had a "respiratory attack" before a cardiac arrest.

Cardiologist and Associate Professor Mark Adams found that Mr Naudi's death was "most likely" caused by "ventricular fibrillation followed by an asystole cardiac arrest", where all electrical activity in the heart has ceased.

Forensic pathologist Dr Leah Clifton believed MDMA intoxication and "prone physical restraint" contributed to Mr Naudi's death.

"It was a perfect storm of events," Dr Clifton said.

"You have an aggravated drug-affected person whose heart rate is high, who's very confused and aggressive at times. He's being restrained, which causes further stress, physiological, emotional."

Dr Clifton said she could not exclude "prone restraint" by police having an impact on his death. The court earlier heard evidence that police placed no pressure on Mr Naudi's back.



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