‘Excited delirium’: how a disputed US term found its way to Australian deaths-incustody inquests
When Dr Cheryl Charlwood gave evidence at the inquest into the death in custody of Wayne Fella Morrison, two words stood out.
Morrison was wrestled to the ground outside his cell at Adelaide’s Yatala Labour prison on 23 September 2016, restrained by his wrists and ankles, placed in a spit hood and carried in the prone position to a prison transport van where he was positioned face-down on the floor. The Wiradjuri, Kokatha and Wirangu man was pulled from the van unresponsive and died in hospital three days later.
Over the course of two days in early June, the South Australian forensic pathologist said she could not pinpoint a single factor that caused Morrison’s death. But Charlwood listed five factors she believed contributed to it: physical exertion, acute psychological stress, excited delirium, genetic susceptibility and a “potential positional element”.
“All these factors need to be considered, and some have more weight than others, but I can’t pathologically determine the exact extent or contribution of all those,” Charlwood said.
To support her evidence, she supplied the coroner with 15 articles published in US medical journals.
It was the use of the phrase “excited delirium” that caught the attention of some observers. Charlwood herself said several times in her evidence it was a “controversial” description, but the extent of the controversy is such that one doctor who has given evidence at a separate Australian inquest has described it as a “created condition”.
What is ‘excited delirium’?
Even among experts it is not entirely clear what excited delirium is supposed to be: a syndrome, a diagnosis or an array of behavioural traits. In the most common rendering, the term is used to describe a state of apparent frenzy in which a person with a history of drug use or psychiatric illness is said to display superhuman strength, an immunity to pain, an attraction to glass or reflective surfaces and an inevitable struggle against attempts to restrain them.
The phrase first came to prominence during the cocaine frenzy that took hold of Miami in the 1980s.
Dr Charles Wetli, a University of Miami pathology professor working in the Dade County coroner’s office, identified a cluster of seven cases in which people appeared to have died suddenly after flying into a rage while under the influence of cocaine.
Wetli minted the phrase “excited delirium” in a medical paper published in 1985 with a colleague, describing the set of behaviours they believed to be behind the deaths.
He would go on to identify 32 more cases he claimed showed distinct signs of “excited delirium”. All the deceased were black women who appeared to have died suddenly in a state of partial undress. All were chronic cocaine users and many were sex workers.
In each case Wetli ruled out homicide as a potential cause of death. In 1989 he told reporters it was his “gut feeling” that cases of excited delirium were linked to the chronic use of crack cocaine – though men and women reacted differently.
“For some reason,” he said, “the male of the species becomes psychotic and the female of the species dies in relation to sex.”
It was a colossal mistake.
In 1992 investigators revisited each case and found the women were likely to have been the victims of a serial killer named Charles Henry Williams, although Williams died before he could face trial. When their bodies were exhumed, all showed signs of asphyxia from strangulation that Wetli had missed.
Scientific dispute
Despite this, excited delirium continued to be discussed, until the first organised attempt to define it was conducted by the American College of Emergency Physicians (Acep). In 2009 Acep put together a taskforce that released a white paper describing excited delirium as a “sub-category of delirium”.
While not always fatal, excited delirium was said to sometimes result in “sudden death” when, during a physical struggle, a surge of catecholamines – a group of chemicals associated with adrenaline – overwhelmed the heart.
Hundreds of cases across the US would go on to be tagged as involving excited delirium either as a cause of death or as one factor among several – especially in situations where the nature of a person’s restraint by police or corrections officers, or a Taser, had been involved.
But not everyone in the medical community embraced the term. Outside Acep, the only other medical bodies in the world to formally recognise excited delirium are the National Association of Medical Examiners in the US and the Royal College of Emergency Medicine in the UK, where it is known as “acute behavioural disturbance”.
The term has found no place in the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-5) or the International Classification of Diseases, and has not been embraced by the World Health Organisation. No Australian medical association recognises “excited delirium” and nor does the European Society for Emergency Medicine, which represents physicians in 30 countries.
It has also faced opposition within the US medical community. Both the National Association of Medical Examiners and the American Psychological Association have no formal policies on “excited delirium” and in July 2021 the American Medical Association issued a new policy advising that the terminology should be avoided.
A 2018 review of the available literature published in the journal of the Academy of Emergency Medicine found “the overall quality of studies [relating to excited delirium] was poor” and that it most commonly appeared in cases involving young black men who were overweight.
Earlier this year the defence of police officer Derek Chauvin invoked “excited delirium” in his trial for the murder of George Floyd.
Body-camera footage of the arrest recorded Chauvin as saying, while his knee was on Floyd’s neck for at least eight minutes, he was “concerned about excited delirium, or whatever”. In that case it took a private post-mortem examination to establish “traumatic asphyxia” as the cause of death.
Coming to Australia
The earliest mention of excited delirium in Australia dates from 2007, but the term came into sharp focus with the inquest into the death of Antonio Galeano in 2009.
Galeano died after police were called to a disturbance in Brandon, north Queensland, and tasered him three times during a 25-minute restraint. The process attracted medical experts from the US to give extensive evidence about the role “excited delirium” played in his death. The term was included as a cause of death by the coroner, although she noted that “there remains some question relating to excited delirium because it is a syndrome described by a collection of observations of behaviours as well as medical symptoms”.
Around this time Dr Anthony Brown, a professor of emergency medicine at the University of Queensland, became aware of the term when he was privately asked by a coroner if he had ever seen a case of excited delirium in the emergency department. He said he had not.
“I went off and started looking at papers,” Brown said. “I was quite amazed that it seemed to be this created condition. And what bothered me was a small group of physicians advocating for it all seemed to be crossreferencing each other.”
Journal articles co-authored by one of those doctors, Gary Vilke, were among those cited by Charlwood at the Morrison inquest. He also gave evidence at the Galeano inquest, and served on the taskforce that wrote the 2009 Acep white paper.
A 2017 investigation by Reuters identified links between other members of that taskforce and the Axon Group, the manufacturer of the Taser. Vilke has no known financial ties to Axon and has never worked for the organisation. No Australian medical practitioner is known to have financial or other ties to the company, and the Guardian does not suggest that is the case.
The Reuters investigation also outlined the aggressive strategy Axon pursued to defend its product, including quickly contacting law enforcement bodies with offers of help in fatal cases where a Taser has been used – sometimes within minutes after a death had been reported.
This support often included offers to send brain and tissue samples to the University of Miami for testing, a supply of medical literature and in some cases sample press releases to be used by law enforcement agencies.
Axon has taken a similar approach in Australia. The Guardian has seen a partial copy of an email sent by the company to police within the past five years, in the wake of a death that involved the use of a Taser. This email was then passed on to the investigating pathologist, who ignored it.
The message was tagged “TIMELY AND URGENT AND REQUIRES ACTION WITHIN 24 HOURS OR LESS”, and was sent to police the same day the person died.
The email contained an offer of help in investigating the matter, including an offer for brain tissue samples to be sent to the University of Miami Brain Endowment Bank to “determine drug abuse and look for excited delirium markers”.
Axon said in a statement the company “has not contacted pathologists assigned to conduct medical examinations for Australian government entities”.
“The only exception to this is if there is active litigation and the pathologist is listed as a fact or expert witness, in which case the rules of court permit contact for the purposes of obtaining information related to the case,” the company said.
“Axon does provide studies and educational materials relating to its TASER energy weapons to anyone who requests such information, including Australian law enforcement entities. Those materials clearly identify the authors of the study or research and, as required by the peer review process, any affiliation they may have with Axon.” ‘No agreed test’
It was 2014 when excited delirium faced its first real challenge in the Australian legal system, during the coronial inquest into the death of Odisseas Vekiaris.
A non-Indigenous man, Vekiares died while being transported to Dandenong police station in the back of a police van. When the pathologist attributed Vekiaris’s death to excited delirium, the Victorian coroner sought independent advice from Brown.
“[Excited delirium has] no agreed definition, no agreed pathophysiological causation, no agreed test or gold-standard measurement and no outcome data demonstrating positive response to preventative measures,” Brown told the court.
The coroner rejected “excited delirium” as a cause of death and recommended that the words be stripped from policies or training materials maintained by Victorian police.
Not all states have trodden the same path. In Western Australia excited delirium entered the police lexicon in 2009. Last month police gave evidence at the inquest into the death in custody of 39-year-old Noongar man Mr Riley, who died in May 2017 after he was tasered 10 times in two minutes, that they were concerned about “excited delirium” .
The coroner has yet to deliver findings on Riley’s death.
Dr Rebecca Scott Bray, an associate professor in criminology at the University of Sydney, says the use of the term often works to obscure or confuse circumstances around a death – particularly in the context of restraint used by police or corrections officers – and does not translate to the Australian context.
“What you have are reports being made drawing on the international literature, which is sometimes problematic,” she says. “It’s a medical controversy, but it’s another kind of controversy because the question of Indigenous deaths in custody is incredibly significant.
“We know there is so much more that goes on in this context. Otherwise, it’s exculpating law enforcement and inculpating the person who has died – who has no recourse to object.”