Excited delirium and deaths in custody.
A controversial medical condition is being used by law enforcement around Australia to defend the use of force and to explain deaths in custody – but it has no agreed definition and may not even exist.
Content warning: This piece contains the names of Aboriginal people who are deceased.
Australian law enforcement agencies are teaching their officers to identify a medical condition known as “excited delirium” – despite the fact many medical experts say it may not exist.
The controversial term has been promoted by a small group of medical researchers and received notoriety during the murder trial of George Floyd in the United States. Its claimed symptoms are manifold and have been used to defend the use of force by police as well as the sudden death of people in custody.
Over the past decade, the term has been incorporated in training programs for Australian law enforcement. The first mentions of excited delirium in Australia appeared in coronial inquests dating back to 2007, but the term became more prominent in 2009. Since then, excited delirium has been relied on in several recent coronial investigations into deaths in custody.
Excited delirium has been included as a factor in the ongoing investigations into the deaths in custody of Indigenous men Wayne Fella Morrison in South Australia and Chad Riley in Western Australia.
The controversial term has also been discussed in four other recent coronial inquests involving both Indigenous and nonindigenous people: Desmond Kickett and
Levi Congdon in Western Australia; Shaun Coolwell in Queensland; and Tristan Naudi in New South Wales.
Some of the issues surrounding the term excited delirium stem from the conflicted nature of medical opinion about its use.
Even among proponents of the term, it is not clear what it actually refers to: a collection of behavioural traits, a diagnosis or a syndrome.
The most common definitions involve a checklist of symptoms: a state of frenzy, a history of drug use or mental illness, superhuman strength, an alleged immunity to pain, high temperature, an attraction to glass or reflective surfaces, and an inevitable struggle against restraint.
“Sudden death” is said to occur during restraint, particularly where a person also has pre-existing conditions such as heart issues or obesity.
Excited delirium is recognised by only three medical bodies in the world: the American College of Emergency Physicians, the National Association of Medical Examiners in the US and the Royal College of Emergency Medicine in Britain, where it is known by the term “acute behavioural disturbance”.
Outside these organisations, excited delirium has received no official endorsement by the World Health Organization or the European Society for Emergency Medicine, which represents physicians in 30 countries.
When The Saturday Paper contacted each state and territory police service to learn how these organisations train their officers to identify and react during interactions with people said to be experiencing excited delirium, most said they could not share their policies.
A spokesperson for Victoria Police told The Saturday Paper the organisation did not offer any explicit training to its officers on excited delirium but had not removed the term from its training regimen as recommended in the 2015 coronial findings following the death of Odisseas Vekiaris.
The Vekiaris inquest represented the first coronial challenge to the use of excited delirium as a cause of death in Australia, with the coroner recommending the term be stripped from police training modules.
In a response to the coroner, then chief commissioner of police, Graham Ashton, said Victoria Police rejected the recommendation.
“Victoria Police acknowledges that within the medical profession there is a level of disagreement whether ‘excited delirium’ is a legitimate medical condition or not, as well as an ongoing debate over the correct terminology,” Ashton said.
“Victoria Police will continue to educate members on the signs and symptoms associated with ‘excited delirium’ until all medical bodies reach agreement.”
A spokesperson for Victoria Police did not respond to detailed questions from The Saturday Paper but said the discussion should be led by medical professionals: “Victoria Police supports an increased role of health professionals in responding to incidents involving people in physical or mental health crisis, which is in line with the recommendations from the Royal Commission into Victoria’s Mental Health System.”
In NSW, coroner Teresa O’sullivan recommended the term be removed from police training modules following the inquest into the death of Tristan Naudi last year. The police there said they were unable to confirm if that had happened, owing to the pandemic. Police in Tasmania and the ACT did not respond by time of publication.
The Western Australia Police Force and the Northern Territory Police confirmed their training covered excited delirium but said their operational policies and training were strictly confidential.
When contacted by The Saturday Paper, South Australia Police declined to answer two detailed sets of questions and directed any inquiries to the organisation’s freedom of information process.
Andrew Carpenter, a victims’ rights lawyer and senior associate with Websters Lawyers, says this is part of a worrying trend in the state.
“In 2015, the South Australian police were forthcoming with information.
Now they’re doubling down and pushing individuals to trial, trying to deep pocket people, threatening them with costs orders,” Carpenter said.
Carpenter said it was “logical” for some material – such as guidelines for handling organised crime groups – to remain off the record. But the lack of transparency makes it impossible to measure the actions of individual officers.
“Their policies and procedures are like Schrödinger’s cat. We can’t know what’s in there until we open it,” Carpenter said. “If other states are making these available to the public, why are we so behind?”
There is increasing concern overseas about the use of the term. In July, the American Medical Association issued a new policy advising that it should be avoided in attributing cause of death. In Britain, the Independent Review of Deaths and Serious Incidents in Police Custody by Dame Elish Angiolini heavily criticised its use in the context of restraint-related deaths.
Dr Anthony Brown, a professor of emergency medicine at the University of Queensland, said the term excited delirium has not been recognised outside a “very, very small group” of doctors in the US.
“Excited delirium is not used
[medically] in Australasia,” Dr Brown said. “It is not found in ICD-10, not found in DSM-5, it is not recognised by the Asia Pacific Coroners Society, it is not recognised by the Royal [Australasian] College of Physicians. It’s not recognised as a defined entity in Australasia.”
Brown said the recent coronial inquest into the death of Levi Congdon in WA served as a cautionary tale.
In that case, a police officer involved in the search of Congdon’s home during an investigation noticed the 27-year-old was acting strangely.
Congdon had ingested a large amount of methamphetamine before his arrest and was experiencing the early stages of an overdose, but the officer on scene read his behaviour as signs of excited delirium in accordance with his training.
When he pressed his commanding officer to call an ambulance for urgent assistance as he had been trained, it was not given priority because excited delirium has no medical meaning.
The ambulance took an hour to arrive – despite repeated follow-up calls for help.
“If you call St John Ambulance and say this person has ‘excited delirium’ – that means nothing,” Brown said. “You will not activate a medical response because you’re not using a recognised medical term. If you say, ‘This person had taken a large amount of methamphetamine and is acting strangely,’ you would have had a response.”
Dr Hannah Mcglade, a human rights lawyer, academic and member of the UN Permanent Forum on Indigenous Issues, says the combination of a lack of transparency and the reliance on questionable medical terminology is especially lethal in the context of Indigenous deaths in custody matters.
Mcglade points to the ongoing coronial inquest into the death in custody of Chad
Riley as an example of the way excited delirium works to shift a coroner’s focus onto the individual and their underlying medical conditions.
Riley was in psychiatric distress when he was confronted by officers outside an Officeworks in East Perth in 2017. The officers tasered the 39-year-old Noongar man multiple times after he allegedly advanced upon them.
“You could see it in the court, police were just so keen to talk about ‘excited delirium’ and yet it isn’t even recognised as a medical condition,” Mcglade said.
“It really swept aside the violence that’s been done to Mr Riley and I’m sure many others. We’re talking about what’s medically wrong with these people, rather than what’s been done to them.”
In that matter, the coroner has issued a suppression order over any mention of police policy and refused the family’s requests to make public the police body camera footage.
Nearly 500 Indigenous people have died in custody since the 1991 Royal Commission into Aboriginal Deaths in Custody – 10 since March this year.
Recommendation 123 of that commission called on police and corrective services to “establish clear policies in relation to breaches of departmental instructions”, saying “such instructions should be available to the public”.
“We’ve had an international movement for Black Lives,” Mcglade said. “Aboriginal lives in this country are not considered worthy enough. If we can’t even see the policies or have them independently reviewed, we don’t stand a chance. The world has changed, but not here.”
“You could see it in the court, police were just so keen to talk about ‘excited delirium’ and yet it isn’t even recognised as a medical condition.”