Inquest into the Death of Joshua Fredrik VAN MALSSEN

Inquest into the Death of Joshua Fredrik VAN MALSSEN

Delivered on : 2 February 2026

Delivered at : Perth

Finding of : Acting Deputy State Coroner Jenkin

Recommendations :Yes

Recommendation No. 1

The Public Transport Authority (PTA) should take immediate steps to ensure that transit officers are keenly aware that persons being detained in the prone position are at grave risk of experiencing positional asphyxia and the need to minimise the time people spend in that position.  The measures taken by the PTA should include (but are not limited to):

1. Liaising with Western Australian Police Force (WAPOL) to determine whether any of WAPOL’s resources and/or policies relating to positional asphyxia are applicable to the PTA;
2. Revising the Defensive Tactics manual (the Manual) so that the guidance offered to transit officers monitoring persons being detained in the prone position is more detailed and prescriptive, and further:
   1. the Manual should provide concrete examples of factors which can place a person at greater risk of experiencing positional asphyxia, and the signs and symptoms to look for when monitoring a person detained in the prone position;
   2. the Manual should include information about the circumstances of Josh’s case and the lessons learnt from his death; and
   3. the Manual should emphasise that persons must only be restrained in the prone position for as short a time as possible, and that every second in the prone position exposes the person to the risk of death.
3. Provide transit officers with regular refresher training (including practical scenarios and exercises) aimed at ensuring transit guards understand how to effectively monitor persons being detained in the prone position, and how such monitoring should be undertaken.

Recommendation No. 2

The Public Transport Authority (PTA) should consider providing contextualised life support training to transit officers during their Transit Officer Recruit Training program, and then during annual refresher courses thereafter.

Recommendation No. 3

The Public Transport Authority (PTA) should reassess ASP Hinged Ultra-Cuff handcuffs (ASP) currently issued to transit officers to determine whether they are fit for purpose when detaining persons of large build, and if not, whether an alternative type of restraint device should also be made available to transit officers.

Recommendation No. 4

The Public Transport Authority (PTA) should liaise with Western Australian Police Force (WAPOL) to determine whether the type of leg strap restraint used by WAPOL would be suitable for use by PTA transit officers.

Recommendation No. 5

The Public Transport Authority (the PTA) should ensure that a formal review is conducted following any critical incident involving transit guards where death or serious injury occurs.  Further the PTA should ensure that “lessons learned” from all such reviews are provided to all PTA transit officers.

Orders/Rules : No

Suppression Order : N/A

Summary : Joshua Fredrik Van Malssen (Josh) was 24-years of age when he died on 16 June 2023 from cardiac arrest.  Immediately before his death, Josh was behaving in a disorderly manner in the Perth Underground Train Station (the Station) and had been shouting and swearing.  As a result of his behaviour, Josh was spoken to by Public Transit Authority (PTA) transit officers (the Officers) before being arrested.

After his arrest, Josh was placed on his stomach on the ground in the prone position and handcuffs were applied to his wrists.  Josh was then moved into the recovery position and a short time later it was realised he had stopped breathing.  Josh’s handcuffs were removed and PTA transit officers started CPR and called emergency services.  Ambulance officers arrived at the Station and took over resuscitation efforts, and Josh was taken to Royal Perth Hospital.  Josh could not be revived and he was declared deceased.

The Acting Deputy State Coroner concluded that the interaction between Josh and the Officers was appropriate and in accordance with PTA policies and training.  Josh was treated in a respectful and courteous manner, and numerous efforts were made to de-escalate the situation and have him to leave the Station voluntarily.  The Acting Deputy State Coroner was also satisfied that the decision to arrest Josh was in accordance with PTA’s policy and legislative framework, and was justified given Josh’s disorderly behaviour and his persistent refusal to comply with directions by the Officers that he leave the Station.

However, the Acting Deputy State Coroner concluded that the standard of monitoring by the Officers while Josh was being restrained in the prone position was poor.  The Acting Deputy State Coroner found there was no communication between the Officers about who was monitoring Josh, and that one officer (who was not involved in either applying handcuffs to Josh’s wrists or restraining his feet) should have been more vigilant while monitoring Josh and should have noticed that Josh had stopped breathing at an earlier stage.

The Acting Deputy State Coroner was unable to conclude (to the relevant standard) that the acts or omissions of any the Officers had caused Josh’s death.  However, Josh’s restraint in the prone position was one of the factors that contributed to his cardiac arrest and subsequent death.  In that context, the Acting Deputy State Coroner found that the act of restraining Josh in the prone position had contributed to his death, but only because of the physical and physiological factors that were affecting Josh at the relevant time.

Catch Words : Public Transit Authority : Restraint while in prone position : Positional Asphyxia : Sotos Syndrome : Chronic Medical Conditions : Misadventure

Last updated: 13 February 2026

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