Coroner's Court of Western Australia

Inquest into the Death of Levi Shane Clement CONGDON

Inquest into the Death of Levi Shane Clement CONGDON


Delivered on : 19 November 2020

Delivered at : Perth

Finding of : Deputy State Coroner King

Recommendations :Yes

That the WAPF and SJA implement a liaison process with respect to the training each agency provides to their officers about medical emergency terminology and protocols.

Orders/Rules : N/A

Suppression Order : N/A

Summary : Mr Congdon died on 13 November 2017 at Royal Perth Hospital from methylamphetamine toxicity. He was 27 years old.

On the afternoon and evening of 13 November 2016, WAPF officers executed a search warrant at the house in which Mr Congdon was living with his girlfriend. Mr Congdon was arrested while the officers searched the house. During the search, Mr Congdon appeared anxious. He repeatedly denied having taken any drugs, and he told officers that he was having an anxiety attack. At his request, an officer called SJA and requested an ambulance. Police continued the search.

A short time later, officers noted that Mr Congdon’s anxiety appeared to escalate and that his behaviour became more agitated and manic, possibly from a drug overdose. The officer called SJA again and advised that Mr Congdon was showing signs of excited delirium. When an ambulance had failed to arrive in 20 minutes, the officer again called SJA and advised that Mr Congdon’s behaviour was now manic and borderline violent. Mr Congdon became unconscious, started vomiting and stopped breathing with no pulse. Officers administered CPR until SJA paramedics arrived and conveyed Mr Congdon to RPH, but he could not be revived. The cause of his death was methylamphetamine toxicity

The evidence at the inquest established that the SJA did not respond at a higher priority because SJA were not aware that the term ‘excited delirium’ related to a drug overdose. The WAPF had trained its officers to use that term.

The Deputy State Coroner made a recommendation aimed at improving communication between the WAPF and SJA.

The Deputy State Coroner was satisfied that the supervision, treatment and care provided to Mr Congdon by WAPF officers was exemplary.

Catch Words : Police : SJA : Communication : Methylamphetamine toxicity : Excited Delirium : Misadventure

Last updated: 15-Dec-2020

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