Restraint related deaths and excited delirium syndrome in Ontario (2004-2011)

Restraint related death in individuals in excited delirium syndrome (ExDS) is a rare event that has been the subject of controversies for more than 3 decades. The purpose of this retrospective study was to retrieve data on all restraint related deaths (RRD) that occurred in Ontario during an 8-year period and compare them with an earlier study on RRD in ExDS covering the period 1988-1995 in Ontario. The Office of the Chief Coroner of Ontario website was consulted under verdicts and recommendations. The Canadian Legal Information Institute website was used to consult verdict explanations and coroner's summary of evidence. During the period 2004-2011, RRD occurred in 14 individuals in ExDS, a 33% reduction. Psychiatric illness as a cause of ExDS decreased from 57% to 14%. Cocaine was the cause of ExDS in 11 (79%) individuals. The number of RRD following a violent encounter in cocaine-induced ExDS (8) was identical in the 2 periods. RRD occurred in 6 individuals without ExDS following a violent encounter. Final restraint position preceding cardiorespiratory arrest was available in 36% of individuals with ExDS and 83% of individuals without ExDS. In both groups, cardiorespiratory arrests could be classified as immediate or delayed. All 4 individuals without ExDS who had immediate cardiorespiratory arrests were restrained in the prone position. Delayed cardiorespiratory arrest occurred in the non-prone position in both groups. Although many hypotheses may be put forward to explain changes in the epidemiology of RRD in ExDS in Ontario, multiple warnings and recommendations from coroners' inquests cannot be ignored. There is probably not a unique pathophysiological pathway leading to cardiorespiratory arrest in RRD. The death rate in RRD in ExDS is so low that drawing any conclusions based on statistical studies or on isolated case report could be hazardous.