Canadian coroners starting to reject excited delirium as cause of police-related deaths

As a coroner’s jury takes their seats Monday in the inquest into the death of Myles Gray, they may hear arguments that his death was the result of something called excited delirium, and not the actions of Vancouver police officers.

Excited delirium has also been cited by Ottawa police officers in connection with the death of Abdirahman Abdi during a violent arrest, a coroner’s jury looking into a death in a New Brunswick jail, senior RCMP officers after the death of Robert Dziekanski at Vancouver’s airport, and defence lawyers for the American officer who murdered George Floyd.

The highly contentious term describes a state of agitation, aggression and distress generally linked to drug use or mental illness, and it’s been used as an explanation for sudden, unexpected deaths during interactions with police.

It was one of several possible explanations given by a forensic pathologist for the death of Gray, an unarmed 33-year-old who died in 2015 after being handcuffed, hobbled, punched, kneed, kicked, pepper-sprayed and struck with a baton by several Vancouver officers. He was making a delivery for his florist business at the time, and police had been called after he confronted a homeowner for watering her lawn during an extended drought.

But a major shift is underway, and medical examiners and coroners across Canada and the U.S. are starting to reject excited delirium as a cause of death. Both the American Medical Association and the American Psychiatric Association have dismissed the diagnosis entirely.

Dr. Michael Freeman’s opinion on excited delirium is blunt.

“[It] might as well be a magician waving a wand and saying abracadabra for all the evidence that we have for it,” he said.

Freeman is an associate professor of forensic medicine and epidemiology at Maastricht University in the Netherlands and a clinical professor of forensic psychiatry at Oregon Health and Science University, and he’s analyzed the research on excited delirium.

“It’s an interesting theory which always directs the gaze for the cause of the death away from the restraining personnel, and so if you say it’s excited delirium, it’s basically the fault of the person who died,” he told CBC News.

“Then you don’t have to look any further. You don’t have to look at how potentially the restraint killed the person.”

Freeman said his review of cases described as excited delirium in the scientific literature suggests the term is almost exclusively used when police are restraining a person with handcuffs, hobbles (leg restraints) or other forms of physical force, and death was most likely to result when the restraint was especially aggressive.

WATCH | What Dr. Michael Freeman’s research suggests about excited delirium:

Freeman, an expert in forensic medicine and epidemiology, talks about what he’s learned from reviewing the literature on excited delirium.

‘Quite inappropriate’ as psychiatric diagnosis

Police officers are often trained on identifying and responding to excited delirium. An online description for a one-hour course on the subject offered through the Canadian Police Knowledge Network and designed by the Calgary Police Service claims it “accounts for the majority of custody-related deaths.”

The current Vancouver Police Department regulation and procedures manual says officers should be aware of the signs of excited delirium. Some of the officers on the scene when Myles Gray died said they believed he was suffering from excited delirium, according to a report completed for an investigation overseen by B.C.’s Office of the Police Complaint Commissioner.

But excited delirium is not a recognized diagnosis according to the Diagnostic and Statistical Manual of Mental Disorders (DSM), the International Classification of Diseases, or the World Health Organization.

Dr. Gary Chaimowitz, president of the Canadian Psychiatric Association (CPA), said excited delirium is not a diagnosis he would use, describing it as a set of behaviours more than an actual condition.

“I think it’s quite inappropriate to use that to convey what’s going on with the person until you really are able to unpack exactly what is happening,” he said.

Chaimowitz added that the research suggests there can be racial and ableist biases at play when the term is used.

“It’s often people with mental illness, people of colour, other racial and ethnic groups that are … disproportionately impacted,” he said.

Earlier this spring, the National Association of Medical Examiners made headlines in the U.S. when it released a statement saying it no longer recognizes excited delirium as a cause of death.

Something similar is happening in Canada.

Of the provincial coroners’ services and chief medical examiners offices that responded to queries from CBC News, only New Brunswick said excited delirium can still be cited as a cause of death.

Although there have been no public statements, the offices in B.C., Alberta, Manitoba and Newfoundland all told CBC News they do not recognize excited delirium as a cause of death.

“There wasn’t an instant in time when this transition occurred. It was a response to the evidence-based literature changing over time,” Ryan Panton, a spokesperson for the B.C. Coroners Service, wrote in an email.

Dr. Nash Denic, chief medical examiner for Newfoundland, said he considers excited delirium to be a misnomer, since delirious states caused by drug use, withdrawal or mental illness are inherently excited.

Both he and his counterpart in Manitoba, Dr. John Younes, said excited delirium might be a mechanism of death, but not the cause. For example, cocaine toxicity that causes someone’s death might manifest as a dangerous delirium.

Denic said excited delirium could also contribute to a death in custody.

“If you have somebody under the influence of drugs and during the restraining you have five people on top of him hindering his breathing, obviously the excited delirium wouldn’t be the cause of that [death], but it may have contributed because he would be having difficulty breathing anyway,” Denic said.

Freeman said he was heartened by the move away from excited delirium, but he wouldn’t be surprised to see it replaced by some new explanation for in-custody deaths.

“There’s still going to be an interest in finding an exculpatory diagnosis when there is a death that occurs in restraint because there’s still people who believe you can’t die from restraint,” he said.