Inquest into the death of Keith Titmuss

Case Number: 2020/333632

Findings Date: 3 May 2024

Magistrate: Derek Lee

CORONIAL LAW | cause and manner of death; exertional heat stroke; exertional heat illness; hyperthermia; seizures; National Rugby League; Heat Policy; Manly Warringah Sea Eagles, Heat Stress Index; Kestrel Heat Stress Tracker; cooling strategies; heat management; use of ice packs; transfer to hospital; player acclimatisation; individualised training program; graduated return to training

Responses

Recommendations to	Response
National Rugby League	Awaited
Manly Warringah Sea Eagles	Awaited

Recommendations

National Rugby League (NRL)

1. That the NRL provide Professor Olly Jay and Dr Douglas J. Casa with a copy of the findings and any recommendations made by this Court in the present inquest.

2. That the NRL ask Professor Olly Jay and Dr Douglas J. Casa to consider, in the context of their pending review, whether the NRL’s Heat Policy & Management of Thermal Injury and Hyperthermia (Heat Policy), Handbook and/or Operations Manual should be amended so as to provide greater guidance to clubs as to the circumstances in which environmental conditions (including environmental conditions in all training locations whether indoor and outdoor) prior to and during all training sessions should be ascertained (using the method described in the Heat Policy).

3. That the NRL ask Professor Olly Jay and Dr Douglas J. Casa to consider, in the context of their pending review, whether the Heat Policy, Handbook and/or Operations Manual should be amended so as to deal, specifically, as to what if any measures should be implemented during a training session (whether indoor or outdoor) if a Heat Stress Index (HSI):

a. Is over 150 (but less than 200)

b. Is over 200 (but less than 250)

c. Is over 250

4. That the NRL ask Professor Olly Jay and Dr Douglas J. Casa to consider, in the context of their pending review, whether the Heat Policy, Handbook and/or Operations Manual should be amended so as to mandate adjustments to both indoor and outdoor training and recovery activities based on environmental conditions such as ambient temperature.

5. That the NRL ask Professor Olly Jay and Dr Douglas J. Casa to consider, in the context of their pending review, whether the Heat Policy, Handbook and/or Operations Manual should be amended so as to require:

a. Players participating in training to be screened and classified according to the known risk factors for exertional heat illness such as fitness levels (low aerobic capacity), size, high Body Mass Index (BMI) and training history; and

b. That player’s training plan to be adjusted accordingly.

6. That the NRL ask Professor Olly Jay and Dr Douglas J. Casa to consider, in the context of their pending review, whether the Heat Policy, Handbook and/or Operations Manual should be amended so as to mandate a 14 day period of controlled training load (acclimatisation) for players who return to training after an extended break from training.

7. That the NRL ask Professor Olly Jay and Dr Douglas J. Casa to consider, in the context of their pending review, whether the Heat Policy, Handbook and/or Operations Manual should be amended so as to mandate the attendance of medical officers either:

a. At all NRL training sessions; or

b. At select training sessions which are identified as posing a particular risk to player safety (including, for example, the first 14 days of training after an extended break from training).

8. That the NRL ask Professor Olly Jay and Dr Douglas J. Casa to consider, in the context of their pending review, whether the Heat Policy, Handbook and/or Operations Manual should be amended so as to provide for the sign off or approval of a club medical officer for:

a. Any strength and conditioning plans for players returning to training after an off-season break or an extended break from training; and

b. Any screening of players returning to training after an off-season break or an extended break from training.

9. That the NRL ask Professor Olly Jay and Dr Douglas J. Casa to consider, in the context of their pending review, whether it ought to be mandatory for clubs to comply with the Heat Policy during training sessions (outdoor and Indoor).

10. Consider the extent to which the tragic circumstances of Mr Titmuss’ death might form the basis for a ‘case study’ and ongoing education and awareness by the NRL emphasising the significance of exertional heat illness including but not limited to:

a. The risk factors which may increase a person’s susceptibility to exertional heat illness such as fitness levels (low aerobic capacity) size, high BMI and training history;

b. The fact that exertional heat illness can occur notwithstanding lower ambient temperatures;

c. The signs and symptoms of exertional heat illness; and

d. The appropriate steps to be taken when signs and symptoms of exertional heat illness are present, including where appropriate and where environmental conditions warrant, the use of cold-water immersion, wet towels or the application of ice.

Manly Warringah Sea Eagles

11. Consider the extent to which the tragic circumstances of Mr Titmuss’ death might form the basis for a ‘case study’ and ongoing education and awareness by Manly emphasising the significance of exertional heat illness including but not limited to:

a. The risk factors which may increase a person’s susceptibility to exertional heat illness such as fitness levels (low aerobic capacity) size, high BMI and training history;

b. The fact that exertional heat illness can occur notwithstanding lower ambient temperatures;

c. The signs and symptoms of exertional heat illness; and

d. The appropriate management steps to be taken when signs and symptoms of exertional heat illness are present, including where appropriate and where environmental conditions warrant, the use of cold-water immersion, wet towels or the application of ice.

12. That Manly reconsider and strengthen its record keeping procedures to ensure that any previous incidents where a player has experienced a serious adverse health event whilst at training, and any advice or lessons arising from such an incident are effectively communicated to all:

a. Coaching staff;

b. Members of the high performance unit; and

c. Medical and allied health staff

on at least an annual basis.