Coroner's Finding: Hudson, Simon

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INQUEST INTO THE DEATH OF SIMON HUDSON [2025] SACC 35 Inquest Findings of his Honour State Coroner Whittle 27 November 2025

CORONIAL INQUEST Examination of the cause and circumstances of the death of a man who was arrested by police after being involved in a physical altercation and experiencing a sudden cardiopulmonary arrest. The inquest explored the circumstances of the altercation, the involvement of police and the physiological mechanism of death.

Held:

1. Simon Hudson, aged 41 years of Salisbury Heights, died at Adelaide on 27 May 2022. His cause of death is unascertained, in circumstances of methylamphetamine intoxication, extreme physical exertion and COVID-19 and rhinovirus infections.

2. Circumstances of death as set out in these findings.

No recommendations made.

Counsel Assisting: MR D EVANS Hearing Date/s: 18/07/2025 Inquest No: 13/2025 File No/s: 1243/2022

INQUEST INTO THE DEATH OF SIMON HUDSON [2025] SACC 35 Introduction and background 1 Simon Hudson was born on 21 October 1980.1 He lived at Salisbury Heights with his wife Nicole and their young daughter Ella.2 He and his wife had been together for 20 years and married for ten. He was committed to giving his daughter the best upbringing he could and always gave her everything.3 He worked in the transport industry, with various roles including managerial positions.4 He was a hard worker and cared about doing well. He had been diagnosed with depression for which he was prescribed medication; however he was not taking it.5 For about ten years he had trained in Muaythai and boxing, but he was not a person that was generally aggressive or got into fights.6 He occasionally used illicit drugs. He had no criminal history.7 The events of Friday, 27 May 2022 2 On the evening of Friday, 27 May 2022, Mr and Mrs Hudson took their daughter into the city to see a show at the Festival Theatre. The plan was for Mr Hudson to drop Mrs Hudson and their daughter off at the theatre and then check into a hotel for the night before waiting for the show to finish. He did that and wandered around the city, getting himself some dinner.

3 At about 9:15 pm, the show finished, and Mr Hudson said in a phone call to his wife that he would walk down to Festival Theatre so they could all walk back to the hotel together.8 4 That night, a 17-year-old male had also travelled into the city and had consumed nitrous oxide gas and vodka which had intoxicated him to a high level.9 Pursuant to s 63C of the Young Offenders Act, the identity of this youth cannot be published and his name has been removed from all the tendered documents. In this Finding I shall refer to him as Mr A.

5 A friend of Mr A said that he had spent the night trying to control Mr A’s negative behaviours.10 Mr A and his friends were on King William Street near Festival Theatre when they encountered Mr Hudson walking to meet his family. In keeping with his behaviour that night, Mr A was being loud and aggressive. An independent witness who was leaving the theatre said that Mr A was trying to incite people into a fight at this location.11 6 Police have been able to identify from CCTV footage of the area, together with the accounts of witnesses present, that Mr A approached an unknown person sitting at a bus 1 Exhibit C0 2 Exhibit C0a 3 Exhibit C0a at [31] 4 Exhibit C0a at [30] 5 Exhibit C0a at [27] 6 Exhibit C0a at [24]-[25] 7 Exhibit C91a at 15 8 Exhibit C0a at [9] 9 Exhibit C5, page 1 10 Exhibit C5, pages 1, 3 11 Exhibit C7 at [4]

[2025] SACC 35 State Coroner Whittle stop before throwing a bottle at the ground.12 This occurred at the same moment that Mr Hudson was passing by. He is reported to have told Mr A, ‘Keep your fucking shit down’ and mentioned that there were kids around who were leaving the theatre.13 Another witness heard Mr Hudson say, ‘Take it easy brother’.14 Other witnesses heard glass smashing15 and then Mr Hudson talking to Mr A about the smashing of the glass.16 7 One of Mr A’s friends said that after further words of disagreement, Mr Hudson swung his fist at Mr A, which set off a violent altercation that spilled onto the roadway. Police have identified a number of issues with the statement of this witness and it was suggested that they would treat it with caution.17 No other witnesses specifically saw who became physical first. I shall not make a finding as to whether Mr Hudson first swung his fist, starting the fight. Regardless of that, what started as a verbal altercation turned into a physical altercation.

8 There were seven triple zero calls made, which give various descriptions of the fight, with multiple callers describing Mr A as ‘going ballistic’ or ‘off his chops’.18 Police properly assigned an immediate response category.19 9 During the fight which ensued, each participant was landing blows on the other. Multiple independent witnesses say that at one point Mr Hudson was walking away telling Mr A to give it up while Mr A remained in a boxing stance taunting Mr Hudson and following him.20 Following that, they continued their fight and grappled with each other on the ground. At another point, Mr Hudson had Mr A on the ground in a choke hold and hit his head on the ground.21 Other witnesses saw Mr Hudson holding Mr A’s head into the ground and asking him if he had had enough yet.22 At yet another point, Mr A charged at Mr Hudson and rugby-tackled him to the ground on the roadway.23 Independent witnesses described Mr A as the main aggressor in the situation.24 One witness stated that Mr Hudson appeared to be breathing much more heavily as the fight progressed and that he appeared to become extremely exhausted after the initial part of the fight.25 Another witness also said that Mr Hudson appeared completely exhausted.26 A witness observed one of the men standing over the other on the ground, delivering rapid fire punches to his head.27 This was likely Mr A punching Mr Hudson repeatedly in the head. After this, police arrived.

12 Exhibit C91a at 50 – sequence 8 13 Exhibit C5, page 2 14 Exhibit C9 at [11] 15 Exhibit C10 at [6]; Exhibit C11 at [6] 16 Exhibit C11 at [9] 17 Exhibit C91a, page 11 18 Exhibit C91a, pages 45-47 19 Exhibit C91a, page 25 20 Exhibit C8 at [8]-[9] and [12]; Exhibit C15 at [7]; Exhibit C17 at [26]; Exhibit C28 at [15] 21 Exhibit C10 at [14]; Exhibit C17 at [20]; Exhibit C18 at [20] 22 Exhibit C25 at [9]; Exhibit C26 at [4] 23 Exhibit C8 at [28] 24 Exhibit C14 at [27]; Exhibit C16 at [7] and [18]; Exhibit C21 at [6]; Exhibit C24 at [9] 25 Exhibit C17 at [22] 26 Exhibit C28 at [8] 27 Exhibit C19 at [5]

[2025] SACC 35 State Coroner Whittle 10 CCTV footage records that the entire fight lasted for five minutes and 59 seconds before police arrived and intervened.28 SAPOL arrive on scene 11 Upon arrival, police have indicated that they saw both males punching each other,29 which fits with the evidence of independent witnesses and the footage. Mr Hudson and Mr A were both arrested for fighting in a public place.30 12 An independent witness said that police officers grabbed Mr Hudson’s arms and put handcuffs on him high up on his back which she said was ‘physically brutal’ because she saw Mr Hudson as the ‘good guy’ of the situation.31 She said that she did not see police striking or hitting Mr Hudson.32 She said that her view of the behaviour of police was based on her view that Mr Hudson was not at fault.

13 Another independent witness said that police immediately separated the two parties, handcuffing Mr A and Mr Hudson. This witness said that she did not observe police using any excessive force. She said that Mr Hudson had gone limp and had become unresponsive straight away.33 She said she did not observe what had brought about his unresponsiveness and that she had only turned away momentarily. She turned back to see police officers commence CPR.

14 An officer described Mr Hudson as having a kicking motion towards the officers.34 Another officer said that as Mr Hudson was wiggling around, he placed his knee into Mr Hudson’s back in order to keep him still while another officer held his legs.35 Mr Hudson was still pushing his legs against the officer holding them.36 The officer released the pressure on Mr Hudson’s back once he was handcuffed.37 15 Multiple officers involved in the incident had their body cameras operating, providing me with a close-up record which I was able to view in conjunction with the wider street footage. The footage shows that police arrived as Mr A kicked Mr Hudson to the head, then handcuffs being placed onto Mr A and Mr Hudson at 21:28:53 while he was being asked not to pull his hands away and being told not to resist. He was told to stop kicking and to relax. He can be heard making noises of pain and exhaustion and said to officers, ‘Please help me’. He was told by officers, ‘You’re fine’. He was asked his name and responded ‘Simon’ at 21:29:21. The officers then had a breather and discussed the situation while putting on latex gloves, discussing that neither party appeared to be separating from each other, with the fight being described as ‘punch for punch’. They agreed that Mr Hudson should be moved off the road. They rolled Mr Hudson over at 28 Exhibit C91a, page 3 29 Exhibit C40, page 1 30 Exhibit C40, page 2 31 Exhibit C28 at [18]-[19] 32 Exhibit C28 at [26] 33 Exhibit C18 at [27] 34 Exhibit C45 at [6] 35 Exhibit C43 at [9]; Exhibit C45 at [7] 36 Exhibit C45 at [7] 37 Exhibit C43 at [16]

[2025] SACC 35 State Coroner Whittle 21:30:10, that is, one minute and 17 seconds after the handcuffs were placed on and 49 seconds after he was heard speaking his name.

Mr Hudson is unresponsive 16 At the point that the officers rolled Mr Hudson over, they noticed that he was not responsive. They can be seen trying to elicit a response, tapping his face and his abdomen while checking for a pulse. They realised that he had started turning blue and commenced chest compressions at 21:31:40, one minute and 30 seconds after he was first rolled over and only two minutes and 19 seconds after he was last heard speaking.

17 All of the footage shows that there were no actions of police officers following Mr Hudson being placed in handcuffs and giving his name that might have brought about a cardiorespiratory arrest.

18 Police used a defibrillator device to check Mr Hudson’s situation, and the device found no shockable rhythm, so CPR was continued.38 19 Paramedics attended, arriving at about 9:35pm with police still continuing their CPR.39 Paramedics took over the CPR effort with ongoing assistance from police; administering oxygen, adrenaline and fluids. A MedStar doctor was dispatched from the airport and arrived at 9:50pm. The intensive effort to revive Mr Hudson was continued by paramedics for 30 minutes after arriving, without any response and at 10:05pm they declared life extinct with advice from the MedStar doctor.40 20 Mr A was taken to hospital because he had broken his thumb.41 While at hospital he was agitated and aggressive and remained fixated on Mr Hudson.42 He ripped off ECG leads and tried to remove his cannula. He was detained under the Mental Health Act 2009 by a doctor and was administered two doses of sedative.43 When he was later spoken to by police, he described the fight as just a ‘regular scrap’ and when advised that Mr Hudson had died, he said it sounded like police’s fault.44 He declined to assist police in any way.45 Discussion regarding cause of death 21 Post-mortem examinations were led by senior consultant forensic pathologist, Dr Karen Heath.

22 SA Pathology testing revealed that at the time of his death, Mr Hudson was infected with COVID-19 and rhinovirus.

23 Toxicological analysis of a sample of Mr Hudson’s blood was conducted by forensic scientist, Christine Nash. It revealed a high quantity of methylamphetamine and its metabolite amphetamine in the blood. An expert opinion about the effect of this level of drug has been provided by respected pharmacologist, Professor Jason White from 38 Exhibit C46 at [5] 39 Exhibit C30 at [8] 40 Exhibit C30 at [13]; Exhibit C31 at [13]-[14] 41 Exhibit C84 Annexure A, page 7; Exhibit C91r – imaging results 42 Exhibit C91r – nursing notes 43 Exhibit C91r – progress note dated 28 May 2022 at 0435 and nursing notes 44 Exhibit C84 Annexure A, page 11 45 Exhibit C91a, page 16

[2025] SACC 35 State Coroner Whittle Adelaide University. Professor White said that therapeutic concentrations of methylamphetamine are in the range of 0.02 to 0.05mg/L and recreational usages range between 0.1 to 0.5mg/L. Mr Hudson’s level was 1.6mg/L, but allowing for post-mortem redistribution, this could have been as low as 1.1mg/L at the time of his death.46 Professor White explained that for an experienced user of the drug, each increase of concentration of 0.1mg/L will increase the heart rate by approximately 25 beats per minute while producing only low to average intoxication. Given Mr Hudson’s high level, beyond that of most recreational users, Professor White concluded that Mr Hudson would have experienced profound effects, including mental and physical agitation, impaired decision making, erratic behaviour and the physical effects of raised heart rate, blood pressure, body temperature, sweating, rapid breathing, dilated pupils and muscle tension.47 24 Professor White stated that Mr Hudson’s level of methylamphetamine was higher than the average levels found in overdose deaths across three studies of deaths involving only methylamphetamine. For that reason, Professor White said that the level of methylamphetamine alone could have caused Mr Hudson’s death.48 Professor White also explained that a person’s health status can significantly influence the outcome of taking a large dose of methylamphetamine,49 particularly where there are cardiovascular issues, and also explains that different people have different experiences of the same drug.50 25 Mr Hudson’s heart was examined by specialist pathologist, Dr Anthony Thomas. The heart was largely normal, however there was a portion that showed recent myocardial fibrosis associated with haemosiderin deposition.51 This is effectively an accumulation of iron which can occur in the context of haemorrhage or venous insufficiency. However, Dr Thomas concluded that this was of doubtful significance and said that there was no physical evidence of a cause for the terminal arrhythmia that Mr Hudson had sustained.

26 Mr Hudson’s brain was examined by specialist neuropathologist, Professor Peter Blumbergs, who found swelling and congestion, with minor haemorrhages and minor axonal changes consistent with traumatic brain injury.52 In particular, when observed microscopically, he found congestion and axonal changes to the midbrain, pons and medulla.53 These are the parts of the brainstem that deal with basic functions like breathing.

27 Dr Heath also found evidence of trauma to the head with abrasions and bruises to the face and head, but without any skull or bone fractures. She found no evidence of any injuries to Mr Hudson’s neck, including under the skin, nor within cartilage and bone.54 Dr Heath explained that the contribution of the head injuries to Mr Hudson’s death is unclear. She explained that while the brain injuries found were relatively minor, they were closely temporally associated with each other and she said that where multiple blows to the head 46 Exhibit C39, page 4 47 Exhibit C39, pages 5, 7 48 Exhibit C39, page 3 49 Exhibit C39, page 3 50 Exhibit C39, page 4 51 Exhibit C4a, page 4 52 Exhibits C3a and C3b 53 Exhibit C3b 54 Exhibit C1a, pages 6-7

[2025] SACC 35 State Coroner Whittle are sustained in close succession, cardiopulmonary arrest can occur. She also said that a concussive head injury can lead to death if there is injury to the brainstem centres that control heart rate and respiration.

28 Dr Heath has explained that there are a number of physiological and metabolic events associated with strenuous physical exertion and struggle which can contribute to cardiac arrhythmia and death. This includes derangements of electrolytes or adrenaline levels and the presence of metabolic acidosis which can act individually or in concert, contributing to the mechanism of death. Dr Heath pointed out that individual abnormalities in dopamine activity, either genetic or acquired, can also predispose a person to cardiac arrhythmia in situations of extreme exertion.

29 In addition to those factors, Dr Heath highlights that methylamphetamine and amphetamine were found in Mr Hudson’s blood,55 and explained that these are stimulants which predispose a person to cardiac arrhythmia. She explained that these drugs can act in conjunction with strenuous physical activity to provoke a lethal cardiac arrhythmia.

30 As a result of all of the evidence obtained by Dr Heath and other doctors during the postmortem examinations and the many different sources of potential cardiac arrhythmia or cardiopulmonary arrest, Dr Heath said that a definitive cause of death was not able to be identified. However, she said that the cause of death is likely to be due to the combined effects of methylamphetamine use, strenuous physical activity and head injury, but that it is the individual contributions of these factors which cannot be ascertained with certainty.

Of course, Mr Hudson was unfit and dealing with two viral infections at the time as well.

31 I turn to consider what conclusions should be drawn from all of the evidence.

Criminal offence 32 In relation to Mr A, as I said, police arrested him on the night for fighting in a public place, which is a summary offence. That was perfectly appropriate. However, SAPOL did not pursue that charge and Mr A has not been prosecuted for any offence, including fighting. Given the time that has passed since the incident, there is a statutory bar to charging Mr A with any summary offence, including a charge of fighting in a public place.

Custody and police action 33 Police officers were called to assist in relation to a fight involving two people. When they arrived, they saw both Mr Hudson and Mr A actively participating in a fight. While all witnesses described Mr A as the main aggressor, Mr Hudson was involved and did fight back. Police had to do something to stop the incident. The street footage shows that at the moment they first arrived, Mr Hudson was assaulting Mr A. It was therefore proper for police to arrest him for fighting in a public place. I find that it was lawful and appropriate for police to arrest Mr Hudson and place him in custody.

34 Mr Hudson’s arrest was captured clearly on camera. I have viewed the footage. I have the assistance of a report from Senior Sergeant Darren Matthews, a police officer with 55 Exhibit C2a, page 2

[2025] SACC 35 State Coroner Whittle decades of experience, who was responsible for operational safety training of police officers and who had no dealing with this case at all. Senior Sergeant Matthews confirmed that all police officers involved in Mr Hudson’s arrest had received refresher training on operational safety relating to safe restraint and arrest techniques.56 Senior Sergeant Matthews then reviewed the footage of Mr Hudson’s arrest. He points out that the techniques used were in accordance with training: straight arm, wrist lock and leg lock.57 The wrist lock mechanism includes the officer having a knee in the lower back to control the subject.58 The training on handcuffing suggests checking that the tightness is correct after sitting the subject up to prevent positional asphyxia.59 Other than the light t-shirt which was pulled over Mr Hudson’s head at the end of the fight and was removed by police as soon as the handcuffs were placed, there was nothing around Mr Hudson’s airways during his arrest and there was certainly no force applied to Mr Hudson’s neck.

The footage shows that his position was either on his side or prone, but without any unusual neck positioning that might have brought about asphyxia. Following the arrest, Mr Hudson was able to speak his name. That is to say, he was conscious and responsive after being arrested. I can be satisfied, and I find, that there was no part played by asphyxia.

35 Given that Mr Hudson was being arrested for a violent incident in a public place, it was open to use handcuffs to restrain him. Given that he resisted his arrest and resisted being placed in handcuffs, the actions of police seen on the bodycam footage, of holding Mr Hudson’s legs and placing pressure on his lower back until he was handcuffed, were clearly appropriate and called for. He was left on the ground for a moment while police caught their breaths and put on latex gloves. I find no ground for criticism in police having that moment, particularly as at that point there were no signs of any impending health issue. When Mr Hudson was rolled over, it was quickly realised that he was not breathing and checks were made before commencing CPR in a timely way. There is no basis for criticism of police in calling for the assistance of an ambulance and defibrillator while commencing CPR themselves.

Cause of death 36 Dr Heath’s conclusion was that Mr Hudson’s cause of death cannot be ascertained, but she has explained the factors that were likely involved. There was evidence of independent witnesses that Mr Hudson had become extremely exhausted towards the end of the fight and I heard him on the bodycam footage sound exhausted when police arrived.

I note Dr Heath’s expert opinion that methylamphetamine intoxication and extreme physical exertion can combine to bring about cardiovascular collapse.

37 I accept the opinion and conclusion of Dr Heath that Mr Hudson’s cause of death cannot be ascertained, and I also conclude, in accordance with her opinion, that there were specific factors likely involved and that Mr Hudson’s death was likely a result of the 56 Exhibit C90 at [9] and [11] 57 Exhibit C90 at [14] 58 Exhibit C90 at [18] 59 Exhibit C90 at [27]

[2025] SACC 35 State Coroner Whittle combined adverse effects of the combination of a high level of methylamphetamine and a high level of physical exertion in an unfit man whose body was fighting infections.

38 I find that Simon Hudson, aged 41 years of Salisbury Heights, died at Adelaide on 27 May

2022. His cause of death is unascertained, in circumstances of methylamphetamine intoxication, extreme physical exertion and COVID-19 and rhinovirus infections.

Recommendations 39 The investigating officer understandably suggested in his report that SAPOL could provide public education about the risks involved in being a good Samaritan in the face of antisocial and offensive behaviour.

40 However, in my opinion, while this would be an excellent initiative, it is something for SAPOL to consider in the context of ongoing policing operations and is not something that requires a Coroner’s recommendation for specific action.

41 I make no recommendations.

Keywords: Death in Custody; Police