The coroner has urged the NRL to review its heat policy after a Manly Sea Eagles player suffered a “devastating” death from heatstroke after an “inappropriate” pre-season training.
On November 23, 2020, 20-year-old Keith Titmuss suffered a seizure after a grueling indoor workout at the Sydney club’s northern beaches base.
Titmus was taken to Royal North Shore Hospital but died five hours later from cardiac arrest.
Deputy State Coroner Derek Lee found that the budding NFL player’s cause of death was exertional heatstroke and that pre-existing heart disease was unlikely to be one of the factors.
Lee released his findings on Friday, urging the NRL to consider enforcing a two-week acclimatization period when players return from the off-season and using the deaths as a case study to raise awareness of heatstroke.
Lee also suggested that the game’s governing body, as part of a review of its heat policy, consider making it mandatory for clubs to report incidents of heatstroke.
He urged Manly to review its record-keeping processes around adverse health events such as heatstroke to ensure they were “robust and reliable”.
The coroner found that pre-season training at the club’s Narrabeen gym following an outdoor session was “likely to be inappropriate”.
When Titmus entered the “very hot and humid” dojo, he was likely dehydrated before suffering exertional heat stroke, Lee said.
He cited testimony that the demanding workouts were designed to shake players off fatigue, while noting that Titmus, while extremely fit, had low aerobic fitness levels in the game group.
He said it was unclear whether fans in the gym were running and nearby ice could have been applied to his body, although it was unclear whether that helped relieve Titmus’ symptoms.
The coroner found that attempts to treat Titmus’ hyperventilation with paper bags were “misguided”.
Evidence at the trial showed paramedics at the scene noticed Titmus’ temperature was 41.9 degrees Celsius and his heart rate was more than 140 beats per minute.
A former team-mate told police the intensity of the session was rated a 9 out of 10, but then-Manly coach Des Hasler rated it a 6 or 7.
Lee said Titmus’ death was “tragic and devastating,” describing the young man as kind, gentle, respectful and “a rock on this earth.”
The coroner said: “His friends called him the Pied Piper of the group.”
Outside court, his mother Lafo Titmuss said she was pleased the cause of her son’s death had been determined and urged everyone involved to adopt the recommendations.
Flanked by her family and supporters, she said she hoped the NRL would emphasize the importance of heat policy rather than underplay the impact of heat.
Rafael Titmus has previously said she hoped the inquiry’s recommendations would shed light on the NRL and other sports regulations.
Manly chief executive Tony Mestroff said a death like Titmus’s would never happen again in the game.
“We all understand this and we don’t want this to happen again under Manley’s watch,” Mestov told reporters.
The NRL has been approached for comment.
