Claims of a culture of caring at the Manly club were ‘rarely seen’

The NSW Deputy State Coroner was highly critical of Manly for attempting to blame Keith Titmuss’s existing health problems.

The NSW Deputy State Coroner was highly critical of the Manly Sea Eagles for attempting to blame Keith Titmuss’s existing health problems for his death, stating it had been the NRL club’s failures that had contributed to the fatality in 2020 from exertional heat stroke.

Derek Lee was scathing of the club for not implementing heat stress recommendations of a doctor after another player, Lloyd Perrett, almost died in similar circumstances while training with Manly in 2017.

“You are leaving yourself and the club open to litigation if a player suffers heat stroke or, at worst, dies,” doctor Luke Inman wrote in an email to Manly staff in 2018.

Then Manly coach Des Hasler told the inquest he didn’t recall ­receiving that email.

Keith’s parents, Lafo and Paul Titmuss, told The Weekend Australian they were “very happy” with Lee’s wide-ranging recommendations to the NRL surrounding pre-season training and heat stress.

“We knew about Lloyd Perrett soon after Keithy had passed,” Lafo Titmuss said. “I think Manly should have had better record keeping and there should have been a better handover because there is a high turnover of manager and training staff.”

Paul and Lafo Titmuss, parents of Keith Titmuss, depart the Coroner's Court of New South Wales in Sydney on Friday. Picture: AAP Image/Bianca De Marchi

She said what happened to Lloyd Perrett “should have been passed on” and the club should have learnt some lessons from his near death from exertional heat stroke.

“I’m very happy with the coroner’s recommendations and it really is all about saving another family having to go through this process and saving lives,” she said.

Lee said that while the club had consistently tried to convey that it fostered a “culture of caring about players” this was “incongruous” as it was “surprising and rarely seen”. He said the degree to which Manly had raised the heart issue during the hearings was a source of distress to Titmuss’s ­family. He found it had not been a contributing factor.

“The coronary artery disease (found at) autopsy most likely did not cause his death,” Lee said.

He also criticised the club for its failure to adopt the recommendations of Inman who had emailed Manly officials pleading for them to adopt better practices and be aware of “exertional heat illness” – the cause of Titmuss’s death.

Following the incident with Perrett, Inman said the club should be using a Kestrel device – a heat stress monitor – which he said could save players’ lives.

“Please, it does not take long to set up,” he implored.

Many Sea Eagles player Keith Titmuss. Picture: NRL

The deputy coroner made a number of recommendations to the NRL and its clubs, including mandating a 14-day period of controlled training load acclimatisation following the off-season, or extended break for a player, and education about exertional heat stroke. He also recommended that Manly improve its record-keeping policies.

He made mention of the 2017 incident where former player Perrett collapsed during training after allegedly being denied water.

“Following the incident involving Lloyd Perrett, Dr Inman made a number of well-informed and helpful recommendations aimed at educating staff at Manly about the signs and symptoms of exertional heat illness, and preventing the occurrence of a similar event,” Lee said.

“The evidence is unclear as to the extent to which this information was received and retained by medical staff at Manly.”

The coroner said Dr Inman’s information, including a detailed PowerPoint presentation, on exertional heat stroke was not passed on to the new chief medical officer Nathan Gibbs, who started in late 2019. It was also revealed Gibbs was also not told about the Perrett incident at training in 2017.

“Indeed, Dr Gibbs first learned about these matters in 2024,” Lee said.

Titmuss’s family has asked, and the deputy coroner has recommended, that the NRL have mandatory reporting of all heat-related injuries in order to create a comprehensive understanding of the issue.

On Friday, Lee said the “training session” Titmuss endured was “more likely than not inappropriate” and that the 20-year-old was “most likely suffering involuntary dehydration” when he entered the “hot and stuffy” gym where he started to seize.

An attending paramedic registered his body temperature of 41.9C – the hottest the medic had ever seen. Titmuss later suffered a cardiac arrest at hospital and died.

Manly Warringah chief executive Tony Mestrov. Picture: AAP Image/Bianca De Marchi

He had gained 4.9kg in the off-season and was the least aerobically fit in the squad.

Deputy coroner Lee said the NRL should consider implementing individual training sessions in light of varying individual body mass, underlying conditions and physical shape upon return to pre-season training.

He also recommended a copy of the findings be provided to the NRL and their experts as they review their heat policy. He made a number of recommendations to the NRL to consider including mandating a 14-day period of controlled training load acclimatisation following an off-season or extended break for players.

He also said there should be consideration given to use Titmuss’ death as a case study and raise awareness of exertional heat illness to NRL clubs to be aware of the risk factors – for example, lower aerobic fitness, a high body mass index, as well training history. He said awareness should be raised that exertional heat illness can occur in lower ambient temperatures. It was 24C on the day Titmuss died.

The deputy coroner said that the NRL and its clubs should identify what cooling strategies could be implemented for outdoor and indoor training sessions.

The NRL is continuing to review its heat policy.

Manly chief executive Tony Mestrov, who sat in on the findings at the court alongside football club manager John Bonasera, said the club would fully adopt the recommendations.

“This can’t happen again in the game, we all understand that,” Mestrov said.

“We don’t want it to happen under Manly’s watch ever again.”

He also recommended that Manly and the NRL use Titmuss’s tragic death as a case study for education around heat illnesses.