AN INQUEST INTO THE DEATH OF STEVEN CLAUDE FREEMAN

Contributing factors

• Opioid naive or low-tolerance patient prescribed methadone without adequate objective verification of dependency
• Lack of formal clinical opiate withdrawal scale assessment
• No urinalysis conducted prior to methadone commencement despite availability
• Failure to conduct 2-3 hour post-dose toxicity assessment as per national guidelines
• Inadequate handover of methadone patient information to correctional services
• Inadequate morning wellbeing check procedures
• Access to illicit substances and 'spit methadone' within facility
• No daily medical review during critical first week of induction

Coroner's recommendations

1. Review security and wellbeing check procedures to ensure eye contact and facial recognition rather than just verbal response or foot movement, with periodic evaluation of compliance through CCTV review
2. Implement structured daily physical education and training programs coupled with drug rehabilitation counselling as part of methadone maintenance programs in custody
3. Minimise infiltration of illicit substances into custodial facilities through enhanced screening technology and security protocols
4. Obtain and share court alcohol and drug assessment reports, prior medical records, and urinalysis results with treating doctors at methadone assessment and with correctional services conducting headcounts
5. Review and amend ACT Standard Operating Procedures to allow individualised commencement dosing of 5-20 mg rather than prescriptive 25 mg minimum, with daily medical review
6. Review policy allowing detainees to self-prescribe methadone dose increases on Sundays without medical review; restrict such increases for recently commenced patients for a set period
7. Clarify inconsistencies between ACT SOPs and National Guidelines for methadone maintenance; consider adopting National Guidelines to replace ACT Opioid Maintenance Treatment Guidelines
8. Incorporate mandatory urinalysis and blood testing where there is no objective medical history of opioid dependence prior to methadone placement
9. Establish 2-3 hour post-dose assessment protocols for intoxication as per National Guidelines, not delayed to next-day dosing