Inquest into the death of Hugh David LISLE

Contributing factors

• accidental overdose of prescribed and non-prescribed drugs
• severe sedation from combination of benzodiazepines, antipsychotics, antidepressants and illicitly obtained buprenorphine
• face-down sleeping position on pillow
• body habitus and obesity increasing respiratory compromise risk
• patient's undisclosed illicit drug use
• inadequate monitoring for signs of excessive sedation despite complaints
• failure to comprehensively document and escalate concerning behaviours and observations
• access to non-prescribed buprenorphine while in supervised care

Coroner's recommendations

1. Ramsay Health should review the level of resuscitation training currently provided to staff at the NCC, the manner in which it is provided, and the frequency with which it is refreshed to ensure that at all times there are staff on the premises who can adequately respond to foreseeable emergencies, specifically ensuring advanced life support capability is available given the elevated risk of cardio-respiratory arrest in this patient population
2. Improve communication of clinically significant information and note-taking procedures to ensure that all incidents relevant to patient safety (such as drug-seeking behaviour, reports of apparent intoxication, patient complaints of over-sedation) are accurately recorded and appropriately escalated
3. Strengthen monitoring procedures when medication is dispensed to detect signs of unexpected intoxication or sedation that may indicate patient access to non-prescribed substances