Inquest into the death of David Veech

Contributing factors

• Inadequate supervision of resident in residential care facility
• Insecure medication storage and access controls
• Failure to implement required twice-hourly night checks from behaviour support plan
• Lack of staff training on drug-seeking behaviour and Fentanyl abuse methods
• Failure to provide drug and alcohol rehabilitation services despite urgent clinical indication
• Poor inter-agency coordination between Lifestyle Solutions, Goulburn Community Health Centre, mental health services, and probation and parole
• Inappropriate placement in intensive residential support without prior detoxification
• Staff fear and avoidance of supervision due to perceived threat from resident
• Poor shift handover procedures and documentation
• Lack of communication between GP and clinical psychologist regarding Fentanyl prescription
• Insecure office environment with unlocked doors and restricted access
• Inadequate staffing ratios for two residents with known drug-seeking behaviour
• Absence of protocol for safe disposal of transdermal patches
• Unreliable drug screening (unsupervised urine test)

Coroner's recommendations

1. Southern NSW Local Health District to liaise with NSW Health to provide copy of findings and seek urgent consideration of need for increased capacity for residential drug and alcohol rehabilitation beds in NSW, particularly for patients exiting criminal justice system with history of aggression, ambivalent response to treatment, or known lack of insight, and patients with mental health diagnosis
2. Lifestyle Solutions to action each of the changes referred to in the document headed 'Systems Changes and Acknowledgements Arising from the Inquest and Agreed to by Lifestyle Solutions' according to the timetable foreshadowed, including: policy on disposal of transdermal patches; policy on management of drug-seeking behaviour; policy ensuring clinical psychologist awareness of prescription medication changes; policy requiring clinical psychologist review and approval of behavioural support plan changes; policy ensuring treating doctor informed of person's circumstances; policy on improving communication with relevant agencies including case management meetings; appropriate key registers in all residential care facilities
3. Lifestyle Solutions to conduct an audit of Tarlo IRS in 12 months from inquest to gauge whether lasting change and improvements in training have been achieved