Inquest into the death of Alan BUGDEN and Amaru BESTRIN

Contributing factors

• undetected collapse for prolonged period (over 20 hours for Bugden, over 11 hours for Bestrin)
• failure to check toilets during closure of ambulatory care centre
• inadequate cleaning protocols and lack of toilet monitoring systems
• absence of emergency alert buttons or communication systems in publicly accessible toilets
• lack of documented checking procedures for occupied toilets
• poor escalation procedures for welfare concerns
• inadequate auditing of cleaning compliance
• use of hospital toilets as de facto injecting sites without supervision (Bestrin)
• no minimum spacing requirement between cleaning rounds
• security and cleaning staff unfamiliar with welfare check escalation procedures
• incomplete CCTV coverage after facilities closed
• no documented system tracking incidents of collapse in toilets

Coroner's recommendations

1. Create central register at NSW Health of all deaths and collapses in publicly accessible and clinical toilets with specified details including medical cause, toilet layout, discovery timeframe, cleaning history, and audit compliance
2. Create central register at Liverpool Hospital for toilet incidents with similar specifications
3. Establish notification procedures at Liverpool Hospital to inform management of drug-related collapse incidents
4. Amend Liverpool Hospital 'Cleaning of Public Toilets' Policy to escalate welfare concerns to MET team/clinical staff rather than security
5. Conduct annual review of central register by NSW Department of Health to determine if risk mitigation warranted
6. Undertake documented internal audit of toilet audit sheets at Liverpool Hospital every 3 months with compliance documentation
7. Undertake documented external audit of toilet audit sheets at Liverpool Hospital every 2 years
8. SWSLHD conduct documented internal audit of cleaning system operation including recorded compliance rates
9. Liverpool Hospital undertake overall risk assessment of publicly accessible toilets including consultation with cleaning, security, drug health, and harm reduction staff
10. Liverpool Hospital undertake immediate costing for shortening doors to disability toilets at Concourse Level near Lifts B and D to provide visibility of collapse
11. Liverpool Hospital implement structural changes to disability toilet doors at Concourse Level near Lifts B and D so they open outwards
12. Liverpool Hospital urgently undertake costings for 'high-risk' toilets for door lock timers, LIDAR technology, or other detection measures
13. Liverpool Hospital provide first aid training to all cleaners and security staff with focus on overdose response and recovery position
14. Liverpool Hospital provide training package to all cleaners including simplified policy summary, escalation procedures, overdose response, and testing with minimum pass rate
15. Liverpool Hospital provide details regarding feedback and performance management for non-compliance with cleaning policies
16. Liverpool Hospital train all cleaners and security staff in naloxone nasal spray use and provide naloxone to all staff
17. NSW Health undertake feasibility study for supervised injecting space within Liverpool Hospital grounds