Inquest into the death of Rebecca Maher
Deceased
Rebecca Maher
Demographics
36y, female
Date of death
2016-07-19
Finding date
2019-07-05
Cause of death
respiratory depression after loss of consciousness caused by mixed drug toxicity and possibly aspiration of vomit
AI-generated summary
Rebecca Maher, a 36-year-old Aboriginal woman, died from respiratory depression caused by mixed drug toxicity (high levels of Alprazolam and Methadone) while detained as an intoxicated person at Maitland police station. Preventable clinical and custodial failures included: (1) Dr W. prescribing Alprazolam without verifying Rebecca's drug dependence or checking her methadone program, despite multiple red flags; (2) failure to search Rebecca, largely due to unfounded fear of HIV/Hepatitis C infection, preventing discovery of hidden pill bottles; (3) inadequate in-person observations—inspections conducted via CCTV rather than attempting to physically rouse her; (4) failure to recognise she was severely intoxicated and required hospital care; (5) police awareness of abnormal breathing but no ambulance called despite clear medical deterioration. An ambulance should have been called when Rebecca became unable to complete risk assessment or by 1:34am when she lay down slumping. Dr V.'s evidence indicates she would likely have survived with proper airway management and oxygenation support in hospital.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- inappropriate prescription of Alprazolam without verification of drug dependence or awareness of methadone program
- failure to search detainee, preventing discovery of hidden benzodiazepine tablets
- failure to conduct in-person observations and physical rousing of intoxicated detainee
- monitoring via CCTV only rather than required in-person assessments
- failure to recognise severe intoxication requiring hospital transfer
- failure to call ambulance despite observations of abnormal breathing and awareness of health concerns
- inadequate completion of risk assessment due to detainee intoxication
- failure to identify and locate responsible person
- failure to provide food and water despite detainee intoxication
Coroner's recommendations
- Attorney General to consider amending Law Enforcement (Powers and Responsibilities) legislation to ensure Aboriginal persons detained under Part 16 as intoxicated have access to Aboriginal Legal Service Custody Notification Service
- Commonwealth Minister for Aboriginal Affairs to continue working with NSW government on funding options for extending Aboriginal Legal Service CNS to Part 16 detentions
- NSWPF to improve education and training on infectious diseases and transmission risks, particularly HIV and Hepatitis C from saliva and use of protective barriers
- NSWPF to improve education on circumstances requiring search of persons detained as intoxicated, particularly those with prescription drugs
- NSWPF to implement requirement that all custody managers undertake Safe Custody Course including duty to locate 'responsible person' and danger of 'sleep it off' approach
- NSWPF to modify Custody Management System to record what occurred when custody manager attempted to rouse intoxicated detainee and assessment of consciousness level, and efforts to identify responsible person including consultation of previous records
- NSWPF to use Rebecca Maher's death at Maitland police station as case study in custody manager training
Full text
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