Coronial
NSWhospital

Inquest into the death of Ross MARTIN

Deceased

Ross Martin

Demographics

56y, male

Date of death

2016-09-13

Finding date

2019-11-21

Cause of death

acute pentobarbitone toxicity

AI-generated summary

Ross Martin, a 56-year-old man with a long history of depression, died from acute pentobarbitone (Nembutal) toxicity obtained online, combined with toxic levels of zopiclone, less than two weeks after premature discharge from involuntary mental health care. After two suicide attempts in July and August 2016, the psychiatric team made critical deficiencies in the discharge decision on 1 September 2016. Dr K. and Dr S. failed to conduct a proper review of Mr Martin's extensive medical history, particularly the detailed Form 1 documenting deliberate, elaborate suicide planning. The decision was based largely on Mr Martin's misleading account and limited cross-sectional assessment without accessing prior records or collateral information. Police also returned a parcel of zopiclone to Mr Martin on the morning of his death without proper regard to suicide risk. Clinicians should thoroughly review historical records before discharging involuntary patients, particularly when family members provide concerning collateral information suggesting deception, and consider the risk posed by returning potentially lethal drugs to acutely suicidal individuals.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Specialties

psychiatrygeneral practicerespiratory medicinecardiothoracic surgeryintensive care

Error types

diagnosticcommunicationsystemdelay

Drugs involved

pentobarbitonezopiclonezolpidemtemazepamamitriptylinesertralineMDMA

Clinical conditions

major depressive illnessdepressionsuicidal ideationchronic insomniaadjustment disorder with depressed moodaspiration pneumoniaESBL infectiontype II diabetescoronary artery disease

Contributing factors

  • premature discharge from involuntary mental health care
  • inadequate review of medical history by discharging team
  • failure to access prior records documenting elaborate suicide planning
  • reliance on patient's misleading account of impulsive overdose
  • failure to obtain full collateral information from family despite their concerns
  • inadequate discharge planning with no confirmation of community mental health follow-up
  • community mental health team unable to provide adequate support within safe timeframe
  • police returned zopiclone to patient on morning of death despite known suicide risk
  • unclear police powers regarding seizure and retention of potentially lethal drugs
  • poor communication between police officers regarding handling of drug packages

Coroner's recommendations

  1. Commissioner of Police undertake a review of the Exhibits Procedures Manual and Police Handbook chapters on EFIMS, Exhibits and Miscellaneous Property to clarify police powers to open and retain property where suspected on reasonable grounds of containing something that may cause harm to police or any other person
  2. Commissioner of Police undertake a review to require that where any officer obtains advice as to the retention or return of an exhibit or miscellaneous property, a record of the advice is made within EFIMS
  3. Commissioner of Police undertake a review of Exhibits Procedures Manual to: create a single system and common procedure across NSW for the retention and disposal of exhibits and miscellaneous property; require that a notification is logged on EFIMS where a Coronial Investigation has been commenced and an exhibit or miscellaneous property is held that relates to the deceased person; require that photographs are taken and retained for all exhibits and miscellaneous property booked onto EFIMS
  4. Western Sydney Local Health District undertake a review or audit of the note taking of clinical staff working in consultation-liaison psychiatry at Westmead Hospital for the period September 2016 to the present
  5. Western Sydney Local Health District consider organising supplementary training for clinical staff working in consultation-liaison psychiatry at Westmead Hospital in relation to clinical note taking
  6. Referral to NSW Medical Council of Dr N., Dr S., Dr K. and Dr S.
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