Inquest into the death of Julian HORNE

Contributing factors

• severe binge relapse after 2.5 years abstinence
• relationship breakdown
• untreated depression and anxiety
• use of methylated spirits and other non-beverage alcohol
• repeated self-discharge against medical advice
• lack of coordinated cross-LHD care
• incomplete medical records access for ED physicians
• no embedded drug/alcohol specialist in ED after-hours
• family advocacy not effectively incorporated into care plans
• no frequent presenter identification system
• lack of assertive follow-up or outreach

Coroner's recommendations

1. Ministry and NBMLHD to consider findings and review management of severe alcohol disorders with binge patterns including periods of abstinence
2. NSW Health to prioritise assessment and determination of St Vincent's Specialty Network's controlled drinking trial (managed alcohol) proposal for commencement forthwith
3. NSW Health to prioritise undertaking and completing evaluation of Assertive Community Management (ACM) and Drug and Alcohol Consultation Liaison Programs with particular consideration of family engagement
4. NSW Health to consider means of promoting or lobbying Commonwealth regarding improving availability of Disulfiram medication in Australia including potential PBS inclusion
5. NSW Health to consider promoting data capture of alcohol-related elements to National Minimum Dataset for National Non-admitted Patient Emergency Department Care (NNAPEDC)
6. NSW Health to consider engaging with ACEM to develop training modules for ED clinicians regarding treatment options for severe alcohol disorders
7. NSW Health to examine feasibility of providing support for embedding a Clinical Nurse Consultant specialising in alcohol and drug issues within Emergency Departments during after-hours
8. NSW Health to examine feasibility of establishing working groups for specific hospitals or across LHDs to identify and manage frequent presenters with severe alcohol or drug-related issues