Inquest into the death of ZA
Deceased
ZA
Demographics
male
Date of death
2020-09-14
Finding date
2022-10-06
Cause of death
Fentanyl toxicity, with aspiration pneumonia as a significant contributing condition
AI-generated summary
A man (ZA) died from fentanyl toxicity in custody at Shortland Correctional Centre after his cellmate, who had brought fentanyl into the prison by concealing it in his rectum, shared it with him. Both men snorted the powder; ZA lost consciousness and developed aspiration pneumonia. Despite vigorous CPR by correctional officers, he could not be revived before ambulance arrival 20 minutes later. Clinical lessons include: (1) illicit fentanyl enters prisons and may not be detected by standard strip searches; (2) X-ray body scanners can improve detection of concealed contraband; (3) naloxone (narcan) availability at prisons could be life-saving for opioid overdoses, especially when Justice Health staff are absent overnight; (4) policies should clearly address situations where medical emergencies overlap with crime scenes, while maintaining that medical response takes priority.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Drugs involved
Clinical conditions
Contributing factors
- Illicit fentanyl smuggled into correctional centre in cellmate's body cavity
- Cellmate supplied fentanyl to deceased
- Deceased naively ingested fentanyl without understanding potency or risks
- Prolonged unconsciousness before respiratory distress detected
- Aspiration of gastric contents during unconsciousness
- No naloxone (narcan) available at facility
- Justice Health medical staff not present overnight
- Ambulance response time approximately 20 minutes
Coroner's recommendations
- That Corrective Services NSW (CSNSW) review Custodial Operations Policy and Procedures (COPP) sections 13.2, 13.3 and 13.8 for the purpose of identifying whether all or one of them should be amended.
- That CSNSW investigate the provision of Naloxone (aka Narcan) to correctional officers as medication to assist in cases of opioid overdose, especially and urgently in correctional centres where Justice Health medical practitioners are not present at all times of the day and night.
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