Inquest into the death of Simon Miles
Deceased
Simon Miles
Demographics
42y, male
Date of death
2021-11-28
Finding date
2023-08-08
Cause of death
heroin and methylamphetamine toxicity
AI-generated summary
Simon Miles, a 42-year-old First Nations man with severe heroin and methylamphetamine dependence, died from accidental drug overdose while on Stage 2.5 of the Compulsory Drug Treatment Program (CDTP). Despite progressing well through rehabilitation, his transition to community living was complicated by several factors: suspension of drug testing due to COVID-19 (effective 27 August 2021), only fortnightly rather than weekly contact with his case coordinator, and placement in inner-city Waterloo where he had prior drug contacts rather than with his partner in Griffith. Expert opinion indicated his severe opioid dependence would have justified more vigorous advocacy for Opioid Substitution Therapy (OST), which he declined. The coroner found the CDTP insufficiently culturally adapted for First Nations participants and identified failure to inform the supervising Drug Court that testing had ceased. Key clinical lessons include the need for enhanced case management when testing is unavailable, more assertive management of high-risk patients regarding OST, and culturally appropriate transitions to community.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- severe opioid dependence with history of relapses
- suspension of drug testing from 27 August 2021 due to COVID-19 pandemic
- only fortnightly contact with case coordinator instead of weekly
- placement in high-risk environment (inner-city Waterloo) with known drug availability
- lack of Opioid Substitution Therapy despite severe dependence
- reduced tolerance to opioids following period in custody
- inadequate communication to Drug Court regarding cessation of testing
- loss of regular face-to-face monitoring and returns to CDTCC
- insufficient cultural adaptation of program for First Nations participants
Coroner's recommendations
- Consider revising relevant CDTP policy (following consultation with relevant stakeholders) to describe how the CDTP, including its therapeutic programs, can be delivered to First Nations participants in a culturally competent and culturally safe manner
- Consider revising relevant CDTP policy to identify culturally appropriate services available for First Nations participants in the community
- Consider revising relevant CDTP policy to describe the process for assessing the suitability and practicability of a First Nations participant residing on country in a regional area during Stages 2 or 3 of the CDTP
- Consider revising relevant CDTP policy to provide guidance on circumstances in which a participant can be required to undertake Opioid Substitution Therapy as a condition of progressing to Stage 2 or 3 (including where deemed at high risk of relapse)
- Consider revising relevant CDTP policy to describe how a determination about OST requirement should be documented
- CDTP policy should be modified to include specific information about intergenerational trauma and adverse childhood experiences relevant to First Nations people
- Consider stronger involvement of families throughout the three CDTP stages, incorporating family in multidisciplinary meetings and case reviews
- Highlight for families and clients the First Nations staff within CDTP and the roles they played
- Better align CDTP with First Nations understandings of social and emotional wellbeing, including cultural concepts of healing
- Incorporate a Cultural Plan alongside each participant's Personal Plan
Full text
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