Coronial
NSWother

Inquest into the death of Mohamed Warwar

Deceased

Mohamed Warwar

Demographics

35y, male

Coroner

Decision ofDeputy State Coroner O'Neil

Date of death

2021-10-23

Finding date

2024-05-21

Cause of death

cardiac arrhythmia with amisulpride toxicity, and myocarditis being contributory factors

AI-generated summary

35-year-old Mohamed Warwar died in custody at Metropolitan Remand & Reception Centre from cardiac arrhythmia with amisulpride toxicity and myocarditis. He was admitted to custody with a history of mental health issues and drug-induced psychosis, prescribed amisulpride 200mg which was increased to 600mg on 20 October. On 22-23 October, Warwar made three knock-up calls reporting severe distress, neck/back pain, and hallucinations. Both nurse and correctional officer failures occurred: nurses did not attend despite being called; correctional officers did not escalate or document concerns despite observing hallucinations and screaming between midnight and 3am. Postmortem toxicology showed 4.4mg/L amisulpride (toxic level), suggesting overdose, though cause of access remains unclear. The coroner found multiple systemic failures in handover procedures, record-keeping, HPNF completion, and communication between security and health staff, though no intervention was causally proven to prevent death. These deficiencies in experienced staff despite extensive training highlight policy implementation failures.

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

Specialties

psychiatrycardiologytoxicologygeneral medicine

Error types

communicationdiagnosticsystemdelay

Drugs involved

amisulpridemethamphetamineheroinbuprenorphinebenzodiazepinesalprazolam

Clinical conditions

drug-induced psychosisamphetamine-induced psychotic disorderacute myocarditiscardiac arrhythmiaamisulpride toxicitysubstance use disordermental health condition

Contributing factors

  • focal lymphocytic myocarditis
  • amisulpride toxicity at toxic blood level (4.4 mg/L)
  • recent Pfizer COVID-19 vaccination
  • possible viral infection
  • failure of nursing staff to assess despite request
  • failure of correctional officers to escalate despite observations of distress
  • poor communication between correctional services and nursing staff
  • inadequate record-keeping of deterioration overnight
  • substance use history and drug-seeking behaviour

Coroner's recommendations

  1. Consideration be given to ensuring HPNFs are easily available and accessible to staff managing inmates in accommodation areas
  2. Consideration be given to deficiencies in practice and procedure (not attending handover, failing to keep appropriate records, correctional officers not referring to HPNFs), the qualifications and training of responsible staff, policies directing correct practice, and the volume of policies and training, with a view to exploring better ways to minimise risk of employees not following policy
  3. Mandatory refresher training on HPNFs for all current and future serving Correctional Officers, with frequency to be determined after stakeholder consultation
  4. Consideration be given by Justice Health to deficiencies in practice and procedure (not attending handover, failing to keep records, not filling in HPNFs appropriately), qualifications and training of responsible staff, policies directing correct practice, and volume of policies and training, with a view to exploring better ways to minimise risk of employees not following policy
  5. Mandatory refresher training on HPNFs at least once every 2 years for all current and future serving Justice Health clinical staff statewide
  6. A shadow study be undertaken to determine what work is required on a regular evening shift at MRRC, where time pressures arise, and what support would best assist staff on evening shift
  7. Once the shadow study has been undertaken, steps be taken to put in place the identified support requirements
Full text
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