Coronial
NSWother

Inquest into the Death of Frank Dwayne COLEMAN

Deceased

Frank Dwayne Coleman

Demographics

43y, male

Coroner

Decision ofState Coroner O'Sullivan

Date of death

2021-07-08

Finding date

2025-10-22

Cause of death

methadone toxicity

AI-generated summary

Frank Coleman, a 43-year-old First Nations man, died of methadone toxicity after being supplied diverted methadone by another inmate while imprisoned at Long Bay Correctional Complex. Mr Coleman had repeatedly requested access to opioid agonist therapy (OAT), but had not yet been formally assessed or commenced on the program at the time of his death. He had multiple predisposing factors for opioid toxicity including cardiomyopathy, congestive cardiac failure, obesity, and mental health comorbidities. The coroner found that Mr Coleman should have been offered drug replacement therapy given his extensive drug history, repeated requests for treatment, and high-risk medical profile. Key clinical lessons include the importance of timely assessment and commencement of evidence-based addiction treatment in custodial settings, particularly for vulnerable individuals with cardiac disease who are at heightened risk of fatal opioid toxicity. The finding highlights systemic delays in accessing Drug and Alcohol services within prisons and inadequate diversion prevention measures for methadone administered under supervised programs.

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

Specialties

addiction medicinepsychiatrycardiologygeneral practicecorrectional healthtoxicology

Error types

diagnosticsystemdelay

Drugs involved

methadone

Clinical conditions

methadone toxicityopioid use disordercardiomyopathycongestive cardiac failurechronic schizophreniahepatitis Bhepatitis Chepatitis Dgastro-oesophageal reflux diseasehypercholesterolaemiahypertensionobesity

Contributing factors

  • methadone diversion by fellow inmate not on opioid agonist therapy
  • denial of access to opioid agonist therapy despite repeated requests
  • inadequate systems to prevent methadone diversion in custody
  • delays in Drug and Alcohol assessment
  • pre-existing cardiomyopathy and congestive cardiac failure
  • obesity
  • history of chronic schizophrenia and mental health comorbidity
  • lack of documented communication between Justice Health and Corrective Services NSW regarding suspected methadone diversion

Coroner's recommendations

  1. Justice Health, in coordination with Corrective Services NSW, review the models of care and resourcing of Drug and Alcohol assessments for the commencement of opioid agonist therapy (OAT), with a view to increasing access and capacity, and produce a joint report estimating unmet need in the public jail system and outlining the optimum wait time, and produce a joint mapping report indicating what resources would be necessary to achieve the optimum wait time (including staffing and infrastructure needs)
  2. Justice Health, in coordination with Corrective Services NSW, assess the viability of Drug and Alcohol reviews being conducted via telehealth, including in-cell, and if deemed viable, trial providing Drug and Alcohol reviews by in-cell telehealth
Full text
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