Inquest into the death of Edward Laurie

Contributing factors

• chronic petrol sniffing addiction from age 10
• underlying mental health condition with psychosis and auditory hallucinations
• failure to apply the Volatile Substance Abuse Prevention Act
• Assessors did not prepare formal assessment reports or provide them to Chief Health Officer
• Assessors case-managed rather than following statutory assessment procedures
• lack of available treatment facilities suitable for individuals with violence/aggression
• failure of health service leadership to resource appropriate interventions
• misinterpretation of 'treatment program' definition under the Act
• inadequate compliance with the Volatile Substance Abuse Clinical Guideline
• non-compliant with mental health medications during periods of abuse
• social and family circumstances; absence from positive influences

Coroner's recommendations

1. Conduct comprehensive review of all facets of Volatile Substance Abuse processes, procedures, Guideline and Act
2. Provide immediate training and supervision to ensure compliance with the substance and intent of the Volatile Substance Abuse Prevention Act
3. Ensure Assessors properly follow section 34 duties: assess persons, prepare formal assessment reports with treatment options, and provide them to the Chief Health Officer
4. Develop and resource appropriate treatment or intervention programs suitable for persons with volatile substance abuse who are angry, violent, or non-compliant
5. Establish leadership and supervision mechanisms to ensure statutory compliance and that the Act's objects are realised