Inquest into the death of John Munkara

Contributing factors

• severe chronic alcohol intoxication (0.36% at time of death)
• failure of police communications call-taker to record request for ambulance, delaying response by two hours
• absence of facemask in police vehicles compromising early CPR delivery
• previous unlawful discharge from Alcohol Mandatory Treatment facility in May 2015 without tribunal order
• failure of assessment facility to understand and apply statutory release provisions
• lack of available beds in assessment facility preventing timely treatment intervention

Coroner's recommendations

1. Police communications call-takers must be trained to record all relevant information, particularly ambulance requests, in CAD logs and ensure such requests are transmitted to ambulance services
2. Police must implement systematic checking of First Aid kits in all vehicles, including facemasks for CPR, on weekly and monthly bases with recorded documentation
3. Front-line staff in alcohol and other drug services must receive training to understand and properly apply relevant legislation, particularly the Alcohol Mandatory Treatment Act and its successor Banned Drinkers Register legislation
4. Robust clinical frameworks must be established for all coronial matters and sentinel events within health services
5. System-wide governance improvements are needed over coronial matters with enhanced reporting on implementation of recommendations
6. Government agencies must ensure adequate resourcing (beds, staff) to meet the legislative intent when therapeutic laws are enacted