Perry, Anthony Mark
Deceased
Anthony Mark Perry
Demographics
41y, male
Date of death
2010-03-23
Finding date
2012-05-31
Cause of death
Respiratory depression caused by alcohol and morphine poisoning
AI-generated summary
Anthony Mark Perry, aged 41, died in police custody at Rockhampton watch house on 23 March 2010 from respiratory depression due to morphine and alcohol. He was arrested for breaching a domestic violence order after drinking heavily. Police were unaware he had injected morphine earlier that afternoon and subsequently ingested additional slow-release morphine tablets. The watch house sergeant assessed him as intoxicated from alcohol alone and reasonably decided no medical review was necessary based on his ability to walk and respond to questions. However, Perry's presentation included drowsiness consistent with mixed drug and alcohol toxicity. Had police known of morphine use, naloxone administration could theoretically have prevented death, but this knowledge was unavailable. The coroner found police acted reasonably given available information. Key recommendations include separating drug and alcohol questions in health screening, upgrading CCTV equipment, and improving family notification procedures in custody deaths.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Acute mixed alcohol and morphine toxicity
- Injection of crushed morphine tablet in afternoon
- Subsequent ingestion of slow-release morphine tablet(s) prior to or during custody
- Police unaware of morphine ingestion
- Inability to distinguish mixed drug and alcohol intoxication from alcohol intoxication alone
- Lack of full strip search allowing potential concealment of additional morphine tablets
- CCTV recording failure in cell H4 preventing observation of possible tablet ingestion
- No medical assessment despite signs of drowsiness and altered level of consciousness
Coroner's recommendations
- The Health Questionnaire be reviewed with a view to including separate questions about the ingestion of alcohol, prescription drugs, and illicit drugs (rather than composite question), and inclusion in Appendix 16.12 of the QPS OPM of a list of clues or signs that indicate drugs other than alcohol might be responsible for symptoms a prisoner is displaying
- The QPS give priority to replacement of outdated and unreliable CCTV equipment at Rockhampton Watch house with more up to date and reliable equipment
- An appropriate officer within the Central Region ensure all officers stationed in Rockhampton are reminded of the importance of QPS policies relating to notification of relatives of persons who die in custody, including the requirement to advise families sensitively and in compliance with the Commissioner's directive on this matter
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