Coronial
QLDother

McGrath, Nathan David

Deceased

Nathan David McGrath

Demographics

35y, male

Coroner

Ryan

Date of death

2012-06-25

Finding date

2014-04-17

Cause of death

methylamphetamine toxicity

AI-generated summary

Nathan McGrath, 35, died in the Cairns Watchhouse from methylamphetamine toxicity with coronary artery atheroma as a significant contributor. He was arrested on two warrants and a pat-down search located only a small amount of amphetamine in his wallet. A subsequent unclothed search was not conducted. Later that night, he ingested a lethal quantity of methylamphetamine (not found during searches), became acutely agitated with erratic behaviour, and experienced sudden cardiorespiratory arrest. The coroner found that had an unclothed search been conducted, the additional methylamphetamine may have been discovered and his death possibly prevented. Medical response by QAS was timely and appropriate. Key clinical lesson: in custody settings, risk assessment for searches must consider drug trafficking history, possession of drugs, and suicide risk flags to prevent contraband entering cells.

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

Specialties

emergency medicineparamedicineforensic medicine

Error types

proceduralsystem

Drugs involved

methamphetamineamphetaminecannabismidazolam

Clinical conditions

methylamphetamine toxicityexcited delirium syndromecoronary artery atheromacardiorespiratory arresthepatitis Ctesticular cancer (history)

Procedures

pat-Down searchproperty searchcardiopulmonary resuscitation

Contributing factors

  • coronary artery atheroma with greater than 60% narrowing
  • failure to conduct unclothed search despite risk factors including drug trafficking history, possession of drugs, and suicide risk flags
  • ingestion of lethal quantity of methylamphetamine while in custody
  • excited delirium syndrome
  • high-risk drug use pattern

Coroner's recommendations

  1. The CWH Staff Orientation Package and Standing Orders and SOPs should be amended so as to place greater emphasis on s.16.10.2 of the OPM regarding matters to be considered when deciding whether to conduct unclothed searches
  2. Officers at the CWH should place greater emphasis on the matters contained in s.16.10.2 of the OPM during practical training
  3. Implementation of changes made by Senior Sergeant Gardiner post-incident, including the Risk Management Worksheet for shift supervisors to ensure all searches are conducted lawfully and in adherence to OPM guidelines
Full text
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