Coroner's Finding: KEOUGH Thomas Ryan

Contributing factors

• failure to conduct nightly room checks despite vulnerability of residents
• diversion of methadone from unknown source, likely from resident prescribed for pain relief
• staff unaware of methadone-prescribed residents at the facility
• inadequate monitoring and supervision protocols
• unclear documentation of resident movements and leave status
• failure to report suspected drug dealing to police
• inadequate initial and delayed police investigation
• difficulty locating and interviewing key staff members (agency nurse)
• lack of clear policies on drug management at the facility
• young person in mixed-age facility with vulnerable population

Coroner's recommendations

1. Department of Health investigate introduction of system for reconciling quantity of methadone or other opiate pain relief drugs prescribed to palliative care patients after their death
2. Palm Lodge and similar facilities institute policy reporting allegations of illicit drug use or dealing to police expeditiously
3. Palm Lodge policies and procedures be thoroughly reviewed by Department of Health
4. Palm Lodge carry out room checks daily whether or not resident thought to be absent
5. South Australia Police introduce protocols to ensure more rigorous investigation of deaths suspected to have been caused by drug overdose, particularly to ascertain involvement of illicit or illegally obtained drugs
6. South Australia Police required to report to Minister of Police all deaths where deceased believed to have died from ingesting unknown drug and source not ascertained within three months
7. Minister of Police make such reports publicly available with appropriate protections for deceased's identity