Coroner's Finding: REX Michael David

Contributing factors

• undetected ingestion of non-prescribed methadone
• inadequate detection during hourly observations while heavily sedated
• lack of visitor identification and recording systems
• perimeter security gaps allowing contraband passage
• delayed toxicology results
• absence of proactive investigation into possible drug ingestion
• inadequate CCTV retention procedures
• transfer to open ward with access to public areas and visitors

Coroner's recommendations

1. Review the physical nature of fencing to the rear garden area of Ward 5H to prevent passage of illicit drugs
2. Implement policy to govern visitor access to Ward 5H including visitor guidelines, visitor identification requirements for detained patients, and maintenance of visitor record book with documentation of staff observations of patient-visitor interactions
3. Review routine guidelines and reassess manner of checking patients during night and when asleep during day; reassess timeliness of medication administration and provide refresher training
4. Introduce guidelines for minimal course of action by ward staff upon finding of deceased detained persons, including scene securing, witness identification, and mandatory provision of CCTV footage to investigators as soon as practicable
5. Ensure all CCTV footage is retained and not overwritten until permission obtained from State Coroner or police
6. Ensure investigating police take proactive role in identifying possible investigative issues rather than relying on witnesses; police should consider toxicological component in unexplained deaths in hospital settings even before toxicology results available