Coroner's Finding: Crump, Damian Michael

Contributing factors

• Chronic major depressive disorder and anxiety since adolescence
• Unresolved psychological issues including repressed sexuality
• Intravenous opioid addiction in final 12 months
• Longstanding suicide plan involving specific drug combinations known to colleagues
• Inappropriate workplace behaviour tolerated as 'just Crumpy'
• Inadequate medication management and security systems
• Failure to investigate suspected drug thefts in September 2016
• Failure to implement proper drug auditing procedures
• Inadequate mental health and welfare support systems
• Insufficient management capacity (extreme span of control)
• Lack of manager training in mental health and disciplinary issues
• Conflicted management by close friend and manager Monica Baker
• Inadequate response to serious incidents in final weeks of life
• Doctor shopping and dishonesty with medical practitioners
• Fabrication of medical certificates and ongoing psychiatric treatment

Coroner's recommendations

1. Implement random drug and alcohol testing for all Ambulance Tasmania employees as a matter of priority
2. Implement any remaining recommendations from the December 2020 KP Health Medication Management Outcome Assessment as a matter of priority
3. Conduct regular reviews of policies relating to management, storage, safekeeping, handling and accountability of drugs to ensure effectiveness and currency
4. Provide regular training for all staff and managers regarding obligations in respect of medication management policies and implement robust systems of accountability with high compliance standards
5. Implement a system of regular mandatory psychological assessments for employees to identify mental health and psychological issues and changes throughout employment
6. Continue efforts to reduce span of control for duty managers and other managers
7. Regularly review ability of frontline managers to undertake supervision duties adequately
8. Provide regular training for all managers in managing staff generally and in responding to mental health issues
9. Provide training for managers required to conduct or oversee investigations including policy knowledge, investigation skills, reporting requirements and conflict of interest management
10. Complete all outstanding action items from the 73 actions committed to in the Culture Improvement Action Plan July 2022
11. Publish on website a report setting out progress of the 73 action items from the Culture Improvement Action Plan, indicating completion status and timeframes for incomplete items
12. Complete and publish updates of the Culture Improvement Action Plan at appropriate intervals to promote confidence and transparency
13. Develop processes to provide timely assistance in coronial investigations including provision of relevant material addressing scope issues