Finding into death of Justin Peter Foster

Contributing factors

• synthetic cannabis use (8 different synthetic cannabinoids detected)
• polypharmacy: diazepam, temazepam, quetiapine, codeine, oxycodone, paracetamol, ibuprofen
• bipolar affective disorder with manic relapse
• medication non-compliance
• chronic back pain requiring opioid and corticosteroid therapy
• possible cardiac arrhythmia (family history of sudden death in sibling)
• involuntary psychiatric inpatient status

Coroner's recommendations

1. Families and staff should be advised that synthetic cannabis can cause cardiac arrhythmias and sudden death, and testing protocols should include synthetic cannabinoid screening
2. Genetic cardiac arrhythmia disorder screening should be considered in families with multiple sudden deaths in young siblings
3. Medical records should document eating and drinking habits in psychiatric inpatients, particularly during hot weather and when on multiple medications
4. Agency nursing staff should receive appropriate induction and mental health training equivalent to permanent staff in acute psychiatric settings
5. Personal belongings of patients should be properly stored and accounted for upon discharge or after death
6. Privacy and visiting arrangements in psychiatric inpatient facilities should be reviewed