Coronial
VICmental health

Finding into death of Shaun Luke Beagley

Deceased

Shaun Luke Beagley

Demographics

33y, male

Date of death

2014-03-02

Finding date

2016-05-13

Cause of death

Mixed drug toxicity

AI-generated summary

Shaun Beagley, aged 33, died from mixed drug toxicity (heroin, methylamphetamine, benzodiazepines) while on overnight leave from E-PARCS psychiatric residential facility. He had been admitted following suicide attempts and was managing depression, alcohol dependence, and drug use. On 1 March 2014, RPN Pollock approved overnight leave after brief assessment, though Shaun had reported fleeting suicidal ideation in the preceding 48 hours and had not shown improvement in withdrawn behaviour. Critical omissions included: no documented comprehensive mental state examination specific to the leave decision, no contact with family members despite valid consent to do so, no telephone monitoring during leave despite the facility requesting a welfare check that morning, and absence of any formal leave procedure until April 2015. The coroner found the decision to grant leave questionable given recent suicidal ideation, withdrawn presentation, and lack of robust assessment documentation. Improved communication with family and monitoring systems could have prevented this death.

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

Specialties

psychiatry

Error types

assessmentcommunicationsystemdelay

Drugs involved

heroinmethamphetaminediazepammirtazapinezopiclonecodeinenordiazepamoxazepamtemazepam

Clinical conditions

depressionsuicidal ideationalcohol dependenceopioid use disorderamphetamine use disorderhepatitis C

Contributing factors

  • Approval of overnight leave without adequate risk assessment specific to the time of assessment
  • Suboptimal quality and documentation of mental state examination
  • Failure to involve family members despite valid consent
  • Recent fleeting suicidal ideation in preceding 48 hours
  • Persistent withdrawn behaviour and low mood
  • First unescorted overnight leave granted
  • Inadequate telephone monitoring during leave
  • Delayed response to welfare concerns
  • Absence of formal leave procedure at the time
  • Reliance on staff motivation rather than system for monitoring incoming calls

Coroner's recommendations

  1. Amend the Monash Health PARCS Leave Procedure to include a requirement that for first overnight or leave events where the resident will be alone, PARCS staff encourage the resident to notify family and/or friends of the leave, or gain consent to notify them, or if this fails, make telephone contact with the resident while on leave for support and as an indicator of safety
  2. Implement a technological solution such as a mobile or cordless telephone to provide immediate access to incoming calls rather than relying on staff motivation to check message banks
Full text
Official source Archived copy

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Source and disclaimer

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