Coronial
VICother

Finding into death of Helen Julia Mok

Deceased

Helen Julia Mok

Demographics

49y, female

Coroner

Deputy State Coroner Iain West

Date of death

2013-04-06

Finding date

2017-04-20

Cause of death

Multi-drug toxicity from intentional self-administration of intravenous fentanyl and midazolam

AI-generated summary

A 49-year-old paramedic with Ambulance Victoria died from multi-drug toxicity after deliberately self-administering intravenous fentanyl and midazolam accessed from her employer's medication safe. The coroner examined whether workplace factors contributed to her suicide. While evidence showed she had depression, work-related injuries, experienced the suicide of a colleague, faced uncertain return-to-work negotiations, and felt stigma around seeking psychological help, the coroner found no clear causal connection between these employment factors and her death. The primary precipitating factor appeared to be her impending relationship breakdown. The coroner did not find that workplace stress, negotiations, or absence of support services materially contributed to her decision. Clinically, this case highlights paramedics' elevated suicide risk due to access to means, exposure to trauma, and barriers to seeking help, while AV's subsequent security measures, mental health strategies, and support services represent important systemic improvements.

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

Specialties

paramedicinepsychiatryforensic medicine

Error types

system

Drugs involved

fentanylmidazolamalcoholdesvenlafaxineparacetamol

Clinical conditions

depressionmajor depressive disorderchronic painrespiratory depressionopioid toxicity

Procedures

intravenous drug administration

Contributing factors

  • Access to medications at ambulance branch after hours
  • Depression with major depressive disorder
  • Work-related injuries and chronic pain
  • Work colleague suicide (Ron McLeod)
  • Work-related negotiations and uncertainty regarding return-to-work arrangements
  • Impending relationship breakdown
  • Perceived stigma regarding psychological help-seeking
  • Withdrawal from family and social activities

Coroner's recommendations

  1. Dual-swipe access to medication safes implemented (already actioned by AV)
  2. Restrict medication safe access to rostered shifts only (already actioned from November 2016)
  3. Automatic email alerts to regional directors for out-of-shift access attempts (already implemented)
  4. Replace fentanyl vials with lower-concentration ampoules (already actioned)
  5. Install CCTV at all branches (already actioned)
  6. Implement suicide prevention training for all paramedics in partnership with Beyond Blue (commenced September 2016)
  7. Develop mental health training for new graduate paramedics (implemented)
  8. Introduce pre-employment psychological screening for new recruits (commenced early 2017)
  9. Review and expand leadership development programs to support staff mental health (review completed, implementation by 30 June 2017)
  10. Implement flexible work arrangements including points system for shift allocation (implemented)
  11. Expand VACU counselling services and 24-hour crisis support availability (expanded)
  12. Provide peer support programs and chaplaincy services (available)
Full text
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Source and disclaimer

This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.

Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.

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