Natasha Calleja, 32 years old, died from combined drug toxicity (mainly heroin) while an involuntary inpatient at Swanston Centre psychiatric unit after her de facto partner supplied heroin during an unsupervised visit. She had been admitted following erratic driving behaviour and was stabilised on Category 2 observations. Critical failings included: lack of visitor screening despite known substance use risks, unsupervised access to private spaces with a visitor of known drug involvement, and failure to educate patients and visitors about overdose risks after abstinence. Heroin's interaction with her prescribed psychotropic medications (diazepam, amitriptyline) increased toxicity. The coroner did not find compulsory searches warranted but recommended enhanced visitor protocols including pocket searches by consent, prominent overdose risk warnings on visitor sheets, and multilingual information for non-English speaking families.
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polypharmacy with CNS depressants (diazepam, amitriptyline, antipsychotics)
period of abstinence increasing vulnerability to overdose
unsupervised visitor access in private room
inadequate visitor screening procedures
lack of education about overdose risks
low clinical suspicion despite substance use history
Coroner's recommendations
Amend Barwon Health's Searching of a Consumer and their Property/Belongings procedure to include the words: 'Staff should not touch the contents but the visitor should be requested to remove the contents of their bags and their pockets for inspection'
Amend the Swanston Centre Visitor Information Sheets to include the warning in prominent typeface: 'HOSPITAL PATIENTS HAVE AN INCREASED RISK OF OVERDOSE FROM ILLICIT SUBSTANCES'
Barwon Health take steps to ensure that the Swanston Centre Visitor Information Sheets and warning signs are available in other languages or otherwise capable of being understood by persons with non-English speaking backgrounds or poor English literacy
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