Finding into death of Hilton Davis
Deceased
Hilton Davis
Demographics
50y, male
Date of death
2018-04-23
Finding date
2020-11-16
Cause of death
mixed drug (oxycodone and methadone) and ethanol toxicity
AI-generated summary
A 50-year-old Torres Strait Islander man died from mixed drug (oxycodone and methadone) and ethanol toxicity in the context of family violence and suicidality. He had a 7-year history of suicide attempts and mental health issues following a 2012 motor vehicle accident (deliberate self-harm) resulting in chronic pain managed with opioids. On 22 April 2018, following a violent altercation with his wife, police attended but did not document his well-established history of suicidal ideation in their risk assessment form (VP Form L17), despite this information being available in previous police records. Police allowed him to remain at home intoxicated. He died by apparent intentional overdose the following morning. The coroner found no fault with medical services but identified that police failed to accurately reflect suicide risk in their assessment, which may have prompted mental health referral. Subsequent police reforms now require comprehensive mental health and suicide risk assessment in family violence incidents.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- family violence perpetration and exposure
- suicidal ideation and history of suicide attempts
- chronic pain following 2012 motor vehicle accident
- opioid and benzodiazepine use
- alcohol use disorder
- failure to document suicide risk in police risk assessment
- inadequate mental health assessment by responding police
- intoxication at time of police attendance
Coroner's recommendations
- Victoria Police already implemented reforms to VP Form L17 requiring 39 structured questions, with 14 scored items, to be asked in every family violence incident, based on coronial findings and research on family violence predictors
- Victoria Police should ensure Family Violence Liaison Officers provide quality assurance and monitoring of VP Form L17 completion rates and compliance
- Victoria Police Family Violence Training Officers should address deficiencies in L17 reports including poor narrative regarding risk factors
- Victoria Police should continue implementation of mandatory online mental health training and the 'Responding to Mental Health Incidents' training for all frontline police
- Victoria Police should ensure information sharing of VP Form L17s with support agencies including Orange Door safety hubs
- Police should employ strategies to better identify perpetrators with mental health issues, including referrals to CAT Teams and further enquiries about mental health
- Police responses to family violence involving Aboriginal and Torres Strait Islander persons should employ culturally sensitive frameworks acknowledging historic disadvantage and discrimination
Full text
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