Finding into death of Gary Hietanen
Deceased
Gary Hietanen
Demographics
45y, male
Coroner
Coroner Darren Bracken
Date of death
2017-08-08
Finding date
2020-12-23
Cause of death
Combined drug toxicity (methadone, amitriptyline, gabapentin, paracetamol)
AI-generated summary
A 45-year-old male prisoner died in custody from combined drug toxicity after ingesting methadone, amitriptyline, gabapentin and paracetamol. He had a documented history of hoarding and misusing prescribed medications to achieve a euphoric effect. He was admitted to hospital on 21 July 2017 after deliberately overdosing on gabapentin/pregabalin, then discharged to prison six days later. Critical information about his drug-hoarding behaviour was not communicated from the hospital to prison management. The prison's 'trap-to-trap' medication dispensing method (medications passed through cell door traps) provided inadequate supervision for identifying and preventing drug accumulation. Evening lockdown procedures did not reliably establish that prisoners were conscious and responsive. The coroner identified systemic failures in health information sharing between hospital and correctional services, inadequate medication dispensing protocols, and insufficient prison staff protocols for assessing prisoner wellbeing, rather than any single medical error.
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Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- History of hoarding and misusing prescribed medications
- Failure to communicate hospital information about drug-hoarding behaviour to prison management
- Inadequate 'trap-to-trap' medication dispensing supervision
- Prison staff not aware of 21 July 2017 'code black' event
- Inadequate lockdown procedures failing to establish positive signs of life
- Reduced security classification allowing transfer despite recent overdose
- Drug-dependent prisoner with polypharmacy and complex medical history
Coroner's recommendations
- G4S commission independent research into safest and efficient way to dispense medication in Borrowdale Unit, incorporating consideration of: (a) trap-to-trap dispensation and alternatives including opening cell doors; (b) dispensing medication from a central point; (c) whether different methods should be used for different prisoners based on medication type and drug use history
- G4S reiterate to lockdown staff that a verbal spoken response must be obtained from every prisoner; if response not forthcoming from trap enquiry, cell door must be opened and verbal response obtained directly
Full text
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