Finding into death of Shae Harry Paszkiewicz

Contributing factors

• Recent release from prison (6 December 2017, overdose 7 December 2017)
• Opioid dependence with history of heroin use
• Inadequate opioid substitution therapy (OST) in prison and post-release
• Poor continuity of care between prison and community health services
• Absence of naloxone provision at prison discharge
• Absence of needle and syringe program in prison
• Lack of integrated discharge planning
• High-risk period immediately following release from custody
• Benzodiazepine and other drug use (detected in drug testing on day of overdose)
• Limited engagement with community drug treatment services post-release

Coroner's recommendations

1. The Victorian Department of Health should adopt formal responsibility for improving health outcomes and reducing drug-related mortality among people released from prison
2. The Victorian Department of Health should convene a formal advisory group to guide identification, prioritisation, implementation and evaluation of policies and programs to reduce drug-related mortality among people released from prison, including representatives from government departments, non-government organisations, and academic experts
3. The Victorian Department of Health should collaborate with the Department of Justice and Community Safety to link information on all people entering Victoria's prisons with their health outcomes including death within 10 years of release, with annual public reporting and access for researchers
4. The Victorian Department of Justice and Community Safety should immediately introduce a take-home naloxone program (including training in overdose awareness and naloxone administration) for all people in Victorian prisons with a history of opioid use preparing to exit prison