Coronial
VICother

Finding into death of Micky Craig Revera

Deceased

Micky Craig Revera

Demographics

40y, male

Date of death

2019-02-18

Finding date

2022-06-03

Cause of death

Unascertained; opioid withdrawal-related seizure or cardiac arrhythmia could not be excluded

AI-generated summary

Micky Craig Revera, a 40-year-old man with chronic heroin addiction, died in Melbourne Assessment Prison on 18 February 2019 from unascertained causes. He was arrested on 12 February after erratic driving, underwent police restraint with baton strikes and OC spray, then was sedated with ketamine and midazolam at Dandenong Hospital. Despite concerns about his altered consciousness, he was cleared for police custody. In prison, he presented with opioid withdrawal symptoms, minimal oral intake, drowsiness, and difficulty mobilising. Despite appropriate medical and psychiatric assessments over four days, no clear diagnosis emerged. He was found unresponsive in his cell. The autopsy excluded head injury, sepsis, and opioid toxicity but could not definitively exclude withdrawal-related seizure or cardiac arrhythmia. Clinical lessons: diagnostic uncertainty in custody settings warrants lower thresholds for hospital readmission; comprehensive documentation of injuries and mechanism is essential; mobility assessment should accompany trauma evaluation; observations of at-risk prisoners must be thorough and properly documented.

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

Specialties

emergency medicineforensic medicinepsychiatrygeneral practice

Error types

diagnosticcommunicationdelay

Drugs involved

heroinamphetaminemethamphetamineketaminemidazolamdiazepamcodeinemetoclopramideparacetamolibuprofenpantoprazolehyoscine butylbromideoleoresin capsicum

Clinical conditions

opioid withdrawalacute intoxication from ketamine and midazolamaltered level of consciousnesstraumatic injuries from police restraintknee lacerationextensive bruising of right upper and lower limbshepatic steatosis and fibrosischronic hepatitisintravenous drug use complications

Procedures

cardiopulmonary resuscitationwound suturingautopsy

Contributing factors

  • Police restraint with baton strikes and OC spray during arrest
  • Sedation with ketamine and midazolam in pre-hospital setting
  • Unclear mechanism of apparent facial injury
  • Opioid withdrawal in custody
  • Minimal oral intake and poor hydration in prison
  • Altered consciousness and drowsiness persisting over four days
  • Difficulty mobilising due to extensive bruising
  • Diagnostic uncertainty regarding underlying cause of presentation
  • Three-minute delay in commencing CPR after discovery
  • Inadequate prisoner observation check at 9.18am on day of death

Coroner's recommendations

  1. General Manager of MAP to communicate to staff undertaking prisoner reception the importance of accessing information relevant to a prisoner in line with Local Operating Procedure (LOP) 1.11-1 when a prisoner presents with significant physical injuries or is unable to participate in reception due to impairment
  2. General Manager of MAP to communicate to all staff the requirement to record all allegations of assault by persons other than staff on PIMS within 24 hours in line with Commissioner's Requirement (CR) 1.3.1
  3. General Manager of MAP to communicate to all staff the requirement to report all allegations of assault to Victoria Police within two hours or as soon as possible in line with Deputy Commissioner's Instruction (DCI) 1.19
  4. General Manager of MAP to communicate to all staff the requirement to conduct prisoner observations in line with LOP 1.02-4
  5. General Manager of MAP to conduct periodic audits of prisoner observations to ensure compliance with policy, with audit frequency and expected outcomes incorporated into relevant LOP
  6. Correct Care Australasia to review policy CS12.1 Drug and Alcohol Assessment to ensure it meets contemporary practice guidelines
  7. Correct Care Australasia to ensure all staff are fully aware of policy CS12.1 and receive appropriate training in assessing prisoners for substance withdrawal symptoms and prescribing medications to manage withdrawal
  8. Correct Care Australasia to consider mobility and functionality assessments for prisoners who have experienced significant body trauma and update relevant policies, procedures and staff training to ensure mobility and functionality form part of prisoner assessment
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