Finding into death of Michael Garry Suckling

Contributing factors

• Rapid weight gain (117kg over 3 years)
• Morbid obesity with BMI 54.5
• Undiagnosed or inadequately managed obstructive sleep apnoea
• Hypertension
• Medications contributing to weight gain (methadone, mirtazapine, amitriptyline, sodium valproate)
• Medications affecting cardiac electrical function (methadone, amitriptyline)
• Cardiac enlargement from obesity
• Possible myocardial scarring
• Increased blood volume from obesity
• Poor mental health and depression affecting engagement with health interventions
• Chronic pain limiting mobility
• Fragmented healthcare delivery across multiple prisons

Coroner's recommendations

1. Update Justice Health Quality Framework 2023 to measure equivalency of care for Aboriginal prisoners against Aboriginal Community Controlled Health Organisation standards, and reflecting health outcomes in addition to accessibility
2. Update Justice Health Quality Framework 2023 to reflect Equally Well Consensus Statement recommendations
3. Ensure comprehensive medical and psychiatric reception assessments apply to all newly-received prisoners, with notice to prison manager, health provider, and Forensicare for prisoners received via non-reception prisons
4. Justice Health work with all health providers to ensure access to therapeutic counselling/psychologists at all Victorian prisons without tethering to offender behaviour programs
5. Justice Health prepare guideline requiring weight measurements via scales with documentation of method, and distinguishing standing scales from self-reported measurements
6. Justice Health and all providers develop policy for multidisciplinary case management of complex cases, including obesity criteria (BMI >35 or high-risk girth measurement with comorbidity)
7. Justice Health mandate screening for cardiometabolic risks in prisoners prescribed psychotropic medications, with reassessment for significant or rapid weight gain
8. Justice Health modify J-Care system to include clinician details, improved non-attendance coding, and fields for height, weight, waist circumference, and BMI
9. Justice Health explore feasibility of cardiometabolic monitoring prompts and system integration between Gateway and J-Care
10. Justice Health ensure all Aboriginal passings in custody trigger Root Cause Analysis coordinated by primary health provider
11. Health providers proactively consult ACCHOs for in-reach service opportunities
12. Health providers contact ACCHO to provide in-reach services when Aboriginal Health Worker positions vacant for >3 months
13. Justice Health and providers work with Yilam and Aboriginal community to increase Aboriginal Health Worker pool with minimum one full-time equivalent at every Victorian prison
14. Health providers explore opportunities to provide traditional healers' services for Aboriginal and Torres Strait Islander prisoners
15. Health providers develop policy for multidisciplinary case management with clear referral criteria for complex cases
16. Health providers appoint Senior Clinician to organise regular multidisciplinary meetings for complex cases including mental health and medication reviews
17. Health providers develop outcome-focused KPI measurements rather than quantitative measurements
18. Health providers review current KPIs for unintended consequences affecting service quality
19. GEO educate correctional staff about appropriate referral pathways for mental health and medical issues
20. GEO continue addressing weight gain issues with permanent Obesity Management Work Group at Ravenhall
21. GEO undertake feasibility study on obesity, comorbidities, and complex case management interventions to determine appropriate referral criteria