Finding into death of Scott Alan Murdoch

Contributing factors

• Medication hoarding despite supervision protocols
• Prescribing of tricyclic antidepressant with high overdose lethality in high-risk patient
• Inadequate documentation of overdose risk considerations prior to 2017 amitriptyline prescribing
• Medication administration through cell door trap creating diversion risk
• Insufficient exploration of alternative medication options with lower fatality profiles
• Lack of documented review of medication precautions during COVID-19 pandemic affecting staffing
• Inability of mouth checks and cell searches to eliminate hoarding risk entirely
• Chronic suicidal ideation and documented history of previous overdose attempts on amitriptyline

Coroner's recommendations

1. Corrections Victoria, in collaboration with Justice Health and Health Service Providers, identify and implement alternative options for administering supervised medication to enable custodial staff to more closely supervise consumption and inspect medication has been consumed, with specific consideration given to safe and secure options avoiding cell trap administration
2. Prescribers consider alternative medications less likely to be lethal in overdose for patients at high risk of overdose or with past overdose history, only prescribing tricyclic antidepressants where other options have been excluded with clear rationale documented
3. Interagency discussion between Forensicare, Corrections Victoria and Correct Care Australasia regarding reviewing medication supervision guidelines to decrease medication diversion risk, including adaptations for COVID-19 precautions, reviewing medication setting and observation processes for high-risk patients