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Finding into death of PJQ PJQ

Deceased

PJQ

Demographics

18y, female

Coroner

Coroner David Ryan

Date of death

2022-02-25

Finding date

2024-05-14

Cause of death

Multidrug toxicity (GHB, amphetamines, benzodiazepines)

AI-generated summary

PJQ was an 18-year-old in state care who died from multidrug toxicity (GHB, amphetamines, benzodiazepines) after being discharged early from a residential rehabilitation program. She had complex trauma history, PTSD, and polysubstance abuse. Following early discharge from the Gippsland Youth Residential Rehabilitation Program on 15 February 2022, her care team struggled to secure appropriate short-term bridging accommodation. Instead of remaining in planned rehabilitation in Traralgon until her rental property became available on 11 March 2022, PJQ stayed in unsafe environments and resumed substance use. The coroner found that greater flexibility in considering short-term accommodation options (such as Airbnb or motel) during this critical transition period could have provided safer bridging accommodation and potentially prevented her death. The case highlights systemic gaps in post-care housing availability and planning for vulnerable care leavers.

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

Specialties

paediatricspsychiatryaddiction medicineemergency medicine

Error types

systemdelay

Drugs involved

GHBamphetamineetizolamflualprazolamdiazepambenzodiazepines

Clinical conditions

post-traumatic stress disorderpolysubstance abusesubstance use disordertrauma historymultidrug toxicity

Contributing factors

  • Early discharge from residential rehabilitation program without adequate contingency planning
  • Lack of secure short-term bridging accommodation options after early program discharge
  • Vulnerable transition period following state care exit at age 18
  • History of trauma, PTSD, and polysubstance abuse
  • Reduced tolerance to illicit drugs following period of abstinence
  • Unsafe accommodation environment at Dandenong house
  • Inability to remain in Traralgon near planned tenancy and employment
  • System rigidity regarding accommodation options (motel and Airbnb rejected)

Coroner's recommendations

  1. That the Department of Families, Fairness and Housing incorporate a guideline in its risk assessment framework for considering the suitability of short-term accommodation options for children whose Care by Secretary Order is shortly due to expire, which: (a) promotes flexibility; and (b) recognises the importance of safe and stable accommodation during the critical transition period.
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