Finding into death of Narisha Faye Cash

Contributing factors

• High level of alcohol consumption combined with benzodiazepines and other CNS depressants
• Mental health crisis and suicidal intent
• Law enforcement-led rather than health-led emergency response
• Delayed police attendance (1 hour 41 minutes)
• No ambulance dispatched until patient found unresponsive
• Default routing of mental health crisis call to police rather than ambulance
• Failure to recognize situation as medical emergency requiring ambulance
• Inadequate handover between police supervisors
• Lack of clinical assessment in emergency services response
• Supervisor's failure to escalate for additional resources

Coroner's recommendations

1. Triple Zero Victoria and Victoria Police review the Police Structured Call-Taking process across all event types in respect of questions asking whether alcohol and/or drugs have been consumed, and consider if two separate and specific questions should be asked, in lieu of a single combined question, to encourage accuracy of information provided by the caller.
2. Triple Zero Victoria and Victoria Police review its policies, procedures and training to ensure there is clarity for Police Call-Takers in respect of when event types '597-P-EME-THR ATTEMPT OR THREAT SUICIDE' and '594-PSYCHIATRIC PATIENT' should be selected, either alone or in combination, especially in circumstances where a person with a diagnosed psychiatric condition is experiencing a mental health crisis and threatening suicide/self-harm.
3. Triple Zero Victoria and Victoria Police review Police event types and associated event types, specifically in respect of overdoses in the context of self-harm/suicide, to ensure Triple Zero Victoria Ambulance call taking and dispatch functions are notified/activated.
4. Triple Zero Victoria and Victoria Police review their policies, procedures and training in respect of the role and responsibilities of Police Dispatchers, to clarify whether it is the role of the Police Dispatcher to consider whether event type/associated event type, priority, and ESOs notified are appropriate.
5. Triple Zero Victoria and Victoria Police consider amending the CAD system to introduce flagging/alerting of 'threat of suicide' events that have been dispatch assigned and allocated to a unit, or to a supervising 251, and for which there has been no update or action for a set period of time.
6. Victoria Police consult with Ambulance Victoria to clarify the policy/procedure documents that exist between their organisations in respect of Victoria Police requesting AV assistance (in circumstances where Victoria Police do/do not specifically identify safety concerns), and communicate these policies throughout both organisations.
7. The Department of Health implement Recommendation 10 in its entirety.
8. The Department of Health, Ambulance Victoria, Victoria Police, Triple Zero Victoria and the Department of Justice and Community Safety, in implementing Recommendation 10 arising from the Royal Commission into Victoria's Mental Health System, review the circumstances of Nish's passing as detailed within the Finding into death after Inquest.
9. The Department of Justice and Community Safety, Victoria Police, the Department of Health and Triple Zero Victoria separately publicly report on the specific actions taken to progress implementation of Recommendation 10 of the Royal Commission into Victoria's Mental Health System, including revised implementation dates, and the reasons for any delays.
10. The Department of Justice and Community Safety, Victoria Police, the Department of Health and Triple Zero Victoria separately report on their websites the activities undertaken and the outcomes achieved as a result of funding received in the 2021–22 and 2023–24 Budgets to progress Recommendation 10 of the Royal Commission into Victoria's Mental Health System, and any future funding received.