Finding into death of Heather Ida Simone Calgaret

Contributing factors

• Direct initiation to long-acting injectable buprenorphine without stabilisation on sublingual buprenorphine
• Opioid naïvety or very low opioid tolerance
• WHO Class III obesity with likely obstructive sleep apnoea
• Quetiapine use (CNS depressant interactions)
• Type 2 diabetes with poor control
• Cardiac hypertrophy and coronary artery disease
• Lack of post-dose monitoring
• Inadequate assessment of collateral opioid history
• Depression and trauma following child removal from care
• Insufficient mental health support including lack of psychology services
• Weight gain and metabolic syndrome not managed holistically

Coroner's recommendations

1. Justice Health investigate and establish appropriate measures to ensure women who give birth in custody or proximate to remand are adequately screened and monitored for post-natal mental health symptoms with automatic referral to Forensicare
2. Justice Health investigate and establish appropriate measures to support women refused access to Living with Mum Program following removal of newborn, including automatic referral to Forensicare
3. Justice Health modify JCare to allow weights and girths to be entered as specific entries with alerts for significant weight increases
4. Justice Health engage with government and stakeholders to improve access to psychological services for women at DPFC
5. Justice Health collaborate with health service providers to ensure 2023 Quality Framework compliance including multidisciplinary reviews for complex cases, regular pharmacological reviews, baseline testing before psychotropic medication, proper documentation of chronic health care plans, and identification of ongoing health deterioration
6. Justice Health continue exploring in-reach models for Aboriginal Community Controlled Health Organisations and engage with ACCOs to co-design auditing tools for oversight
7. Endorse Ombudsman's Report recommendations regarding Aboriginal Community-Controlled Organisations involvement, Justice Health capacity-building, contract variations, audit frameworks, and Aboriginal health professional development
8. DJCS investigate ways to ensure parole application process is timely, consistent with Commissioner's Requirement 2.6.1, supports Aboriginal self-determination, complies with Recommendation 119 RCIADIC, and respects Charter equality rights particularly for women's access to treatment programs
9. DJCS explore ways to ensure Aboriginal and Torres Strait Islander parole applicants are assigned an Aboriginal Case Manager
10. DJCS in consultation with Yilam explore improved support for Aboriginal parole applicants
11. DJCS in consultation with Yilam raise through Aboriginal Justice Forum concerns about parole process potentially undermining sentence integrity and reducing supervision periods
12. Endorse Justice Review recommendations that Corrections and Justice Services update Practice Guidelines regarding program availability information, clarification of community program options, and documentation of parole officer engagement
13. Justice Health ensure all staff including agency staff are adequately trained in prison processes including Code Black response and emergency equipment use prior to employment and receive regular refresher training
14. Justice Health audit all health service providers to ensure emergency medical equipment is regularly checked and maintained
15. Justice Health work with health service providers to ensure all staff and officers receive training in drug overdoses and naloxone administration
16. Justice Health work with health service providers to provide clear practical training to all staff on basic life support, care escalation and emergency management in prison environment with practical resources