Finding into death of LX

Contributing factors

• failure to centrally control Schedule 8 medications, particularly methadone tablets
• stockpiling of methadone tablets by another resident
• inadequate case management and risk assessment
• failure to escalate concerns from treatment providers about deteriorating mental state
• failure to invoke urinalysis testing despite observable drug intoxication
• failure to provide promised intensive drug and alcohol rehabilitation
• isolation and boredom in residential facility
• lack of mental health support
• lack of structured activities and programming
• poor family contact and visitation arrangements
• failure to maintain lawful instruction for central medication storage
• inadequate supervision and monitoring during COVID-19 quarantine
• lack of staff training in acquired brain injury and ADHD management

Coroner's recommendations

1. Institute a policy requiring residents to disclose Schedule 8 medications (including methadone) and all Schedule 8 medications to be centrally controlled and administered at Corella Place, subject to limited exceptions reviewed by MDAT
2. Serious consideration be given to centrally controlling and administering pregabalin given its potential for abuse, danger in combination with other medications, and prevalence in trading
3. Review medication management policies at Corella Place with view to adopting a system of dispensing medication that replicates systems in other correctional facilities (prisons)
4. Make improvements to Corella Place to allow appropriate family visits at the facility; in interim, allow residents to access Rivergum facilities for family visits, and inform all staff and residents that family visits are permitted at Corella Place in accordance with Local Operating Procedures
5. Specialist Case Managers and Specialist Case Workers receive mandatory, regular and specific training in acquired brain injury, intellectual disability and ADHD management
6. Supervision meetings between Specialist Case Managers and residents be held in person or by video, not by telephone only
7. Department recommit to and emphasise importance of Principal Practitioners engaging in minimum fortnightly supervision with Specialist Case Managers; ensure all handovers are properly documented
8. Take steps to improve general awareness of signs and symptoms of drug overdose/misuse, provide information to residents on how to respond
9. Provide regular and specific training to staff at Corella Place on signs and symptoms of drug misuse and overdose and emergency response
10. Specialist Case Managers and Specialist Case Workers receive regular, updated training on Charter of Human Rights and Responsibilities Act obligations, specific to Corella Place with practical scenarios
11. Request Victorian Equal Opportunity and Human Rights Commission review its training on Charter implementation in unique environment of Corella Place
12. Update Corella Place guidelines to clarify whether and in what circumstances residents in quarantine may be required to undertake urinalysis
13. Make improvements to Corella Place 228 so residents have access to activities and facilities commensurate with Corella Place Main
14. Ensure all correspondence and concerns from family members of Corella Place residents is properly logged and responded to in timely and appropriate manner
15. Provide clearer articulation within supervision framework of what is required by each individual resident to achieve transition to community
16. Undertake review of current rehabilitation services offered at Corella Place with view to providing suite of services tailored to specific needs of Corella Place cohort
17. Therapeutic Goods Administration give serious consideration to re-scheduling pregabalin as Schedule 8 medication given its potential for abuse and danger in combination with other medications
18. Attorney-General review provisions of Coroners Act relating to definition of 'in custody or care' to expand definition and ensure consistency of coronial oversight to include deaths of people required to live in residential facilities such as Corella Place