Inquest into the Death of Martin Raymond Coffey

Contributing factors

• Overdose of prescribed medications (amitriptyline, diazepam, paroxetine, paracetamol, codeine) at high levels
• Impaired consciousness due to combined sedating effects of medications
• History of depression and self-harm
• Marital difficulties and family stress
• Substance abuse history and ongoing drug use
• Failure to respond to home detention monitoring requirements
• Medication access and control issues
• Absence of intensive psychiatric follow-up despite recent suicide attempt

Coroner's recommendations

1. Consideration should be given to improving the provision of relevant information (such as a prisoner's conduct while in prison and home detention suitability assessments) to home detention sponsors so they can make properly informed decisions about sponsoring home detention, while maintaining appropriate confidentiality protections
2. Review of medication control procedures for home detention clients with histories of substance abuse and recent suicide attempts, particularly regarding high-dose controlled medications and the responsibility for medication storage and administration
3. Review of the interplay between home detention monitoring systems (telephone alerts, site verification) and the effects of prescribed sedating medications that may legitimately prevent response to monitoring calls
4. Consideration of enhanced psychiatric and psychological support protocols for home detention clients discharged after suicide attempts, beyond the standard psychiatric clearance for discharge