Inquest into the Death of Paul John Long

Contributing factors

• Self-medication with excessive quetiapine
• Failure of hostel staff to secure month-supply of medication dispensed 1 November 2002
• Lack of communication between Avro Clinic and St Bartholomew's hostel regarding medication safekeeping policy
• Absence of clear protocols for managing residents refusing medical intervention
• Inadequate resourcing of hostel to manage clients with mental health issues
• Masking of deteriorating mental state by deceased during psychiatric review
• Absence of follow-up contact with hostel after large medication dispensing
• Refusal of ambulance transport and medical assistance on 3 November 2002
• Informal observation by untrained support workers without documented protocols
• Chronic schizoaffective disorder and alcohol abuse

Coroner's recommendations

1. Management at St Bartholomew's endeavour to provide a forum in which policies with respect to medication be discussed with staff to explain the relevant sections of the St Bartholomew's Operations and Procedure Manual and the realities of the hostel's position.
2. The Avro Clinic pharmacy in conjunction with the mental health teams consider the benefit of checks prior to the dispensing of potentially harmful amounts of medication.
3. St John's Ambulance ensure its officers consider the possibilities of requesting the assistance of police in potentially life threatening situations involving intoxication.
4. The Western Australian Police Service, Department of Health and Department of Community Development ensure there are appropriate facilities to care for intoxicated persons in need of protection from themselves which need to be adequately provided for and funded if the Protective Custody Act 2000 is to achieve in practice the objectives set out in theory.