Finding into death of LX

31y · Male·mixed drug toxicity (methadone, diazepam, pregabalin, promethazine, pizotifen)

A 31-year-old man subject to a post-sentence supervision order died from mixed drug toxicity (methadone, diazepam, pregabalin, promethazine, pizotifen) at a residential facility. He was a vulnerable person with acquired brain injury, ADHD, PTSD and depression. The coroner found his death was preventable due to multiple system failures: failure to implement promised intensive drug rehabilitation; inadequate case management and risk assessment; failure to centrally control Schedule 8 medication (methadone tablets), which were extensively stockpiled by another resident and accessible to the deceased; failure to escalate serious concerns raised by treatment providers about his deteriorating mental state; failure to invoke urinalysis testing despite observable drug intoxication; and poor family visitation arrangements exacerbating isolation. The facility operated with a lenient medication management approach inconsistent with other security restrictions. Corrections Victoria made inadequate responses to maternal concerns and failed to fulfil commitments made to the supervising judge.