Finding into death of David Patrick Hardisty

32y · Male·Mixed drug toxicity

A 32-year-old man with bipolar disorder and substance abuse history died from mixed drug toxicity (oxycodone 0.7 mg/L, tramadol, benzodiazepines, cannabis and amphetamines). Emergency services attended after his partner reported he had taken excessive medication following an argument. Paramedics assessed him as having capacity, appearing alert and denying overdose, and decided not to transport him to hospital. Key clinical lessons: the deceased displayed signs concerning for self-harm (slurred speech, unsteady gait, recent farewell text messages, history of depression off medications) that may not have been adequately communicated to paramedics or acted upon. Critical information gaps included unknown history of mental illness, empty medication blister packs, and the significance of goodbye messages. The coroner found no policy breaches but noted paramedics could have directly asked about self-harm using their mental state assessment guidelines, particularly when the patient was not fully engaging in conversation.