An Inquest Into the Death of Paul Fennessy

CORONERS COURT OF THE AUSTRALIAN CAPITAL TERRITORY

Case Title:	AN INQUEST INTO THE DEATH OF PAUL FENNESSY
Citation:	[2016] ACTCD 4
Hearing Date(s):	30 November, 1 and 2 December 2015
Date of Findings:	16 December 2016
Before:	Coroner Hunter
Legislation Cited:	Coroners Act 1997 (ACT) Mental Health (Treatment and Care) Act 1994 (ACT)
Cases Cited:	Onuma v The Coroners Court of South Australia [2001] SASC 218 Briginshaw v Briginshaw (1938) 60 CLR 336 WRB Transport v Chivell [1998] SASC 7002 R v Doogan [2005] ACTSC 74 Conway v Jerram [2011] NSWCA 319 Re State Coroner; ex parte Minister for Health [2009] WASCA 165 Matthews v Hunter [1993] 2 NZLR 683
Appearances and Representation:	Ms Amanda Tonkin of Counsel as Counsel Assisting the Coroner. Mr Dan Crowe of Counsel for the Australian Capital Territory, instructed by the ACT Government Solicitor. Mr James Sabharwal of Counsel for Ms Finlay. Mr Robert Clynes of Counsel for Drs Robinson and Lawrence, instructed by Ms Lara Mynott of Moray and Agnew Mr Wayne Sharwood of Counsel for Mr Bailey, instructed by Mr Andrew Freer of KJB Law. Mr Mark Barrow of Ken Cush and Associates for Dr Shannon Craft.
File Number(s):	CD 11 of 2010

CORONERS ACT 1997
IN THE CORONERS COURT
AT CANBERRA IN THE
AUSTRALIAN CAPITAL TERRITORY
FINDINGS
An INQUEST having been held by me, MARGARET ANNE HUNTER, a Coroner for the Territory, including a hearing conducted at the Coroner’s Court at Canberra in the Territory, into the death of:
PAUL FENNESSY
I find that Paul Fennessy born in September 1988, died outside and adjacent to the northern perimeter fence of 2 Zeal Place, Holder, in the Australian Capital Territory at 23:15 hours on 6 January 2010.
I further find that the cause of his death was the combined effect of a cocktail of drugs taken by him, which caused central nervous system depression and respiratory depression leading to positional asphyxia.
I further find that a matter of public safety arises in relation to Mr Fennessy’s death, as further detailed in my reasons.
I make the following recommendations:
1. That the ACT Government implement DAPIS and adapt the real time monitoring system know as DORA.
2. That all medical files, including mental health records, in relation to a patient being treated at a Canberra Public Hospital be made available to all clinical staff at the hospital when required.
DATED this 16^th day of December, 2016.

M. A. HUNTER OAM
CORONER

CORONER HUNTER:

I, Coroner Margaret Hunter, find that Paul Fennessy born in September 1988, died outside and adjacent to the northern perimeter fence of 2 Zeal Place Holder in the Australian Capital Territory at 23:15 hours on 6 January 2010.
I further find that the cause of his death was the combined effect of a cocktail of drugs taken by him, which caused central nervous system depression and respiratory depression leading to positional asphyxia.

Jurisdiction

A coroner must hold an inquest into the manner and cause of death of a person who “dies violently, or unnaturally, in unknown circumstances”: see section 13 (1)(a) of the Coroners Act1997 (ACT) (“the Act”).
Paul Fennessy comes within my jurisdiction given that he died unnaturally on 6 January 2010.

Circumstances

Mr Fennessy came to the attention of health professionals after an incident where on 14 December 2007 he was picked up for what was deemed to be bizarre behaviour and which ultimately was diagnosed as drug induced psychosis. Between 2007 and 2010 when he died, Mr Fennessy had come to the attention of medical professionals from The Canberra Hospital, Calvary Hospital, the ACT Mental Health Crisis Assessment Team, and his general practitioner, as well as a number of other general practitioners.
The focus of the inquest is primarily on the last few days of Mr Fennessy’s life, however an examination of his drug addiction issues prior to that time is important and provided a causal nexus between his addiction problems, his failure to address that addiction, and ultimately his death.
I have had the benefit of a chart provided by Counsel Assisting which documents the date prescriptions were given to Mr Fennessy, the date it was dispensed, the drug, the quantity, the doctor who prescribed it, and the chemist who dispensed it. The document commences on 14 December 2007 and concludes on 1 January 2010. There are 18 different prescribers between these dates. There are at least 18 dispensing chemists used by Mr Fennessy in that period. Mr Fennessy is recorded as having had at least four overdoses in 2009 despite undergoing detoxification programs and management of his drug issues. It was clear from the evidence that his detoxification was marred by his inability to accept the rules in relation to bringing drugs into the detoxification and rehabilitation facilities, with the result that he was discharged without completing his rehabilitation. This behaviour explains his discharge from Karralika in December 2009. On that occasion he presented at the Calvary Hospital Emergency Department after overdosing on drugs.
In January 2010 Mr Fennessy presented on two occasions to the Emergency Department of The Canberra Hospital. The first presentation was because Mr Fennessy had ceased his medication and believed he was hallucinating and that he had had seizures. The second occasion arose as a result of a drug overdose where he was found unconscious and not breathing, whereupon he was resuscitated and admitted to The Canberra Hospital. It was later on, after he left the hospital, that he was found deceased.
An autopsy was performed by Dr Jain, Associate Professor of Pathology and Director of ACT Pathology. Dr Jain produced a report which was exhibited in the proceedings.[1] Dr Jain also sent samples for toxicology. The toxicology report which is attached to his autopsy report indicated at least seven different medications, a number of which were at levels in Mr Fennessy’s blood with toxic effect.
[1] Exhibit 5.
In my view the issues for determination are those as set out in Council Assisting’s submissions. They are:-
(a)The ease with which Mr Fennessy gained access to prescription drugs;
(b)Whether Mr Fennessy should have been discharged from the Canberra Hospital on 6^th January 2010; and
(c)Whether he was given a double dose of methadone hours before he died.

The Oral Evidence

Detective Sergeant Simon Jones Coady

Detective Sergeant Simon Coady gave evidence before me on 30 November 2015. Sgt Coady was the investigating officer tasked with investigating the death of Paul Fennessy. Sgt Coady provided a statement which was exhibited as Exhibit 8. As part of the investigation he collected various documentary materials which were tendered. I received documents such as identification of the deceased Paul Fennessy, a life extinct certificate, photographs of the deceased in situ, a map indicating the whereabouts of the deceased, together with an autopsy report under the hand of Dr Sanjiv Jain. I also received a letter from Ms Finlay, Mr Fennessy’s mother, to Coroner Dingwall, and a police recorded conversation with Ms Finlay. I also received a statement from Dr Robinson, three volumes of documents said to be the coronial brief exhibited as Exhibit 14, 15 and 17, a statement from Jillian Hughes and documents dated 7 September 2010 exhibited as Exhibit 18.
Sgt Coady gave a description of what he found at 2 Zeal Place that evening. He noted that the body was warm to the touch with rigor mortis and lividity consistent with its position. It is clear that Mr Fennessy’s head was down on his chest which is consistent with Dr Jain’s finding of positional asphyxia.[2]
[2] Transcript p12.
Sgt Coady examined a bag found with Mr Fennessy, which contained amongst other things what appeared to be a used syringe and needle. The plunger was retracted and there was blood visible. He also noted there was a blister pack of Gabapentin and opined that it was a chronic pain reliever. Sgt Coady explained that it was the ambulance officers who attended the death scene who told him what Gabapentin was. I note Gabapentin is an anticonvulsant and is used to treat neuropathic pain as well.[3]
[3] Transcript p12.
Sgt Coady examined the area where Mr Fennessy was found and opined that there was nothing found that was indicative of foul play. Dr Catherine Sansum attended and examined Mr Fennessy and noted lividity was consistent with the position of Mr Fennessy’s body. Dr Sansum also noted puncture marks consistent with intravenous drug administration. Dr Sansum opined that these marks could be consistent with intravenous drug administration. I note that some few hours before his death Mr Fennessy was admitted to the Emergency Department of The Canberra Hospital and had a cannula inserted. However I am satisfied that it is likely Mr Fennessy injected himself given the used syringe and the tourniquet found in the bag. Dr Sansum pronounced life extinct and signed the certificate of death.
Sgt Coady summarised the conversation Police had with Ms Finlay. Ms Finlay said that she last saw Paul at approximately 6.30 p.m. on 6 January 2010 at her home in Holder. She told police that her son appeared to be under the influence of drugs and she asked that he leave her house. She saw him leave walking down Cardew Crescent towards De Graff Street.
Ms Finlay gave Police information as to her family’s origins and when they arrived in Australia. Ms Finlay told Police that Paul left school in 2007 after completing his high school certificate however he was unable to hold any permanent employment since that time. Prior to his death Paul was also unable to secure and hold any residential address and he would stay with his mother or sister at various times.
Ms Finlay told Police that Paul had moved out of the family home and moved into the Karralika rehabilitation program, but he was discharged from the program on 23 December 2009 due to an allegation he was in possession of disallowed medications. Ms Finlay said this was not uncommon and Paul had been removed from other shelters and programs for similar reasons. Following his discharge from Karralika Paul moved into Samaritan House however again he was evicted for inappropriate behaviour. It was Ms Finlay’s view that Paul suffered from a long history of mental illness, including depression and anxiety, and was at the time a patient of ACT Mental Health and ACT detox and withdrawal services.
Ms Finlay advised that Paul had suffered serious burns when a gas bottle ignited. He was treated in Concord Burns Unit for burns suffered as a result of the explosion.
In relation to Paul’s use of alcohol and prescription drugs Ms Finlay described Paul as a heavy user of both alcohol and prescription drugs, and said that Paul would also use heroin and ice almost daily. Ms Finlay said that Paul commenced drug and alcohol use at the age of 14 and over the years had a history of self harm and had been admitted to The Canberra Hospital for that reason.
Ms Finlay also told Sgt Coady that Paul had been admitted to The Canberra Hospital on 6 January 2010 with a serious overdose and was treated with Narcan intravenously on two occasions. He was seen by medical staff and was to see the Mental Health team. She advised that Paul was to see the drug and alcohol counselling service the next day.
Ms Finlay advised Police that her son was a ‘doctor shopper’ and would attempt to acquire prescriptions from doctors in order to increase his medication. She was aware that he was on several medications for depression and sleeplessness. She was also aware that he had seen Dr John Robinson at the Phillip Medical Centre prior to his death, and that he had attended Isabella Plains Medical Centre. Ms Finlay opined that Paul had a significant drug and alcohol problem and had overdosed at least three times in the last three days prior to his death.
Sgt Coady gave evidence of a conversation he had with Susan Ellis, who found Mr Fennessy deceased on 6 January 2010. Ms Ellis stated that she advised the residents of 2 Zeal Place and she and the residents walked out to where Mr Fennessy was situated. Neither Ms Ellis nor the residents of 2 Zeal Place touched Mr Fennessy, but he did not respond to their calls.
Sgt Coady said that he walked from Zeal Place to Cardew Crescent and it was about 200 metres. Ms Finlay lives at Cardew Crescent and Sgt Coady said it took him two minutes to walk that distance. Sgt Coady offered Ms Finlay the opportunity to identify Paul’s body the next day however she insisted that she identify him that evening at the place where he died. Sgt Coady delivered Ms Finlay to that area where she identified Paul as being her son and signed the certificate identifying him.
Sgt Coady also indicated that he made contact with ACT Mental Health and requested the records in relation to Paul Fennessy. Several days later he received the Mental Health records, as well as the Drug & Alcohol records. Sgt Coady summarised the records as describing a significantly long history of treatment for drug and alcohol abuse, poly-substance abuse, depression and anxiety disorders related to that abuse. He also noted that Mr Fennessy had been hospitalised on numerous occasions for overdoses and that he had attended residential care over a period of time.
Sgt Coady advised that Mr Fennessy came to the attention of ACT Mental Health in December 2007 when he was reported missing by his mother. Mr Fennessy was later found by police wandering the streets exhibiting bizarre behaviour and appeared to be under the influence of drugs and alcohol.[4] Mr Fennessy admitted that he had used illicit drugs and it appeared that he displayed symptoms of psychosis and delirium as a result of that drug abuse. Mr Fennessy was admitted to the PSU for two nights and was discharged on 16 December 2007.
[4] Transcript p21.
Mr Fennessy next came to the attention of ACT Mental Health on 23 December 2008 when he presented with symptoms of a psychotic illness. This was considered to be due to his drug and alcohol abuse. On this occasion Ms Finlay refused his admission to her home and police took him to the Emergency Department of The Canberra Hospital where he was examined by mental health workers and later released after being deemed not to be at risk.[5]
[5] Transcript p21.
On 28 March 2008 Mr Fennessy was admitted to The Canberra Hospital after an overdose of Clonazepam. Mr Fennessy it is alleged told workers that he had increased his use of opiates and stated that “he would take anything”. It seems Mr Fennessy was oblivious to the risk associated with this drug and was not concerned about his welfare or the consequences of his drug use. Reports show that the medical opinion was that he displayed no sign of psychosis or intention of self harm, however based on his persistent drug use he would continue to be at risk of accidental drug overdose.
Over this period of time there were numerous meetings held by medical professionals, Mr Fennessy and also his mother in relation to options for Mr Fennessy rehabilitation. Mr Fennessy said at the time he was keen to undertake and willing to attend rehabilitation. Mr Fennessy moved into Odyssey House and commenced treatment there, but on 7 June 2008 he and his partner were brought to The Canberra Hospital after an apparent suicide attempt. It was revealed that he had injected Seroquel and Avanza and had taken heroin orally. Mr Fennessy was admitted for further assessment and was discharged on 11 June 2008. The medical staff identified that Mr Fennessy had no suicidal ideation however again commented that he presented as an ongoing risk of misadventure due to his drug use.[6]
[6] Transcript p22.
On 9 December 2008 Mr Fennessy was admitted to The Canberra Hospital for an overdose after being found unconscious outside a shopping centre in Phillip.[7] After being assessed it was considered that this was again an accidental overdose rather than self harm.
[7] Transcript p22.
On 9 December 2008 Mr Fennessy was again admitted to The Canberra Hospital for suspected overdose of opiates.[8] On 25 May 2009 Mr Fennessy overdosed on heroin and required Narcan treatment.[9] On that occasion he received no other treatment but was to be monitored by the Crisis Assessment Team (CATT). Mr Fennessy continued to be treated for poly-substance abuse during that time. Mr Fennessy presented to medical practitioners with sleeplessness and depression, however Sgt Coady said there was little evidence to support Mr Fennessy’s assertion.[10]
[8] Transcript p22.
[9] Transcript p22.
[10] Transcript p22.
In September 2009 Mr Fennessy was involved in a gas bottle explosion and sustained significant burns to his arms and face. On 1 November 2009 Mr Fennessy was admitted to the PSU after a poly-substance overdose. Mr Fennessy stated to medical staff that he was homeless, he was in chronic pain after suffering the burns, and his mother did not want him and he had overdosed. Mr Fennessy was discharged on 6 November 2009 after being cleared of any further risk of self harm.
On 23 December 2009 Mr Fennessy discharged himself from Karralika. It was considered that Mr Fennessy may have been burning his arms so that he could access prescription drugs. On 24 December Mr Fennessy was assessed by the CAT team who identified that Mr Fennessy suffered from the effects of poly-substance abuse but there was no co-morbid psychiatric symptoms identified.[11]
[11] Transcript p23.
On 2 January 2010 Mr Fennessy was evicted from Samaritan House for drug use. On 3 January Mr Fennessy attended The Canberra Hospital and requested to be admitted and return for rehabilitation. It was agreed by Hospital staff that Mr Fennessy could remain in the waiting room for the night so that accommodation could be sought the next day. Mr Fennessy remained in the waiting room until the next morning.[12]
[12] Transcript p27.
At approximately 2:30 pm on 6 January 2010 Mr Fennessy was bought in to The Canberra Hospital by ACT Ambulance Service following an overdose. Mr Fennessy had overdosed on methadone, benzodiazepine and heroin. The history was that Mr Fennessy was found by friends not breathing and was given CPR, and ambulance was called upon arrival the ambulance officers administered Narcan to Mr Fennessy. Mr Fennessy was stabilised and transported to The Canberra Hospital.
At 5:39 pm that afternoon Mr Fennessy was medically discharged and he was released. Mr Fennessy had told staff that he did not intend to overdose and had miscalculated the drugs he took.[13] Mr Fennessy told staff he wanted to go into rehabilitation and agreed to attend an appointment the next day with the Drug & Alcohol Service at 3 pm. Unfortunately Mr Fennessy died that evening.
[13] Transcript p23.
Ms Finlay told Sgt Coady that in her view the overdoses were attempts at suicide. The view of the CAT team was that they were not able to identify any suicidal ideation or psychiatric problem which required intervention.[14] The medical notes from the CAT team reveal that although Mr Fennessy had a lengthy history of drug overdoses and follow-up from the team, the results of those follow-ups were consistent in that they did not identify any suicidal ideation on each of the occasions where Mr Fennessy had overdosed.
[14] Transcript p23.
On the night of his death Ms Finlay described Mr Fennessy as being heavily under the influence of prescription drugs and it was for that reason that she asked him to leave that night. Mr Fennessy walked 200 metres away from his home into an area that was dark and when no persons would naturally be around or observe him and be in a position to render first aid. As a result Mr Fennessy died as a result of the overdose of prescription drugs and methadone.[15]
[15] Transcript p23.
Sgt Coady advised that Mr Fennessy had some involvement with police and there were four active alerts for Mr Fennessy on the system for drug use and self harm.[16]
[16] Transcript p24.

Sgt Coady gave evidence that on 5 January 2010 Mr Fennessy attended the Woden Priceline Pharmacy and presented a prescription for Rivotril. Rivotril is only prescribed by one doctor in the ACT. That doctor was alerted by the pharmacist and it was confirmed that Mr Fennessy had not been prescribed this medication and that the script was a forgery.[17]
[17] Transcript p24.
Sgt Coady gave evidence from the hospital records of 6 January 2010 that Mr Fennessy was brought in by ambulance after having 2 doses of 400 mg of Narcan and was admitted at 1 pm. At 1:15 pm Mr Fennessy requested to leave the hospital however staff negotiated with him so that he remained. He was reviewed and considered not medically fit to be released and at 2:35 pm he was advised he should remain in the Emergency Department for further observation.[18]
[18] Transcript p27.15.
Mr Fennessy remained in the Emergency Department and at 4:45 pm Mr Fennessy again requested to leave stating he felt trapped. Having been observed for some four hours and considering the context in which the medical staff operate and are bound,[19] it was Sgt Coady’s conclusion that medical staff had acted professionally particularly given the two requests to leave. That conclusion was based on the fact that Mr Fennessy was kept under observation until he was medically cleared for release.[20]
[19] Including the Medical Treatment (Health Directions) Act 2006 (ACT).
[20] Transcript p27.30.
Sgt Coady stated that in Ms Finlay’s letter she asked why had staff failed to question Mr Fennessy after he indicated that he intended to pick up a another dose of methadone. Ms Finlay questioned this because Mr Fennessy had already had his dose of methadone that day. Narcan reverses the effect of opioids including methadone so therefore it would not have been unreasonable for the deceased to have a further dose due to the first being reversed.[21] Sgt Coady commented on this fact and noted that the toxicology level of methadone in Mr Fennessy’s blood was within therapeutic levels.[22]
[21] Transcript p28.
[22] Transcript p28.
Ms Finlay was also concerned that ACT Mental Health did not acknowledge Mr Fennessy’s drug and alcohol issues as a mental health issue. Sgt Coady commented that staff must work within the Mental Health (Treatment and Care) Act 1994 (ACT) which in section 5(j) states that those who take drugs and alcohol should not be considered to be mentally ill.[23] [I note that for ease of reference instead of referring to the full title of the Act in these reasons I will refer to the Mental Health Act; this was also a shorthand description employed by a number of the witnesses who gave evidence before me.]
[23] Transcript p28.
In Ms Finlay’s letter she raised an issue in relation to her son’s continued overdoses however Sgt Coady commented that under the mental health legislation he was unable to be detained by staff.
Sgt Coady stated that after conducting a record of conversation with Ms Finlay and investigation of the matter he considered that Mr Fennessy’s use of alcohol and drugs and his extensive history of overdoses from poly-substance abuse were evident and it was likely that Mr Fennessy’s death was as a result of another poly-substance overdose.
Sgt Coady stated that there was no suspicious circumstance involved with the position Mr Fennessy was found in and that it was clear that the deceased was highly affected by drugs, rested in the position in which he was found and that the scenario was consistent with positional asphyxia.[24]
[24] Transcript p29.
Sgt Coady was cross examined by Mr Sabharwal and advised that the information in relation to the appointment on 7 January 2010 was from The Canberra Hospital and Mental Health records and that he took the records at face value.[25] When asked about the property taken from Mr Fennessy after his death, Sgt Coady said he could not recall any paper with an appointment written on it.[26] Sgt Coady indicated that there was no recording of that piece of paper and therefore he could rule out finding it because he would had recorded it. I clarified that position by asking him if the piece of paper had been in his belongings would he have recorded it and he agreed he would have.[27]
[25] Transcript p31.
[26] Transcript p31.
[27] Transcript p32.
In relation to questions about whether he recalled a letter from Ms Finlay asking the Coroner about the vomit that was found on Mr Fennessy at the time of his death, Sgt Coady indicated that he did not recall that letter.
Sgt Coady identified the exercise book he found on Mr Fennessy on the night of 6 January 2010. Sgt Coady recorded the page with writing on it and gave back the book to Ms Finlay.
Sgt Coady was asked about the vomit found on Mr Fennessy and he indicated that he did not have it examined as that was the purview of the pathologist. He advised that he did not cause any examination of that material being the vomit.[28]
[28] Transcript p34.
Sgt Coady advised that he was aware that Ms Finlay had taken exception to some of the opinions expressed in his statement. He was asked whether he recalled reading the report in the mental health notes which said “I am concerned that Mr Fennessy will re present himself within a very short time frame, urgently needs to detox as he has no ability to manage his lifestyle or organise safety, shelter and food.” He said he recalled reading the notes but he did not recall that specific paragraph; however he accepted that that was written in the notes.[29]
[29] Transcript p37.
Sgt Coady also agreed that Mr Fennessy had had three overdoses in the space of less than a week.[30] In questions in relation to residence, Sgt Coady was not aware that Mr Fennessy did not have anywhere to go when he was discharged on 6 January 2010. Sgt Coady was asked how, despite reading that note in the mental health notes, he came to the conclusion that there were no other options for the staff in treating Mr Fennessy. Sgt Coady agreed that medical staff could have perhaps rung a social worker but he referred in his statement to intervening actions in terms of keeping a person in their custody. Sgt Coady agreed that he was confining his opinion to the fact that the staff could not keep him in under the Mental Health Act.
[30] Transcript p37.
Sgt Coady was also asked questions in relation to his opinion as to how, given Mr Fennessy’s overdose that day and overdoses in previous days, he could speculate that if Mr Fennessy had not have been found on the morning of the 6th he could have died. He refused to speculate in that regard because it was not part of the scope of his investigation. [31]
[31] Transcript p39.
It was suggested to Sgt Coady that he had gone through Mr Fennessy’s history from the age of 14 and that history demonstrated that Mr Fennessy was a poly-substance abuser and had had a number of overdoses including a number of overdoses just prior to death. Sgt Coady agreed with that proposition. When asked whether that would cause him to wonder whether there was anything else that could have been done, Sgt Coady suggested that there are a number of factors that were considered and he couldn’t see any other option for Mr Fennessy that night.[32]
[32] Transcript p40.20.
In questions about other options for Mr Fennessy that night Sgt Coady suggested that Mr Fennessy could have stayed at his mother’s place that evening, which is where he was just before he died. It was put to Sgt Coady that Mr Fennessy could not stay there that night and Sgt Coady could not think of any other options that were enforceable.[33]
[33] Transcript p41.
In questions by me about whether Sgt Coady investigated or inquired about why medical staff didn’t call a social worker for Mr Fennessy that evening, he stated it wasn’t part of his investigation. He also said that on that night he had been advised that Mr Fennessy had an appointment with the Drug & Alcohol people the next day and that Mr Fennessy was going to stay at Ms Finlay’s place. [34]
[34] Transcript p42.
Despite the fact that Sgt Coady was advised that Mr Fennessy had an appointment the next day, the Sergeant could not find that appointment on a piece of paper in his belongings.[35]

Jillian Anne Hughes
[35] Transcript p42.20.

Jillian Hughes gave evidence that she was the current Operational Director for Alcohol & Drugs Services within the Division of Mental Health, Justice Health and Alcohol and Drug Services of ACT Health.[36] Ms Hughes has held that position since May 2014. Ms Hughes provided a statement signed on 12 November 2015 which included annexures A to E, and that was exhibited as Exhibit 19 after consent of the parties. Ms Hughes provided a statement because the then Operational Director of Alcohol and Drug Services at the time of Mr Fennessy’s death is no longer employed with ACT Health.[37]
[36] Exhibit 19, p1.
[37] Ibid.
Ms Hughes explained that in March 2011 the ACT Health Directorate underwent an extensive restructure and created the Mental Health, Justice Health and Alcohol & Drug Services Division.
Ms Hughes indicated in her statement that the Alcohol & Drug Service includes:
o   consultation and liaison service – which provides inpatient assessment, support and referral is for people admitted to the Canberra Hospital
o   opioid treatment service – which provides medical advice, nursing and counselling support for people with addiction issues who had been prescribed opioid maintenance treatment
o   Withdrawal inpatient unit – 24 hour medically supervised inpatient unit for people withdrawing from alcohol and other drugs
o   Medical services – providing outpatient services for people accessing opioid treatment service
o   Counselling and treatment services – providing counselling and treatment services for adults and young people in the community with alcohol and other drug issues
o   Diversion services – providing assistance in diverting people arrested and or charged with drug and alcohol related offences out of the judicial system
Referral to this service is by way of self referral, or referral from general practitioners or medical or allied health professionals, or family members. Treatment is by way of consent of the participant.
When asked about the way the system existed around 6 January 2010, Ms Hughes indicated that she was not there at that time however she has made enquiries in relation to the system as at that date. Ms Hughes indicated that the programs involved opioid treatment, withdrawal services, consultation and liaison service provided to inpatients on the wards of The Canberra Hospital, the Emergency Department and the Mental Health Units.[38] Ms Hughes indicated there was also a medical service which was part of the consultation and liaison service, the opioid withdrawal service and clients with an addiction issue. The service also provided counselling and treatment for a diversion program.[39]
[38] Transcript p48.
[39] Transcript p48.
Ms Hughes indicated that there have been significant changes since 2010. Some of those changes include medical advice, nursing and counselling support for people with addiction issues who are prescribed opioid maintenance treatment. That clinic runs from The Canberra Hospital site.[40]
[40] Transcript p49.
Ms Hughes indicated that in 2010 a person requiring treatment through Accident and Emergency (ED) would have been assessed and supported by the consultation liaison team member. Ms Hughes indicated that in January 2010 the requirement would have been someone from the Emergency Department making contact with the service. Ms Hughes indicated that the person assessing someone in the Emergency Department would refer the patient to the specialised 24 hour Alcohol & Drug Service community health intake line or if appropriate refer them to the inpatient withdrawal unit.[41] Ms Hughes further explained that it would be the client who would have to make the effort to contact the unit by telephone. Ms Hughes indicated that for an inpatient referral an addiction specialist in consultation with the staff of the inpatient withdrawal unit would consider the client’s need and admit if required.[42]
[41] Transcript p50.1.
[42] Transcript p50.32.
Ms Hughes further explained that the inpatient service was only for particular persons in particular situations and it was a voluntary service and therefore not suitable for all clients.[43] Ms Hughes further explained the service might take a drug affected person although it was occasional.[44]
[43] Transcript p50.35.
[44] Transcript p51.2.
Ms Hughes clarified that there were protocols in place in January 2010 however; there is now since January 2011 a new standard operating procedure in operation.[45] Ms Hughes stated that the reason for the shift in process was that they reviewed procedures and protocols and standard operating procedures about every three years.[46]
[45] Transcript p52.
[46] Transcript p52.17.
Ms Hughes identified changes to the service since 2010 as including:
o   introduction of the capital IDOSE system, which is an automated dosing system using iris scanning for accurate identification of people receiving their opioid maintenance treatment on Tier 1 at the hospital
o   The introduction of coloured prescriptions, pink scrips of methadone and blue scripts for buprenorphine, for easy identification and differentiation to reduce the risk of medication errors
o   Rapid referral process to opioid treatment service
o   Prescription extensions
o   Clients on opioid replacement treatment who are inpatients of the Canberra Hospital
o   Transfer of pharmacotherapy treatment
o   Urine drug screening
o   Follow-up for Alcohol & Drug clients who do not attend medical appointments
o   A Canberra Hospital and Health Services clinical guideline – Alcohol & Drug services – Key worker support program guideline.
Ms Hughes advised that in March 2011 the ACT Health Directorate underwent executive level restructure and created the service as described above, indicating that the Alcohol & Drug Service has now amalgamated in that division. The role of the ADS Consultation and Liaison Service is to assess inpatients with alcohol and other drug issues and to consult on the care and treatment provided to inpatients, which includes people receiving treatment in the Emergency Department. I note that a person discharged from The Canberra Hospital including the ED, who has not been assessed by ADS Consultation and Liaison Service may be provided with written information on the services offered and they can then arrange a follow-up appointment with the counselling and treatment service through the 24-hour intake line.
The service will be operational seven days per week with an increase of hours of operation in the future. Ms Hughes indicated that this increase will focus on assessment and treatment in the ED, as well as the mental health assessment unit and the adult mental health unit at the hospital. I note that this is prospective.
Ms Hughes agreed that in 2010 if Mr Fennessy had had the opportunity to speak with a consultant from the Consultation and Liaison Service and that discussion had taken place, they could have decided whether he was a candidate for the withdrawal facility or not. In relation to the opioid treatment service, Ms Hughes agreed that Mr Fennessy would have been a Tier 3 patient. Ms Hughes accepted that in her statement she explained that a Tier 3 patient is a person who receives opioid maintenance therapy from a community pharmacy and is medically managed by an approved general practitioner; further that Alcohol & Drug Services are not available in the medical management of such people. She indicated that there are referral pathways which permit a general practitioner to refer that person to Tier 1 under the supervision of the Alcohol & Drug Service if that person becomes unstable.[47]
[47] Transcript p53.5.
Essentially Ms Hughes indicated that given Mr Fennessy was a Tier 3 patient any access to the opioid treatment service would have been voluntary and something that he would have to access himself or be referred by his General practitioner.[48]
[48] Transcript p53.9.
In relation to whether any contact with Mr Fennessy’s approved general practitioner by the Alcohol & Drug Service would have occurred she said it would be either inappropriate or time restrictive and would not have permitted them to done so.[49] Ms Hughes explained the reason for this was because he Mr Fennessy was under the care of the Emergency Department and a referral would have been required for a member of the Alcohol & Drug Service to attend, and the consent of the client would have been required. [50]
[49] Transcript p53.25.
[50] Transcript p53.40.
Ms Hughes indicated that the records reflect that Mr Fennessy had a poor record of engagement with the service and given that he was quite chaotic and difficult to engage in treatment because of a chronic relapsing condition, it was difficult to prepare a comprehensive treatment plan for him. This was why there was no treatment plan in place for him, despite him being referred as early as 2009 to the Service; he failed to engage with the Service.[51]
[51] Transcript p54 and 55.
Ms Hughes agreed that there was a review of Mr Fennessy by the multidisciplinary team on 5 January 2010.[52] The multidisciplinary team consisted of the mental health team which included a psychiatrist, who was unavailable at the time of the assessment, a psychiatric registrar, a team leader, Mr Aloisi, and a senior clinician; however there was no one from the Alcohol & Drug Service.[53]
[52] Transcript p55.
[53] Transcript p56.1.
Ms Hughes indicated that the multidisciplinary team members have now changed and one could now expect a representative from the Alcohol & Drug Service in that multidisciplinary review for someone with an addiction problem and history of overdosing.[54]
[54] Transcript p56.15.
Ms Hughes was taken through the history of 4 January 2010 in relation to whether Mr Fennessy had been seen by the Alcohol & Drug Service liaison service. There appeared in the nursing notes to be a reference to him being seen by a social worker and Drug & Alcohol liaison nurse; Mr Fennessy was to phone Karralika for an assessment with admission in possibly two days. However there was no entry by the Drug & Alcohol liaison officer to that effect. Ms Hughes indicated that this is usually documented in that situation in the emergency notes and that the usual practice is to refer patients to the 24-hour line.[55] I note that there was no referral to that service on the 6^th: see exhibit 18.
[55] Transcript p59.1.
Ms Hughes was referred to the mental health notes in Exhibit 16, page 374, where no date was inserted on that page. I note, however, the document is from the Emergency Department continuation sheet and the time is 15:00 hours. This note indicates that Mr Fennessy was homeless but will go to his sister’s place and is waiting a bed to withdraw and then go to Karralika. Ms Hughes indicated this particular note should be in the patient hospital file rather than the patient mental health file.[56]
[56] Transcript p60.21.
Ms Hughes was taken to the following page dated 6 January 2010: ‘No referral for D/A review however Mr Fennessy admitted overnight due to overdose of medications including methadone. Advised by Fiona from CAT who is aware Mr Fennessy may have stolen prescriptions from ED when admitted on 4 January 2010’. That note was under the hand of RN Coghlan.[57] Ms Hughes was also taken to a document under the hand of the Manager, Clinical Services, Alcohol & Drug Program, ACT Community Health, where the note records that Mr Fennessy had spoken with an ADP consultant nurse who attended Mr Fennessy in an Emergency Department on 4 January 2010 and that the ADP withdrawal unit requested an admission for Mr Fennessy pending a decision by Karralika rehabilitation program. Ms Hughes agreed that it appeared that the withdrawal unit was expecting Mr Fennessy pending confirmation of a bed at Karralika.
[57] Exhibit 16, p395.

Ms Hughes stated that a requirement that was not fulfilled was for Mr Fennessy to have a medical review by an addiction specialist or a multidisciplinary team if required.[58] Ms Hughes accepted it was clear from the record that despite the fact that there was a request from Mr Fennessy to attend the inpatient service, because there was no medical assessment of him by either alcohol and drugs or multidisciplinary team members, Mr Fennessy was not admitted.[59]
[58] Transcript p62.15.
[59] Transcript p62.23.
Ms Hughes in her statement provided that the current process for admission to the withdrawal unit has been updated. The process is the same as was used in 2010 except for:
o Direct admission from the Mental Health Assessment Unit or ED can be arranged where the person has been medically cleared for discharge, triaged as suitable for admission by the withdrawal unit and there is a bed available within the unit; and
o A person with mental health co morbidities who has been admitted to the Adult Mental Health Unit can be transferred to the withdrawal unit once assessed and found suitable by the ADS Consultation and Liaison Service when a bed becomes available.
In her statement Ms Hughes indicated that in 2009 the withdrawal unit closed between 24 December 2009 and 4 January 2010, but now the unit remains fully operational during the Christmas period.
Under cross-examination by Mr Sabharwal Ms Hughes described the process of admission into the inpatient withdrawal unit, as requiring an assessment by Consultation and Liaison Service, contacting the Alcohol & Drug Service intake line, and possible admission or admission through direct transfer from the Emergency Department after assessment by an addiction specialist; after which, having been found suitable, the patient can then be admitted.
Mr Sabharwal suggested a scenario where a patient - in this case Mr Fennessy - had been observed and there was a concern that he would re-present himself within a short time frame and that he had no ability to manage his lifestyle or have safety, shelter and food. Ms Hughes was then asked what service could be provided. She said that there was nothing in place after 5 pm even now as at November 2015, although she indicated the service would be expanding into the evening and that it is now seven days a week.
I note in her statement Ms Hughes said that Mr Fennessy benefited from the opioid treatment service in February 2009, however he did not attend appointments that had been made. Given Mr Fennessy received treatment and opioid maintenance by his general practitioner and receive dosing at the community pharmacy he was classified as a Tier 3 patient and was not under the supervision or management of ADS. Mr Fennessy would not have been assigned a key worker because he was not a Tier 1 or Tier 2 client.[60]
[60] Exhibit 19, p8.
Ms Hughes said that in terms of drug and alcohol patients, the liaison service goes to the Emergency Department and provides advice; however they do not provide any other type of advice such as housing which is more to do with social work.
In her statement Ms Hughes further commented that she noted Mr Fennessy’s interactions with mental health clinicians and ongoing treatment needs were reviewed at a multidisciplinary team meeting on 5 January 2010 where a decision was made that no further case management was required at that point in time.[61]
[61] Exhibit 20, p9.
I note in Exhibit 19 Attachment D the criteria for any person seeking withdrawal from any substance are as follows:
o   Clients with a history of seizures during alcohol withdrawal
o   Clients withdrawing from alcohol have priority as alcohol withdrawal is potentially serious and often needs specific medication
o   Opiate dependent clients may be better managed on maintenance therapy, however if the client insists on wanting to try withdrawal initially, the case will be assessed on an individual basis
o   Pregnant opioid dependent clients are generally not suitable for admission aiming for drug withdrawal, as opioid withdrawal is dangerous to the fetus; admission for stabilisation poly drug use in pregnant clients may be very appropriate, and pregnant opioid using clients will normally be strongly encouraged to enter a maintenance program
o   Withdrawal from cannabis and amphetamines will be assessed on an individual basis
o   Interstate clients can be admitted as there are cross-border agreements with other states, however ACT clients have priority.[62]
[62] Exhibit 20, Attachment D.
I note in Attachment D, assessment for the withdrawal service either inpatient or outpatient is assessed by phone prior to admission. That assessment is based on the client’s self-reported history of current symptoms, reported drug, alcohol medical, and psychosocial history as well as other information available to the assessor.[63]
[63] Exhibit 20, Attachment E.
Ms Hughes commented that Mr Fennessy’s contact with ADS and mental health was sporadic and his level of engagement in the services offered were not sufficient to develop a comprehensive treatment plan. I note however that Mr Fennessy’s clinical records, particularly his MHAGIC (Mental Health) records, indicate there was communication and liaison between ACT Mental Health clinicians and ADS and ED at The Canberra Hospital, as well as Mr Fennessy’s general practitioner and non-government organisations in relation to the care and treatment provided to him. I also note that amongst the factors to be considered during assessment is any prior history of complicated withdrawals including seizures and/or delirium tremens, as well as the presence of significant mental health or medical issues.
Ms Hughes was asked questions in relation to Karralika and she replied that she knew there was a waiting list and that the person wishing to be admitted had to phone to see if there was a bed available.[64] During cross-examination by Mr Crowe, Ms Hughes was referred to Exhibit 16, page 394, which read “Mr Fennessy homeless although will go to sisters post discharge AD, Awaiting a bed with withdrawal unit before going to Karralika. For phone assessment with Karralika rehab service, Wednesday PM, Once bed confirmed with Karralika Mr Fennessy to liaise with withdrawal unit for bed prior to rehab”.[65]
[64] Transcript p65.
[65] Transcript p66.36.
I asked about a situation like that which Mr Fennessy found himself in, that after discharge from an overdose he clearly had consumed more drugs or the drugs he had in his system were aggravated or potentiated. I pointed out also that there are many multidrug abusers in the system. Ms Hughes said that the Alcohol & Drug Service try to engage those patients in treatment and that the client must be willing to engage in treatment. Ms Hughes further explained the Tier system as to how that system works, in that if a person is a Tier 1 patient they get a case manager who helps them navigate the system, they also have timely medical reviews to support them and have regular appointments with addiction specialists, they are also dosed at the hospital and assessed there by team of nurses on a daily basis.[66] Tier 1 patients also have social workers available to them if they have homelessness issues.[67] Ms Hughes indicated that both Tier 1 and Tier 2 have these services available to them. She indicated that all of these patients, whether drug addicted, with mental health issues or both, must voluntarily access the programmes. Ms Hughes also noted that Tier 3 patients do not receive these services because they are prescribed their medications by their general practitioner.[68]
[66] Transcript p67-68.
[67] Transcript p68.
[68] Transcript p68.20.
In answer to Mr Crowe’s question in relation to the 24-hour intake line, Ms Hughes indicated that the line works 24 hours Monday to Friday with specialised trained staff who can assess those requesting their help. The staff will give advice and referral to an opioid treatment and counselling service. This service is also available after hours because the phone is diverted to the inpatient withdrawal services where specialist nurses can assist, advise and refer.[69]

Bruno Aloisi

[69] Transcript p69.10.

Mr Aloisi is a psychologist who at the time of giving evidence was the Operational Director for Adult Community Mental Health Services. Mr Aloisi understood that the alcohol and drug services provided to persons such as Mr Fennessy would have been referred by not just mental health services but other services within the hospital when someone is identified as having a significant substance abuse or use issue. He understood that a medical review was required in the first instance and Mental Health can recommend patients to the opioid treatment service, however generally the pathway would be a referral from the Alcohol & Drug Service for an assessment to be made as to what is required.[70]
[70] Transcript p6 (1/12/15).
In relation to the inpatient withdrawal unit Mr Aloisi confirmed that that service was in existence in January 2010. His understanding was that it would be a phone referral and possibly face-to-face interview but would require medical review prior to admission or as part of the admission.[71]
[71] Transcript p7 (1/12/15).
Mr Aloisi stated that the Alcohol & Drug Service now sits within the Division of Mental Health, Justice Health, Alcohol & Drug Services.[72] In relation to whether ACT Mental Health could refer a client to the addiction specialists Mr Aloisi stated that that occurs now although he was unsure whether that was available in 2010. Mr Aloisi indicated that the Alcohol & Drug Service is based on a voluntary model in that the client self refers.[73] Mr Aloisi indicated that it is still the case although the relationship with the Alcohol & Drug Service has opened up new referral pathways.[74] Mr Aloisi stated that the counselling and treatment service was also available in January 2010 and again it was a voluntary self referring program.[75]
[72] Transcript p7.
[73] Transcript p7.
[74] Transcript p7.
[75] Transcript p8.1.
Mr Aloisi was taken to Exhibit 15, page 787, a document he described as a statement of actions taken. He described the document as essentially the enactment of the emergency apprehension provisions under the Mental Health Act. Mr Aloisi indicated that it was not an emergency treatment order but rather details of the emergency apprehension that was taken, he said “it is not treatment per se but enables a person to be brought into hospital for assessment”.[76] Mr Aloisi agreed that the document on that page indicated that Mr Fennessy was brought in by Police in December 2007 after having been reported missing by his mother and police found him wandering the streets plucking at objects and the like, and Police were authorised pursuant to the Mental Health (Treatment and Care) Act to apprehend him and take him to the hospital for assessment.[77] Mr Aloisi indicated that on page 779 that document indicated Mr Fennessy was monitored and then discharged from the Psychiatric Services Unit (PSU) with follow-up by the Crisis, Assessment and Treatment (CAT) team initially and then for GP follow-up. Mr Aloisi indicated this is a long-term follow-up plan.[78]
[76] Transcript p8.21-37.
[77] Transcript p8.35-45.
[78] Transcript p9.29.
Mr Aloisi was taken to Exhibit 16, page 38, and identified that document as a MHAGIC record. Mr Aloisi identified that acroynym stood for Mental Health Assessment Generation Information Collection, an electronic collection of material and mental health records.[79] Mr Aloisi was taken to a record with date 14 December 2007. This document outlined the general description of Mr Fennessy’s appearance at the time and there was a number two circled which read priority response within 12 hours, which required the patient to be seen within that 12 hours following presentation.[80] Further down the page there were tick boxes to be marked in relation to evidence of mental illness which Mr Aloisi described as probably a suggestion from the review of the patient that some mental issue was evident.[81] Mr Aloisi was taken to the parts of the document in relation to risk of suicide and he indicated that it was an assessment to determine risks. Mr Aloisi identified a couple of risk factors in relation to Mr Fennessy which had been entered by a clinician which indicated a low to moderate risk.[82] It was Mr Aloisi’s view that the risk factors identified indicate that further assessments would be required as there is some concern about the risk, and that risk needs to be explored further.[83]
[79] Transcript p9.43.
[80] Transcript p10.15.
[81] Transcript p10.20.
[82] Transcript p10.40.
[83] Transcript p11.5.
Mr Aloisi indicated that even though Mental Health at that time were not associated with the Drug & Alcohol assessment service, and they were not the direct service provider, co-morbid drug and alcohol use can be associated with mental health issues at times and it will be something that the Service would need to be aware of as part of the assessment which is done by a mental health clinician.[84]
[84] Transcript p11.15.
Mr Aloisi was taken to page 114 of Exhibit 16 which is a summarised version of notes of Mr Fennessy’s admission in 2007 which indicated he had been assessed in the Low Dependency Unit of the PSU. The discharge note on page 132 was an overview of his diagnosis with the CAT team to follow-up and to see GP within one week of discharge. Mr Aloisi indicated that at that point whilst in the PSU Mr Fennessy was under the care of Mental Health and also for the purposes of a review contact with Mr Fennessy, and after that assessment Mr Fennessy was under the care of his GP.[85]
[85] Transcript p12.30-40.
In relation to a question about whether the discharge and follow-up with the GP meant that Mr Fennessy did not have a mental health issue, Mr Aloisi indicated that that did not mean that Mr Fennessy did not have some mental health issues, however they weren’t sufficient to warrant a specialist mental health service to be involved.[86] The threshold for a mental health service to be involved was based around essentially a clinical judgement as to the severity of the symptoms and the need for voluntary treatment. Mr Aloisi said “for example, it might be about the need for involuntary treatment so, for example, we have people who might need treatment but won’t actively engage in the community so – and because of the risks associated with it might need involuntary treatment so there are a number of sort of clinical factors you would be looking at to assign clinical management service.” [87]
[86] Transcript p13.1.
[87] Transcript p13.10.
Mr Aloisi was asked about Mr Fennessy’s low to moderate risk of suicide and he said “if it was fairly persistent, for example, then you might argue – say, for example, if someone was considered – assessed as continuously at high risk of suicide, you might – there would be a strong argument for providing clinical management to provide ongoing monitoring and review.”[88]
[88] Transcript p13.19.
Mr Aloisi was taken to Exhibit 16, page 124, and asked for his comments in relation to the meaning of the notes displayed on that page. Essentially Mr Aloisi said that the visits were for a physical check and for further review. He also indicated in respect of page 125 that his interpretation is that the CAT team worker may be able to assist in accommodation and indeed did so. The note also indicated there was a mental state examination undertaken.[89] Mr Aloisi also agreed that Mr Fennessy was prescribed Zyprexa and was to stay in a CAT flat, which was a flat leased by city housing which could accommodate and support people who did not have accommodation but who had high needs. Mr Aloisi indicated that flat was available in January 2010 but has since been dispensed with.[90]
[89] Transcript p14.25–35.
[90] Transcript p15.1-21.
Mr Aloisi identified that the 14 March 2008 notes reflected the CAT team case closure due to resolved episodes of care and no ongoing risk issues identified after a multi-disciplinary team review was conducted. This team review did not include alcohol and drugs workers specifically as part of the review.[91] Mr Aloisi indicated that now those areas would be involved if it were required given the closer relationships between the services.
[91] Transcript p16.1.
It was suggested that if Mr Fennessy had come along on 1 December 2015 he would have had access to alcohol and drugs staff as part of the review. Mr Aloisi indicated that there are multiple processes and within mental health services there is a co-morbidity clinician who can provide specialist assistance.[92]
[92] Transcript p16.16.
Mr Aloisi was taken to Exhibit 16, page 133, which indicated that Mr Fennessy had been brought into The Canberra Hospital Emergency Department after taking different medications and alcohol. He was assessed by the CAT team and asked about the overdose it was reported that he said “I do it because I like it”.[93] Mental Health then engaged with Mr Fennessy. Mr Aloisi indicated that EA meant emergency apprehension and when admitted under this indicator patients require a psychiatric review.[94]
[93] Transcript p16.35.
[94] Transcript p17.1.
In relation to the acronym HoNOS Mr Aloisi was unsure but said he thought it meant Health of the Nation Outcome Scale which was basically a way of scoring a person’s functionality with certain criteria. Mr Aloisi was taken to the previous assessment where Mr Fennessy recorded a score of four. Mr Aloisi believes that it is an assessment which can vary depending on circumstances.[95]
[95] Transcript p18.5.
Mr Aloisi was asked in relation to an admission of Mr Fennessy to the Calvary mental health facility Ward 2N on 28 March 2008 and the references in page 135 of Exhibit 16. Essentially Mr Aloisi stated that a co morbidity clinician, Steve Harnett, had reviewed Mr Fennessy specifically given his specialty. Mr Aloisi indicated that where the referral programs for rehabilitation from alcohol and drugs occurred.[96]
[96] Transcript p18.1-30.
The next entry Mr Aloisi assisted with was in relation to a presentation to The Canberra Hospital on 7 June 2008. That presentation was by ambulance where Mr Fennessy was taken after being found collapsed in the toilet by security guards. Mr Fennessy had been discharged from a rehabilitation place. Staff were advised that Mr Fennessy had injected Seroquel, Avanza and had taken oral heroin, oxazepam and alcohol, and he was to be admitted to the PSU.[97] It appears Mr Fennessy was admitted to the PSU and that he was discharged from the mental health facility on 11 June 2008. Mr Aloisi agreed that the document indicated the outcome to be risk of misadventure, risk of drug use. The notes indicated that Mr Fennessy was quite irritable and anxious, and continued to drug seek. Mr Fennessy was discharged with medication for follow-up with his GP, who Mr Aloisi stated was Mr Fennessy’s primary treating physician.[98]
[97] Transcript p18.40.
[98] Transcript p20.15.
Mr Aloisi was taken to page 149 of Exhibit 16 where a comprehensive history was recorded of Mr Fennessy’s admission to The Canberra Hospital and the PSU on 27 June 2008. Mr Fennessy was found having taken several prescription drugs, with the possibility of cocaine and heroin being injected by him, although he denied this. It is noted Mr Fennessy’s girlfriend was found with two syringes with one having liquid in it.[99] Mr Fennessy was admitted to Ward 6 of The Canberra Hospital with a diagnosis of clinical pneumonia, haematemesis and overdose of drugs.[100] Mr Aloisi was taken to page 164 where a note from Dr John Edgar was made in relation to problems with Mr Fennessy leaving the ward. It was suggested that this note appears to be the only note in relation to that admission from the mental health team. However Mr Aloisi interpreted the note to mean that Dr Edgar as part of the mental health Consultation and Liaison Service was assessing and reviewing Mr Fennessy at that time.[101]
[99] Transcript p21.19-30.
[100] Exhibit 15, p607-611.
[101] Transcript p22.1.

In relation to the admission of 6 January 2010 I note in the medical notes the ED registrar’s plan in relation to Mr Fennessy included that Karralika had called and will call patient back, for the CAT team to review, to have IV access, for Mr Fennessy to eat and drink, for Mr Fennessy to have neurological observations, for a chest x-ray and some blood tests. There was nothing in the plan in relation to a Drug & Alcohol Service review. I note the observation nursing notes include the transfer to the EMU, that Mr Fennessy was seen by CAT team, and was to be seen by the Drug & Alcohol Service on 7 January at 15:00 hours.[336]
[336] Exhibit 15, p321.
In relation to the discharge of Mr Fennessy on 6 January 2010, clearly there was no formal discharge from either the medical practitioner or Mr Bailey. The evidence is clear that there were no notes on file as to the discharge and no discharge document. There is no evidence that a discharge letter was sent to Dr Craft. In my view this is concerning particularly given the consequences which followed. I note there was no case management plan devised for Mr Fennessy on his discharge that day despite the concerns articulated by Ms Finlay. There was a tenuous reference to Mr Fennessy having an appointment to see someone from the Drug & Alcohol program. It appears that there was an appointment made on 4 January which could have been what Mr Fennessy had referred to, although that is speculative.
In any event there was no entry in the notes of Mr Fennessy’s discharge. There is no evidence that Mr Fennessy was sent away with a treatment plan or care plan.
There was knowledge by at least Mr Bailey that Mr Fennessy was off to the pharmacy to get his dose of methadone in a situation where he had been brought in by ambulance, unconscious, requiring CPR and Narcan to reverse the effects of the drugs he had consumed.[337] It was clearly evident from the MHAGIC note written by Mr Bailey on 6 January that he had significant concerns that Mr Fennessy would present in a very short time frame and that he had no ability to manage his lifestyle or organise safety, food, or shelter. I interpret that to mean Mr Fennessy would present to emergency with an overdose within a short period of time. Mr Bailey was also concerned that Mr Fennessy would not keep his Alcohol & Drug review appointment the next day.[338]
[337] Exhibit 16, p232–233.
[338] Exhibit 16, p234.
Given those concerns, there does not appear to be any evidence that a plan to thwart that situation was devised by any of the medical staff.

Adverse comment – the ACT

I caused a notice to be sent to the ACT Government Solicitor on behalf of the Australian Capital Territory in relation to comments that I had considered I may make in relation to this inquest.
As I have already said supra I have taken considerable cognition of the authorities and the legislation referred to me by Counsel for the ACT. I also considered very carefully the submissions of Counsel. Having considered those matters I make the following comments.
In relation to communications between agencies, at the time of Mr Fennessy’s death there appeared to be at least from the evidence before me, a lack of communication, coordination and referrals between agencies for Mr Fennessy, who clearly had some mental health and drug and alcohol issues, in particular, Mr Fennessy’s clear addiction to both prescription and illicit substances. These two factors caused him to have multiple hospital admissions over the years, some culminating from suicidal ideation and some from his hopeless addiction to medication.
As an example of this I refer to the evidence of Ms Hughes. Ms Hughes was taken to the 4 January 2010 admission and I note she agreed that an assessment was conducted by the A&D consultant nurse and that a request was made for admission to the A&D withdrawal unit pending a bed being available at Karralika. Mr Fennessy was expected to be admitted, but no medical review by an addiction specialist was conducted as required and so he could not be admitted.[339]
[339] Transcript 30/11/15.
At other times it was left to Mr Fennessy to make his own arrangements and was merely given a phone number, discharged and told to ring the relevant agency.
It appears to me that Mr Fennessy was a person who was clearly unable to look after himself or make any considered decisions about himself in relation to his addiction. Yet he was required to self refer for appointments to Alcohol & Drug Services and/or rehabilitation clinics on numerous occasions. I was told by Dr Craft that was a requirement for persons seeking rehabilitation.
It appears that Mr Fennessy was unable to get his life organised sufficiently to keep appointments and to assist in his own rehabilitation. When he did attend rehabilitation Mr Fennessy spent very little time there as he broke the rules because of his significant addiction to medication and illicit drugs.
The evidence shows that Mr Fennessy was admitted on multiple occasions to a health facility in the ACT. In my view it was clear from the evidence before me that Mr Fennessy was hopelessly addicted to prescription drugs and to some extent illicit substances. It is also my view that Mr Fennessy was unable to help himself.
I note that the Territory in its submissions in reply referred to Mr Fennessy’s opioid addiction being managed by his GP. Clearly Mr Fennessy’s problem was more than opioid addiction: in fact he was a chronic doctor shopper who consumed a multitude of various drugs in various quantities over a period of time. In that regard having considered the very helpful evidence of Ms Hughes in respect of the three tier system, it is my view that consideration should have been given to whether Mr Fennessy’s tier level was the appropriate level for him given his presentations for overdosing of prescription medications on multiple occasions.
There was no evidence before me indicating that upon review by the multidisciplinary team consideration was given to whether the level of support should be increased to a level of Tier 1. That in my view was unfortunate because it seems to me given the evidence, Mr Fennessy would have benefited from that increased level of support. It may even have precluded him from the ability to doctor shop.
It appears from the evidence as a whole that Mr Fennessy just fell through the cracks despite the efforts of treating clinicians. In my view, it is the system at the time that allowed this to occur not a particular person or agency. This was a failing of the system in place at the time. Clearly this was recognised by the relevant departments because now improvements have been made. As I have indicated supra there is a division known as ACT Mental Health, Justice Health and Alcohol and Drug Services. Following on from the implementation of that umbrella division, the new system would facilitate someone like Mr Fennessy who has varying degrees of symptomology for mental health issues and a significant drug and alcohol addiction. It appears that if Mr Fennessy were to present today the multidisciplinary team which now includes Alcohol & Drug Services could review the situation. I anticipate that would also include an addiction specialist. I cannot say whether that would have saved Mr Fennessy’s life but at least it would have been a better option for him as he may have been elevated to a more supportive environment as seen in Tier 1 clients.

Possible adverse comment – Bill Bailey

I caused a notice to be sent to the ACT Government Solicitor on behalf of Mr Bailey in relation to comments that I had considered I may make in relation to this inquest. I do not propose to make any adverse comments as set out in the notice. I will comment on the following matters.
I accept that Mr Bailey gave his evidence in a manner which did cause me some concern at first blush, however I accept that Mr Bailey was asked to recall an incident that occurred six years previously, was asked to recall events for a statement to be prepared for an event that occurred six years previously. Mr Bailey was asked to recall whether he knew Mr Fennessy after having only seen him once prior to 6 January 2010.
In giving evidence I noted that Mr Bailey was distracted and had difficulty recalling matters. It was suggested to him that he was lying, however I accept Mr Bailey was nervous and had difficulty recounting events because of the passage of time. In my view that is understandable given that Mr Bailey was only recently required to recall the events.
I note Mr Bailey relied on the notes he took on 6 January 2010 where he said that he had conducted a risk assessment, had considered the previous MHAGIC notes and in his view there was no risk of self harm and he was happy to discharge Mr Fennessy because Mr Fennessy was keen to leave and felt trapped. I also note that it was a very limited assessment however Mr Bailey explained why that was so given Mr Fennessy’s behaviour.
I am satisfied that despite the fact that Mr Bailey knew Mr Fennessy would most likely not attend his appointment and would most likely represent again in a short period of time, he took the view that he could not hold Mr Fennessy because of the restriction placed upon him. Mr Bailey noted in the MHAGIC notes that he did not have any grounds to hold Mr Fennessy under the Mental Health Act because he formed the view Mr Fennessy was not mentally ill.
Mr Bailey accepted that he had failed to discharge Mr Fennessy properly in so far as he did not prepare a discharge summary for him.

Possible adverse comment – Dr Shannon Craft

I caused a notice to be sent to Dr Craft in relation to comments that I had considered I may make in relation to this inquest. I do not propose to make any adverse comments as set out in the notice. I will comment on the following matters.
As I have noted supra I found Dr Craft to be an honest witness who appeared to genuinely care for Mr Fennessy. There are things that Dr Craft could have done better in caring for Mr Fennessy but I accept that she did as much as she thought she could and was open to her.

Adverse comment – Australian Pharmacy Group (trading as Coolamon Court Pharmacy)

I caused a notice to be directed to the Coolamon Court pharmacy trading as the Australian Pharmacy Group in relation to the care provided to Mr Fennessy on 6 January 2010. The notice was given in relation to whether Mr Fennessy received a double dose of methadone that day.
I received submissions under the hand of Simon Blacker who accepted that Mr Fennessy did receive a second dose contrary to the prescription. Mr Blacker described how the medication came to be given twice as an error by his pharmacist who did not follow protocol. The morning dose had been noted and I have dealt with that issue supra. Mr Blacker also indicated that because of Mr Fennessy’s behaviour in attempting to steal some medications somehow that was an explanation as to why he was given his methadone incorrectly.
I do not accept this explanation. It is clear that the pharmacist for whatever reason gave Mr Fennessy the dose and then went to examine the record and it was only upon examination of the record after the dose had been administered that it was discovered he had an earlier dose that day. That was a failure in protocol.

Conclusion

I find that it was not unreasonable, on the balance of probabilities, for medical staff to have discharged Mr Fennessy on 6 January 2010, given they believed they had no mechanism available to detain him.
I further find that Mr Fennessy was given a double dose of Methadone on 6 January 2010 where he was only prescribed one dose.
I further find Mr Fennessy was able to access prescriptions from multiple prescribers and have the prescriptions dispensed by multiple pharmacies. It was clearly evident that Mr Fennessy successfully doctor shopped his prescriptions enabling him to consume significantly more quantities of drugs than proposed by the treating medical practitioners, to the point he overdosed on numerous occasions.
It appears that neither the doctors nor the pharmacists were aware of just how many prescriptions Mr Fennessy had available to him. If there had been a real time mechanism for detecting overprescription and overdispensing such as that described by Ms Hughes in her evidence (DAPIS and DORA) the pharmacists would have been able to detect the misuse of the prescriptions in real time thus avoiding over supply of prescription drugs. This would have prevented Mr Fennessy from having access to the multitude of drugs he did have access to, thus preventing him from overdosing at least on prescription drugs and at least in the ACT. It would have also shown just what drugs were being prescribed and which doctors were prescribing them.
I note that the ACT has available a data base (DAPIS) which could if utilised in the Territory, be adapted to provide a real time monitoring system (DORA). I am also aware that Coroners across Australia have called for such a system to be available nationwide.[340]
[340] Coroners Conference 2015 Tasmania.

Findings confirming Interim Findings

I find that Paul Fennessy born in September 1988, died outside and adjacent to the northern perimeter fence of 2 Zeal Place Holder in the Australian Capital Territory at 23:15 hours on 6 January 2010.
I further find that the cause of his death was the combined effect of a cocktail of drugs taken by him, which caused central nervous system depression and respiratory depression leading to positional asphyxia.

Recommendations

1. That the ACT Government implement DAPIS and adapt the real time monitoring system know as DORA.
2. That all medical files, including mental health records, in relation to a patient being treated at a Canberra Public Hospital be made available to all clinical staff at the hospital when required.

[2016] ACTCD 4

16 December 2016