Inquest into the death of Shane McMillan

CORONERS COURT OF NEW SOUTH WALES Inquest: Inquest into the death of Shane McMillan Hearing dates: 5-7 November 2025, Orange Local Court Date of findings: 22 December 2025 Place of findings: Coroners Court, Lidcombe Findings of: Deputy State Coroner, Magistrate Hosking Catchwords: Death in custody; search on arrest; medical treatment in custody.

File number: 2022/00367479 Representation: Counsel assisting the inquest, Jake Harris, instructed by Alana Galasso of the Crown Solicitors’ Office Kim Burke, instructed by Stuart Robinson of the Office of the General Counsel, for the Commissioner of Police and involved officers Patrick Rooney, instructed by Matthew Renwick of McCabes Lawyers, for Western NSW Sydney Local Health District and NSW Ambulance Cameron Jackson, instructed by Judith Alderson of Avant Law, for Dr Shamus Shepherd.

Findings: Identity of deceased: Shane McMillan Date of death: 2 December 2022 Place of death: Orange Health Service (OHS) Manner of death: Unintentional drug overdose Cause of death: Acute methylamphetamine toxicity Inquest into the death of Shane Daniel McMillan 1

Was an adequate and appropriate personal search conducted on Shane following his arrest Did police take adequate and appropriate steps to obtain medical assistance for Shane on Was the assessment and management of Shane at Orange Health Service adequate; were the decisions to discharge him appropriate; and were his discharge plans appropriate? .... 20 Should health staff have consulted a toxicologist, and/or contacted the NSW Poisons Information Centre about Shane’s management, and if so, when? Is it likely that this would When and in what circumstances did Shane consume methylamphetamine? What is the Is it necessary or desirable to make any recommendations in relation to any matter Inquest into the death of Shane Daniel McMillan 2

FINDINGS Introduction 1 These are the findings of an inquest into the circumstances of the death of Shane McMillan born on 19 July 1982 to Ian and Lynette (Ruth) McMillan.

2 Shane died on 2 December 2022 at Orange Health Service (OHS). At the time, Shane was in Police custody having been charged with domestic violence offences and bail refused the day prior.

3 Tragically, Shane’s brother Luke also died in custody in 2006 from suicide.

Luke’s death significantly impacted Shane and his family.

4 Shane was the much loved partner of Jessica Snowden, father and stepfather.

5 Shane’s partner and mother both attended parts of the inquest. I extend to them my sincere condolences for their sad loss.

The role of the coroner 6 The role of the coroner is to make findings as to the identity of the nominated person and in relation to the place and date of their death1. The coroner is also to address issues concerning the manner and cause of the person’s death. A coroner may make recommendations, arising from the evidence, in relation to matters that have the capacity to improve public health and safety in the future2.

7 This inquest is mandatory on two bases: (1) at the time of his death, Shane was in the custody of the NSW Police Force (NSWPF) having been charged and bail refused3; and 1 s 81 of the Coroners Act 2009 (NSW) (the Act).

2 s 82 of the Act.

3 ss 23 (1)(a) and 27 (1)(b) of the Act.

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(2) to the extent that Shane’s arrest caused or contributed to his death, his death was ‘as a result of police operations’4.

The issues examined at the inquest 8 The statutory findings as to the identity of the deceased, the date and place of death, and the cause of death, have been sufficiently disclosed.

9 Regarding the manner of death, the following issues arise.

(1) Was an adequate and appropriate personal search conducted on Shane following his arrest on 1 December 2022, prior to his transport to Orange Police Station?

(2) Did police take adequate and appropriate steps to obtain medical assistance for Shane on 1 and 2 December 2022?

(3) Was the assessment and management of Shane at Orange Health Service (OHS) adequate during each presentation on 1 and 2 December 2022?

(4) Should health staff have consulted a toxicologist, and/or contacted the NSW Poisons Information Centre (the NSWPIC) about Shane’s management, and if so, when? Is it likely that this would have resulted in any different management?

(5) Was it appropriate to discharge Shane from OHS at about 5pm on 1 December 2022, and again at about 11pm on 1 December 2022? Was there an adequate discharge plan on each occasion?

(6) When and in what circumstances did Shane consume methylamphetamine? What is the most likely explanation for the reading of 51mg/L methylamphetamine found in his post-mortem toxicology?

4 ss 23 (c) and 27(1)(b) of the Act.

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(7) Is it necessary or desirable to make any recommendations in relation to any matter connected with the death?

The evidence 10 Tendered to the court was a 6 volume brief of evidence compiled by Det. lnsp.

Griffith, Senior Critical Incident Investigator and supplemented by the Assisting Team.

11 Oral evidence was received at the inquest from: (1) Chief lnsp. David Maher, NSWPF (2) Sen. Cst. Brady McGovern, NSWPF (3) Sen. Cst. Abbey Golder, NSWPF (4) Sgt. Joanne Little, NSWPF5 (5) Sgt. Adam Tonkin, custody manager, NSWPF (6) Det. lnsp. Griffith, Senior Critical Incident Investigator, NSWPF (7) Sgt. Nathan Wallace, institutional witness, NSWPF (8) Paramedic Carl Bevan (9) Dr Sally Clunas, Emergency Physician, OHS (10) Dr Katie Hobbs, Junior Medical Officer, OHS (11) Dr Shamus Shepherd, Emergency Consultant, OHS 5 McGivernb, Golder and Little were all at the scene when Shane was originally arrested.

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(12) Assoc./Prof Gunja, Speicalist in Emergency Medicine and Toxicology (13) Dr Greggory Button, Director of the Emergency Department.

Findings and recommendations 12 Having reviewed all of the evidence and submissions, I make the findings that follow.

(1) While not ‘optimal’, the search undertaken of Shane’s person before he was initially transported to Orange Police Station was reasonable in all of the circumstances.

(2) I find that the NSWPF took adequate and appropriate steps to ensure Shane’s welfare while in their custody and to obtain for him appropriate medical treatment.

(3) I find that the treatment provided to Shane by OHS on 1 and 2 December 2022 was appropriate including their decisions to discharge him.

(4) Given the relative experience of Shane’s treating doctors, the information available to them and Shane’s presentation, I do not find that they ought to have consulted a toxicologist or the NSWPIC.

(5) Absent any other rational or reasonable explanation for the delay in Shane’s ultimately fatal symptomatology, I accept the opinion of Assoc./Prof Gunja that it is likely that Shane had swallowed an additional packet of methylamphetamine either when he was in the long grass or shortly after, when he was in the back of Orange 15. The packaging failed/dissolved between when Shane was discharged from OHS and when his symptoms of toxicity appeared in the morning of 2 December 2022.

13 For the reasons outlined herein I make no recommendations.

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Background Events of 1 and 2 December 2022 14 In the morning of 1 December 2022, there was an altercation between Shane and Jessica at their home. At 9.05am, Sharon Cummins, a neighbour, heard a female voice yelling, ‘please help me’. She could also hear a male yelling, ‘Shut the fuck up’. Cummins went to her back window and saw Jessica trying to climb the fence, with a male pulling her around the waist. At 9.14am, Cummins called the NSWPF.

Police attend the premises 15 At 9.19am, Sgt. Little and Sen. Cst. McGovern attended the scene. Sgt. Little had a conversation with Jessica at the door while McGovern went to the back of the property. Sgt. Little saw Jessica had some grazes on her neck and red marks on both sides of her neck. Jessica did not disclose that Shane had assaulted her but did say that she was scared of him.

16 Sen. Cst. Golder also attended the scene. She opened the side gate to the home and saw Shane run out the back door and jump the back fence. She gave chase with Sen. Cst. McGovern. When they found Shane in bushes nearby, he was dry retching. Sen. Cst. Golder formed the view that he had committed a domestic violence offence and placed him under arrest.

17 Sgt. Little also saw Shane was dry retching, and he appeared distressed and out of breath. Shane said, ‘I’m going to spew, I’m going to spew’. He said he had run because he was scared. Sgt. Little saw him vomit a brown thumbnail-sized amount of vomit.

18 The officers moved Shane back to the caged police vehicle. Sgt. Little formally placed Shane under arrest for breaching an AVO by committing an act of intimidation.

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Personal search of Shane 19 Sen. Cst. McGovern conducted a search6. He was primarily looking for objects that could harm police or Shane. He patted down the outer layer of Shane’s clothing from the waist down, emptied his pockets, and took Shane’s shoes off.

Sen. Cst. McGovern found a bag containing a crystalline substance on or around Shane’s leg. Sen. Cst. McGovern cautioned him and asked what it was, and Shane said that it was ice and that he had found it down the street on the ground. He was also found to have $780 in cash. At that stage, neither Sen. Cst, Golder nor Sen. Cst. McGovern gave consideration to conducting a strip search.

20 After he was arrested, Shane was not handcuffed.

21 Sgt. Little spoke with Jessica, who said she did not want to take part in a DVEC7 interview. Their conversation is recorded on BWV.

Orange Police Station 22 On arrival at Orange Police Station, Sgt. Little opened the rear cage of the police vehicle and saw brown vomit on the floor. There was a crystalline substance sitting around and in the vomit.

23 Sen. Cst. Golder likewise observed the vomit and saw that the crystalline substance was mixed with but also separate from the vomit. She was confused as to where Shane had obtained the substance and considered there was a large quantity. She asked Shane, ‘When did you take this?’ but Shane did not respond. She called an ambulance via police radio. She observed that Shane was going in and out of consciousness.

24 Sen. Cst. Golder told Chief lnsp. Maher, ‘I think he’ll be very sick … He’s swallowed a lot of ice’. She told Sgt Bayad and Chief lnsp. Maher, ‘I believe he 6 This process was captured on body worn video (BWV).

7 Domestic Violence Evidence in Chief.

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has more ice on him because there was clean ice in that pod’. She suggested that Shane should be strip-searched.

25 An ambulance was called at 9.46am. The first ambulance (Paramedic Melinda Ellis) attended at 9.57am, followed by a second (Paramedic David Stein) at 10.05am.

26 Sen. Cst. Golder told Paramedic Ellis that Shane had consumed a large amount of ice. According to Paramedic Ellis, a male police officer told her that Shane may have consumed something. Sen. Cst. Golder stated she suspected Shane had taken ice, and that crystals could be seen in his vomit. Paramedic Ellis also saw Shane while he was still in the pod of the vehicle and noted there was vomit and some white crystals on the step.

27 Paramedic Ellis conducted observations, took a blood sugar level and performed an ECG, which were all within normal limits. Nonetheless, she determined Shane should be taken to OHS.

28 A crime scene was created, and photos were taken of the vomit. The vomit was not sampled or analysed, as it was considered a biohazard.

First admission to Orange Health Service 29 Shane was taken to OHS via ambulance, with police in attendance. He arrived at 9.55am and was triaged by RN Bott at 10.31am. She recalls being told by police that Shane had vomited and that crystals had been seen in the vomit.

Shane reported he had been on ice and alcohol for 2 days. She took observations and did not identify any immediate concerns. She assessed Shane as ‘ATS Category 2’8, based on the uncertainty about what Shane might have ingested.

8 On the Australasian triage scale.

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30 Cst. Evans heard paramedics tell the triage nurse that Shane had been found with a large quantity of methylamphetamine and had possibly consumed an unknown quantity.

31 Shane was moved to the resuscitation bay9, where RN Woodlock took over his care. RN Woodlock was told by paramedics and police that Shane had ingested and vomited some crystals. Police showed her a photo of the vomit and crystals. Shane told RN Woodlock that he did not know what he had ingested or how much. Shane had an elevated heart rate and was initially drowsy but otherwise had normal vital signs.

32 Dr Clunas reviewed Shane. She was informed that Shane had ingested a crystalline substance, and that police were concerned because he was vomiting and appeared unwell. She ordered an ECG, IV cannula, and bloods for testing.

Observations were normal and venous blood gases showed ‘no stark abnormality’. A decision was made to keep Shane in the ED10 for observation.

33 Shane was moved to a bed in the main ED, where he was nursed by RN Michael.

Shane was later reviewed by Dr Blake. Shane told Dr Blake he had ingested ice and said he used the drug daily. Shane also reported a sore right knee and ankles.

34 Sen. Cst. Golder and Cst. Evans were concerned that Shane had something secreted on his person and indicated to Shane they wanted to strip search him.

Shane removed his clothing and police were satisfied that Shane did not have anything in his clothing. However, he had clenched his buttocks during the process, and police were suspicious he had something placed in his anus.

35 Police asked medical staff to perform a cavity search. However, Shane denied he had inserted anything into his anus. Dr Clunas considered that, as Shane was not acutely unwell, and was denying having inserted anything, an internal examination could only be performed with his consent (which he declined). Dr 9 He did not require resuscitation at this stage – this was simply an available space.

10 Emergency Department.

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Blake explained this position to police, although Sen. Cst. Golder continued to express concern that Shane had something internally. Dr Blake also explained the risk posed by inserting drugs to Shane.

36 An X-ray was performed of Shane’s lower limbs, which did not show any abnormality. Police asked if an X-ray could also be performed of his pelvis. This was offered to Shane, but he again denied having inserted anything. The doctors explained to police that an X-ray would not reliably exclude the presence of drugs.

37 Dr Clunas discussed the case with the oncoming emergency physician, Dr Shamus Shepherd, who agreed with the decision to observe Shane in the ED.

38 During Shane’s admission, Shane told Sen. Cst. Golder and Cst. Evans that he had hallucinated about a man called ‘John’ or ‘Tom’. He also said he had swallowed ‘a huge handful’ of ice in the bushes while hiding from police. He denied consuming any methylamphetamine in the pod of the caged police vehicle, and said the drugs observed by police in the police vehicle must have fallen loose from his pants.

39 Chief Insp. Maher also attended the OHS. Shane maintained his account that he had only swallowed methylamphetamine in the bushes.

40 Dr Clunas stated that there were no reports during the admission about Shane having any acute psychotic symptoms. However, a review was sought from a mental health clinical nurse consultant, RN Stelzer. She formed the view that Shane was not mentally ill, although he described longstanding auditory hallucinations that told him to take drugs. There is reference in the notes to olanzapine (antipsychotic) being prescribed, although it is unclear whether it was administered.

41 When Shane was told he was to be cleared from a mental health perspective, he asked to see the nurse again. He became elevated and said it was unfair and he wanted to speak to a doctor. Dr Clunas attended, she believed he was Inquest into the death of Shane Daniel McMillan 11

coherent. She also spoke to a female police officer, who did not express concerns about Shane’s mental health.

42 At 4.45pm, Dr Clunas and Dr Blake decided that Shane could be discharged. A written discharge summary was prepared, and Dr Blake provided verbal instructions to police. The written summary included the following plan: Plan on Discharge: Discharged into care of NSW Police on 01/12/22 Please seek medical attention should your withdrawal from methamphetamine become intolerable – acutely likely to experience, fatigue, irritability, anxiety, chills and insomnia, sub- acutely may experience significant mood swings Please continue to rest, ice in 20 minute periods and compress your ankles, and right knee as best you can - If lower limb pain in ankles or knee continues longer than 3 days inpatient facility to organise for patient to see GP Return to Emergency or call for ambulance if condition worsens.

43 The discharge summary also records, ‘cardio: No new skipping beats or racing heart reported, no chest pain’.

44 Shane was discharged at about 5pm to 5.30pm.

45 Sgt. Little attended the OHS to convey Shane back to the police station. At the time of her arrival, Shane was talking with staff, was not distressed and had relaxed. She and Sen. Cst. McGovern took Shane back to the police station.

Return to Orange Police Station 46 Sgt. Tonkin was due to commence as custody manager at 6pm. He attended the station at about 5.20pm and was informed that Shane had consumed ‘huge amounts of ice’.

47 Sgt. Tonkin conducted a strip search, with Cst. Evans. That process was recorded on video. Nothing was found. At the end of the search, Shane told Sgt. Tonkin he had chest pains on his left side. Sgt. Tonkin called an ambulance.

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48 Paramedics attended (Melissa Troy and Darren). Sgt. Tonkin told them that Shane had ingested drugs and had been released from the OHS but had been reporting chest pains.

49 The paramedics provided Shane Nurofen and Panadol and then left. They told Sgt. Tonkin there was no need for Shane to present to the OHS and that his heart rate was satisfactory. Shane was then placed in a cell.

50 At around 7:15pm, Shane again complained of chest pains. Sgt. Tonkin recalled the paramedics. Paramedic Melissa Troy attended at about 7.30pm and at 7:44pm, they conveyed Shane back to OHS.

Second admission to Orange Health Service 51 Shane was triaged at 8.11pm by RN Austemin. He reported ‘very bad’ chest pain. His vital signs were normal. He was triaged ATS Category 2 and was commenced on the cardiac pathway.

52 RN Sturt then took over Shane’s care in the ED. Shane told RN Sturt that he had ingested 5 grams of ice. RN Sturt thought this was odd, as Shane’s heart rate was not high (51bpm) which would have been expected. RN Sturt conducted an ECG and took blood for testing.

53 Shane was kept at OHS under observation until 11:22pm. He was reviewed by Dr Hobbs, who discussed the case with the emergency physician, Dr Shepherd.

Shane’s chest pain resolved, his ECG was unremarkable, and his blood test results were normal. It was determined that he was safe for discharge.

54 Shane was conveyed back to Orange Police Station and was booked back into custody at about midnight.

55 Sgt. Tonkin conducted 30-minute checks on Shane throughout the night. On each occasion, he recorded Shane’s intoxication level as ‘not affected’. Shane spoke with the ALS at about 12.10am. He declined an interview, although a brief interview was conducted in the dock area. Among other things, Shane Inquest into the death of Shane Daniel McMillan 13

stated he had been experiencing psychosis for the past 4 days and had been seeing and hearing things which were not real. He was then charged with Common assault, Contravene ADVO, Stalk/intimidate and Supply prohibited drug (>indictable < commercial). Bail was refused at 3.18am.

Events at Orange Police Station on 2 December 2022 56 At 5:30am on 2 December 2022, Sgt. Little commenced as duty supervisor.

Sgt. Irwin informed her of Shane’s return to the OHS and back to custody. Sen.

Cst. Golder was allocated custody manager. Sgt. Tonkin provided a brief handover.

57 Shane was woken up at 5.49am.

58 At 6.18am, Sen. Cst. Golder checked on Shane, who moved his foot and did not raise any complaints11. This was repeated at 6.50am.

59 At 7.20am, Sen. Cst. Golder told Shane she would get him breakfast.

60 At 7.49am, Shane got up and went to the toilet.

61 At 8:10am, Sen. Cst. Golder spoke with Shane about the ALS being contacted.

Shane was cold to the touch. She asked if he was okay, and he said, ‘Yeah, I’m just coming down’. Sen. Cst. Golder says she did not know the symptoms of a drug ‘come down’ so was unable to determine whether his symptoms were normal.

62 At 8.22am, Shane spoke to the ALS about a forensic procedure.

63 Shortly after this, Sen. Cst. Golder observed that Shane appeared to be having hallucinations. She called Sgt. Little, who told her to call an ambulance, which she did at 8.50am.

11 It was common practice that inmates would be advised that they could acknowledge a check by raising their foot, their arm or grunting which would not require them to fully wake up during the middle of the night.

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64 Paramedics Catherine O’Brien and Carl Bevan attended 8 minutes later.

65 Sen. Cst. Golder said that when the paramedics first arrived, they were reluctant to take Shane. Paramedic Bevan said ‘Well, what do you want us to do with him?’. When Sen. Cst. Golder said Shane was not fit for custody, Paramedic Bevan replied that the ‘hospital’12 is not going to want him.

66 When Paramedic O’Brien first attended, Shane was seated in a cell. He was conscious and responsive and was shaking in what she described as ‘a withdrawal type shake as if he was coming down from an illicit drug’.

67 A short while later, Shane slid down from the chair onto the floor.

68 Paramedic Bevan told Sgt. Little that Shane needed to be taken to the OHS.

Paramedic O’Brien moved the ambulance to the back of the station and brought the stretcher in. On her return, Shane was lying on the ground and was conscious, but appeared agitated, with jerking movements.

69 Sgt. Little recalled that Shane’s skin colour changed, and his eyes began rolling back in his head. He was frothing at the mouth and going limp. She spoke to her supervising officer to request assistance.

70 Shane was placed onto the stretcher and moved to the ambulance. As this occurred, Shane became unresponsive. Paramedic O’Brien announced that Shane was in cardiac arrest. According to Sen. Cst. Golder, he said Shane was going to die. Chest compressions were commenced. Sen. Cst. Golder and Det.

Sgt. Casey, assisted with CPR, until a Lucas Device was set up to perform automatic compressions.

71 A second ambulance arrived, with Intensive Care Paramedic Gary Elliott and Paramedic Timothy Mills.

12 Is the OHS.

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72 Shane was conveyed back to OHS, arriving at 9.51am. He was placed in a resuscitation bay and ventilated and was administered adrenaline and bicarbonate. However, a bedside ultrasound confirmed no cardiac activity, and resuscitation was ceased.

73 Shane was pronounced deceased at 10:07am.

Autopsy 74 A three-cavity autopsy was performed by Dr Benjamin Harding on 8 December

2022. Dr Harding recorded the cause of death as ‘Acute methylamphetamine toxicity.’ 75 Toxicology revealed the presence of illicit drugs (methylamphetamine, MDMA and cannabis) in both ante mortem samples (taken at 11:36am on 1 December

2022. and post-mortem samples.

76 The ante mortem concentration of methylamphetamine was 0.2mg/L, whereas the post-mortem concentration was very high, at 51mg/L. Ranges above 0.3mg/L are seen in deaths solely attributed to methylamphetamine toxicity.

The drug can undergo significant post-mortem redistribution.

77 In Dr Harding’s view, it was plausible that Shane was still absorbing methylamphetamine when an ante-mortem sample was taken. He concluded that it is more likely that the very high level of methylamphetamine is as a result of further absorption.

Issues The statutory findings 78 It is not in contention that Shane died on 2 December 2022 at OHS from acute methylamphetamine toxicity.

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79 The inquest explored in detail the circumstances in which the methylamphetamine was consumed. My conclusions on manner of death follow that analysis.

Was an adequate and appropriate personal search conducted on Shane following his arrest on 1 December 2022, prior to his transport to Orange Police Station?

80 Shane was arrested 3 times: (1) by Sen. Cst. Golder prior to being brought to police vehicle (2) by Sgt. Little for breach of AVO and intimidation (3) by Sen. Cst. McGovern when he found the packet of ice on his person.

81 Given the arrest, the NSWPF was entitled to search Shane13. Sen. Cst.

McGovern indicated that when he undertook the search, his focus was on ensuring that Shane did not have any items or weapons which could be used to harm himself, harm others or to escape.

82 Sgt. Wallace identified deficiencies in the personal search conducted by Sen.

Cst. McGovern including at the scene: (1) Sen. Cst. McGovern did not search the top half of Shane’s body (2) the time he spent on the search was brief and therefore unlikely to be effective (3) Sen. Cst. McGovern used the ‘pat down’ technique which is not recommended (although Sen. Cst. McGovern said he did scrunch at least part of Shane’s trousers) 13 Pursuant to s 27 Law Enforcement (Powers and Responsibilities) Act 2002 (NSW) (LEPRA).

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(4) he did not get Shane to turn out his pockets (though he did identify items in Shane’s pockets) (5) he did not consider it urgent or necessary to do a strip search at the scene.

83 Sgt. Wallace acknowledged that the search was being conducted at the scene (a public place) and in circumstances where Shane was unwell. This is very different to a search being conducted at the station. The nature of the search also varies with the circumstances.

84 There exists a necessary tension between the need for a search to be thorough and systematic and the legislative requirements that a search be quick and no longer than reasonably necessary, and that a person’s privacy and dignity be respected14.

85 Sgt. Wallce concluded, and I accept, that in view of how police are trained to search, the search was not optimal, but it was reasonable in all of the circumstances.

Did police take adequate and appropriate steps to obtain medical assistance for Shane on 1 and 2 December 2022?

86 The first time police considered calling an ambulance was at the time of arrest, about 9.22am on 1 December. Shane was dry retching and appeared to have a cut on his left hand, which he cut while mounting the fence. Police told him they would get an ambulance but no ambulance was called.

87 Shane seemed to have recovered and was no longer dry retching when they reached Orange 1515.

14 Ss 27(1)(a) and 32 LEPRA.

15 The vehicle which ultimately transported Shane.

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88 Sen. Cst. McGovern reflected in evidence that he thought the communication about an ambulance at the scene could have been improved.

89 The Police did call an ambulance 4 times.

(1) On 1 December 2022, when they discovered that Shane had vomited in the rear pod of Orange 15. He was obviously unwell. Sen. Cst. Golder thought that Shane was going in and out of consciousness. She called an ambulance and he was taken to OHS arriving at around 9.55am. He remained in the care of the OHS until discharge at 4.45pm and returned to Orange Police Station.

(2) When Shane reported chest pains at about 5.45pm the same day, an ambulance was called. He was assessed by paramedics, he reported a headache and was not transported.

(3) Shane again reported chest pains at 7.15pm, an ambulance was called and he returned to the OHS from 8pm to 11.30pm before returning to Orange Police Station.

(4) The next morning, he was shaking and looking unwell in the dock area at about 8.50am. An ambulance was again called, prior to his collapse and prior to seizure.

90 While Shane was in OHS, Police advocated for investigations to determine if Shane had drugs inside him. Their motivation was Shane’s health, not criminal charges, although we cannot know if Shane was concerned about the latter.

These investigations could not be undertaken without Shane’s consent. Shane did not consent and consistently denied that he had swallowed or otherwise inserted any drugs.

91 While Shane was within the station overnight, Sgt. Tonkin was the cell manager. He attended Shane’s cell to check on him, some inspections were slightly longer, and he did not always fully wake Shane up but looked for signs Inquest into the death of Shane Daniel McMillan 19

of acknowledgement such as a grunt or the lifting of a foot. This was to allow Shane to rest. Sgt Tonkin saw no signs that Shane was intoxicated or otherwise unwell.

92 When she came on shift, Sen. Cst. Golder did not undertake a face to face inspection but she did attend at 6.18am, at which point he appeared fine.

93 I find that the NSWPF took adequate and appropriate steps to ensure Shane’s welfare while in their custody and to obtain for him appropriate medical treatment.

Was the assessment and management of Shane at Orange Health Service adequate; were the decisions to discharge him appropriate; and were his discharge plans appropriate?

First presentation 94 Shane was assessed by Dr Blake and reviewed by Dr Clunas. Dr Clunas understood the concern that Shane had ingested a large quantity of drugs, believed to be methylamphetamine (which they also referred to by the colloquial term ‘ice’).

95 In her evidence, Dr Clunas explained: (1) there is no prescribed procedure, but are guidelines and an accepted process for the treatment, monitoring and management of methylamphetamine ingestion; (2) she was looking for ‘sympathomimetic toxidrome’;16 (3) she undertook/requested observations, blood tests, an echocardiogram (ECG), monitoring of symptoms including pupils, sweats, muscles; and (4) Shane remained ‘under observation’ for a period in excess of 6 hours – it was believed that if he had consumed a toxic level of 16 essentially the symptoms of drug toxicity.

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methylamphetamine, he would have become symptomatic during this period.

96 During this initial observation period, Shane did not present with symptoms and his tests were within normal ranges.

97 Dr Clunas was asked by Police to undertake a rectal exam or x-ray to determine if there were additional drugs present which would pose a risk to Shane. Shane denied having inserted or swallowed any packaged drugs. The risks were explained to him and he refused to consent to the proposed tests. Dr Clunas appropriately could not perform them in those circumstances.

98 Assoc./Prof Gunja confirmed there were no specific guidelines and endorsed a period in excess of 6 hours observation as being supported by studies.

99 I find the treatment provided to Shane during the first admission, and the decision to discharge him, was appropriate.

Second presentation 100 On his send presentation, Shane was assessed by Dr Hobbs. Noting the complaint of chest pains, appropriate investigations were undertaken including an ECG, troponin levels, blood tests, the taking of his history and an examination. Dr Hobbs looked at Shane’s prior history and notes and understood that when Shane had presented earlier that day, drug ingestion was suspected. Shane’s treating team remained concerned that Shane’s symptoms related to drugs. However, his chest pain resolved while he was in OHS, he had no further symptoms, and his tests were all normal.

101 On this second presentation, Shane remained under observation for over 3 hours.

102 In the context of Shane’s earlier admission that day, by the time of his discharge, almost 14 hours had lapsed since his last known ingestion at 9.20.am.

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103 While Assoc./Prof Gunja indicated he would have undertaken subsequent troponin testing17, he accepted that may not be standard practice elsewhere.

While Dr Shepherd agreed that it can be appropriate to undertake subsequent testing, he considered it unnecessary given the brief nature of the chest pains.

104 In the context of a period of 14 hours post known ingestion, Shane’s denials that any packaged drugs had been consumed or inserted, the absence of ongoing symptoms of toxicity, it was appropriate that Shane be discharged.

105 There was no evidence which suggested that the discharge plans recorded following each admission were not appropriate. It was clear to the NSWPF that should Shane deteriorate, further medical assistance should be sought, which they did.

Should health staff have consulted a toxicologist, and/or contacted the NSW Poisons Information Centre about Shane’s management, and if so, when? Is it likely that this would have resulted in any different management?

106 Both Dr Clunas and Dr Shepherd were impressive witnesses.

107 Dr Clunas explained that she had experience in toxicology, from her medical training, in her career, and in practice, as it is not unusual for patients to present at OHS with symptoms of toxicity. While she has and does contact the NSWPIC from time to time, she does this in circumstances where the presentation is unusual or the first line treatment is not working. In this case, Shane was asymptomatic at the time of his discharge which was consistent with his denial that additional drugs had been swallowed or inserted.

108 She does not consider that contacting the NSWPIC would have changed her management of Shane.

109 Dr Shepherd was equally impressive. He also outlined that he regularly encountered patients with acute toxicity and that he considered Shane’s 17 Shows markers for heart damage.

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presentation to be within the scope of his practice. He also considered that calling the NSWPIC would not have altered his management of Shane.

110 Dr Button concurred that there was a prevalence of patients presenting with acute and chronic methylamphetamine toxicity at OHS such that what Dr Clunas and Dr Shepherd faced with Shane was not unusual.

111 Dr Button indicated that there is no protocol per se as the symptoms of drug toxicity varies between patients, they treat the symptoms as they present.

112 Dr Button considered Shane was appropriately treated and did not think that contacting the NSWPIC would have impacted the proposed treatment regime.

113 Given the relative experience of Shane’s treating doctors, the information available to them, and Shane’s presentation, I do not find that they ought to have consulted a toxicologist or the NSWPIC.

When and in what circumstances did Shane consume methylamphetamine? What is the most likely explanation for the reading of 51mg/L methylamphetamine found in his post-mortem toxicology?

114 Shane had injected methylamphetamine twice in the morning of his arrest.

What is uncertain, is whether any additional methylamphetamine was consumed after he was in the custody of the NSWPF.

115 If further drugs were consumed, the evidence suggests there were only two opportunities to do so. Either when he was in the long grass after he ran from police, or while he was in the back of Orange 15. At all other times, Shane was under observation and/or in the view of body worn video or CCTV.

116 On Shane’s own account, he had swallowed a ‘huge handful’ in the long grass.

This is consistent with him later vomiting visible crystals at around 9.20am and 9.45am. Shane denied having any more at any later point or inserting or swallowing a package containing drugs.

Inquest into the death of Shane Daniel McMillan 23

117 Given the limitations of the personal search at the scene, there is a possibility that Shane still had items concealed in his clothing.

118 We know that blood taken from Shane at 11.36am had a modest reading of methylamphetamine 0.2mg/L. What is unexplained is how he then had an extremely high reading in his post-mortem blood of 51mg/L.

119 While post-mortem distribution can explain a differential, Assoc./Prof Gunja did not consider it could explain the vast difference in this case.

120 Assoc./Prof Gunja opined that the only explanation is that Shane had consumed a package of drugs and that the package dissolved resulting in the late onset of fatal toxicity and the absence of packaging found at autopsy.

121 Absent any other rational or reasonable explanation for the delay in Shane’s ultimately fatal symptomatology, I accept the opinion of Assoc./Prof Gunja that it is likely that Shane had swallowed an additional packet of methylamphetamine either when he was in the long grass or shortly after when he was in the back of Orange 15. The packaging failed/dissolved between when Shane was discharged from OHS and when his symptoms of toxicity appeared in the morning of 2 December 2022.

Manner of death 122 There was no evidence suggesting that Shane’s overdose was intentional for the purpose of causing self-harm or suicide. I find that the overdose was accidental.

Is it necessary or desirable to make any recommendations in relation to any matter connected with the death?

123 Having considered all of the evidence and the submissions in this inquest, I do not consider it necessary or desirable to make any recommendations in relation to any matter connected with Shane’s death.

Inquest into the death of Shane Daniel McMillan 24

Concluding remarks 124 I will close by conveying to Shane’s family, friends and community, my sympathy for the loss of Shane.

125 I thank the Assisting team for their outstanding support in the conduct of this inquest. I also thank the representatives of the participants for their respectful conduct in the course of the inquest.

126 I thank the officer in charge, Detective Inspector Griffith, for his tireless work in conducting the investigation and compiling the brief of evidence which was supplemented by the Assisting team. In particular, the time and effort he spent in reviewing all of the available footage to assist the court to understand the circumstances in which Shane died.

Findings required by s 82(1) Identify Shane Daniel McMillan Date 2 December 2022 Place Orange Health Service, Orange NSW Cause Acute methylamphetamine toxicity Manner Accidental overdose, death occurred in police custody.

I close this inquest.

Magistrate R Hosking Deputy State Coroner Lidcombe ********** Inquest into the death of Shane Daniel McMillan 25