Finding into death of Jarrad John Ford

FORM 38 Rule 60(2) ~

FINDING INTO DEATH WITHOUT INQUEST Section 67 of the Coroners Act 2008 Court Reference: 541/08

In the Coroners Court of Victoria at Morwell

1 E.C Batt, Coroner having investigated the death of:

Details of deceased: Sumame: . Ford First name: Jarrad John Address: 59 Service Road Moe Victoria 3825

without holding an inquest: find that the identity of the deceased was Jarrad John Ford and death occurred on 6th February 2008 at Moe from

la) Aspiration pneumonia secondary to drug abuse and overdose of multiple drugs.

In the following circumstances: The deceased, aged 24, was diagnosed with schizophrenia.

On the day before his death, the deceased arrived at his mother’s home at 59 Service Road Moe, affected by valium tablets (Diazepam) he had taken, He told his mother, Carol Ann Ford, that he had taken four or five tablets, an excess of this prescription medication, in order to stop ‘the voices’ he was hearing in his head. He appeared groggy, but expressed no suicidal ideation. His mother was concerned that he may have taken more tablets than he reported and wanted to call an ambulance. however, her son insisted that this was unnecessary, and if one was called he would run off. :

As always, Ms Ford was protective and caring towards her son on this occasion. She got him to bed and then telephoned Latrobe Regional Hospital Mental Health Service to seek guidance, Triage practitioner Steve Gallop, advised her to check her son every half hour and he would be attended to the following day. Ms Ford followed the advice until, exhausted, she fell asleep herself at approximately 3.30am. Her son had been snoring loudly, however, when she awoke at approximately 5.00am he was unresponsive. Police were called but no suspicious circumstances were found. Ultimately, the deceased was conveyed to the Latrobe Regional Hospital and death was pronounced by Doctor Mihir Patel at 8.47am on 6 February 2008.

Post Mortem examination concluded that death was accidental and caused by aspiration pheumonia secondary to drug overdose of multiple drugs. Toxicology tests detected the presence of 9-Tetrahydrocannabinol, Ibuprofen, Morphine, Valporic Acid and Tramadol.

RECOMMENDATIONS:

Pursuant to Section 72(2) of the Coroners Act 2008, I make the following recommendation(s) conneeted with the death:

In this case the presence of a “step-up/step-down” facility in the Latrobe valley may have had a significant impact on the management of the deceased in this time of crisis. If an admission to hospital was not called for in the opinion of the Mental Health Service in this case, an alternative “step-up” facility where the observations endeavouring to be undertaken by the deceased’s Mother, could have been managed by a suitably trained person within such a facility. Had the deceased been admitted to hospital and ultimately discharged, his progress upon on going hospital prescribed treatment would have a better chance of success if it could have been initiated through a “step-down” facility before release back into the general community. Whilst such a “step-up/step-down” facility is available in Bairnsdale (in certain cases) that is geographically inaccessible to Latrobe area residents, Funding for such a facility in the Latrobe Region should be seriously considered by the Minister for Mental Health.

Signature:

Date: