Finding into death of Natasha Calleja

IN THE CORONERS COURT

OF VICTORIA.

AT MELBOURNE Court Reference: COR 2015 004329

FINDING INTO DEATH WITH INQUEST Form 37 Rule 60(1) Section 67 of the Coroners Act 2008

Deceased: NATASHA CALLEJA

Delivered on: 7 April 2017

Delivered at: Coroners Court of Victoria,

65 Kavanagh Street, Southbank

Hearing date: 20 March 2017

Findings of: ROSEMARY CARLIN, CORONER

Counsel assisting the Coroner: Leading Senior Constable Stuart Hastings

Representation Mr Paul Lamb

Page |

HER HONOUR:

BACKGROUND

1. Natasha Calleja was born on 18 January 1983. She was 32 years old when she died on 25 August 2015 after injecting heroin. At the time of her death she was an involuntary inpatient at the Swanston Centre Acute Psychiatric Unit at Geelong Hospital. She died in hospital after a visit from her de facto husband, Mr Jemi Ho, who supplied her with the heroin.

2. Ms Calleja had a medical history of insomnia, asthma, drug-induced psychosis, suicide attempts and chronic heroin abuse. She had previously participated in a methadone program.

She was approximately 5-6 months post-partum at the time of her death.

3. Ms Calleja was much loved by her family and friends and her death has had a profound and

lasting impact upon them.

THE CORONIAL INVESTIGATION

4. Ms Calleja’s death constituted a ‘reportable death’ under the Coroners Act 2008 (Vic) (the Act), as her death occurred in Victoria, was unexpected and unnatural and she was ‘in care’ at the time. Her ‘in care’ status arose from the fact she was subject to an Inpatient Temporary Treatment Order (‘ITTO’) under the Mental Health Act 2014 (Vic) (MHA) at the time of her death.

5. The jurisdiction of the Coroners Court of Victoria is inquisitorial. The role of a coroner is to independently investigate reportable deaths to find, if possible, identity, medical cause of death and with some exceptions, surrounding circumstances. Surrounding circumstances are limited to events which are sufficiently proximate and causally related to the death.

6. It is not the role of a coroner to lay or apportion blame, but to establish the facts.' It is not a coroner’s role to determine criminal or civil liability arising from the death under investigation, or to determine disciplinary matters.

7. The cause of death refers to the medical cause of death, incorporating where possible, the mode or mechanism of death.

8. Under the Act, coroners also have the important functions of helping to prevent deaths and

promoting public health and safety and the administration of justice through the making of

' Keown v Kahn (1999) 1 VR 69.

comments or recommendations in appropriate cases about any matter connected to the death under investigation.

In the coronial jurisdiction facts must be proved on the balance of probabilities with due regard to the principles enunciated in Briginshaw v Briginshaw.? The effect of this and similar authorities is that coroners should not make adverse findings against, or comments about, individuals, unless the evidence provides a comfortable level of satisfaction as to those matters taking into account the consequences of such findings or comments.

Victoria Police assigned an officer to be the Coroner’s Investigator for the investigation into Ms Calleja’s death. The Coroner’s Investigator conducted inquiries on my behalf, including obtaining statements from key nursing and administrative staff working at the Swanston Centre at the time of Ms Calleja’s death on the evening of 25 August 2015 and submitted a coronial

brief of evidence.

. After receipt of the brief, I obtained additional material including further statements from

Geelong Hospital, letters of concern from family members and relevant hospital policies.

Ordinarily when a person dies ‘in care’ from unnatural causes an inquest into the death is mandatory. However, as Ms Calleja’s de facto spouse Mr Ho was charged with an indictable offence (namely possession of heroin) in respect of her death, the holding of an inquest was

discretionary.

. After reviewing all the material I determined that I would hold an inquest into Ms Calleja’s

death. Although the circumstances of her death were adequately revealed by the coronial brief I was of the view that I would benefit from hearing evidence about hospital policies and procedures in relation to the searching of visitors to the Swanston Centre.

An inquest was held on 20 March 2017. Barwon Health appeared and was represented by Mr Lamb of Counsel. Ms Calleja’s brother Joseph Calleja and his wife Ellen attended but were not represented. One witness was called, namely Associate Professor Richard Harvey, a psychiatrist responsible for the overall care of Ms Calleja and the Clinical Director of Mental Health, Drugs and Alcohol Services, Barwon Health. Professor Harvey was involved in the drafting of relevant hospital procedures.

This finding is based on the totality of the material obtained during my coronial investigation, including the inquest. Whilst I have considered all the material, I will only refer to that which

is directly relevant to my findings or necessary for narrative clarity.

2 (1938) 60 CLR 336.

Circumstances

Motor Vehicle Accident

le.

Ms Calleja’s admission to the Swanston Centre was precipitated by a motor vehicle accident some two weeks earlier.

On Monday 10 August 2015 at approximately 5.30pm Ms Calleja left her house in St Leonards with her two children Paul (then 8 years old), and Jemisha (then 6 months old). Ms Calleja’s family members did not have any contact with her over the next 24 hours as she was not carrying a mobile telephone.?

On Tuesday 11 August 2015 at approximately 10.00pm Joseph Calleja received a telephone call from the Geelong Police Station advising him that his sister Natasha and her two children had been involved in a single vehicle accident. Ms Calleja’s family were informed that Ms Calleja was unhurt but required a mental health assessment.*

A police officer who attended the accident, Constable Zac Taylor, provided a written account of the incident.* He and his partner were notified that a car was driving erratically on the Princes Highway at approximately 8.00pm that evening. When they arrived they saw the car mount the median strip at the cross intersection of Breed and Princes Highway and continue to speed past their police van. The police van turned right onto the Princes Highway and followed the car at a distance. It failed to stop at two red lights and travelled in an emergency lane to avoid the stationary traffic. The police officers momentarily lost sight of the car before coming across debris at a roundabout. They then saw the car about 200 metres east of the roundabout where it had collided with a metal fence. Ms Calleja got out of the car with her two children.

When asked by Constable Taylor if her children had any injuries Ms Calleja held her daughter Jemisha upside down by the legs and said ‘She’s fine’ and ‘Don’t touch my children’. She appeared ‘vague and disorientated’ and was struggling to understand questions. She was unwilling to let the police officers check Jemisha for injuries. Ms Calleja and her children were taken to Latrobe Regional Hospital by ambulance with a police escort.

Ms Calleja was admitted to the Flynn Unit at the Latrobe Regional Hospital. She was initially placed on an Inpatient Assessment Order under the MHA and then an ITTO under that Act. On 14 August 2015 she was transferred to the Swanston Centre psychiatric unit at Geelong Hospital pursuant to the terms of her ITTO. Ms Calleja then spent 11 days as an inpatient at

the Swanston Centre prior to her death.

3 Combined statements of Calleja family (3 June 2016), Inquest Brief p 1.

• Ibid.

Statement of Constable Zac Taylor (21 February 2016), Inquest Brief pp 48-49.

Circumstances proximate to death

Ms Calleja started the day of 25 August 2015 on Category 3 visual observations which required her to be sighted every 15 minutes. Nursing staff later downgraded her to Category 2 which required her to be sighted every 30 minutes.® This decision was made as Ms Calleja was ‘more co-operative, was spending majority of her time in open areas of the unit where staff could see her, she was more settled in her presentation- less impulsive and no longer agitated as she was in the previous shift’.”

At approximately 1.20pm Registered Psychiatric Nurse Alida Verschuur (RN Verschuur) commenced her shift and received a handover from enrolled nurse Mark Drayton (EN Drayton), who had been looking after Ms Calleja in the morning. RN Verschuur was the primary nurse for five patients, including Ms Calleja, during the afternoon-evening nursing shift on 25 August 2015 at the Swanston Centre. She had not looked after or met Ms Calleja before.®

EN Drayton explained the recent downgrade in Ms Calleja’s level of observations. He described Ms Calleja’s behaviour earlier in the day as ‘aggressive and abusive’ due, he believed, to the restriction on smoking in the Swanston Centre. He said she was ‘disorganised, paranoid and had not developed any insight into her situation’. He did not report that she was a suicide risk.

The handover sheet provided to RN Verschuur by EN Drayton described Ms Calleja as having a history of borderline personality disorder, drug induced psychosis from poly-substance abuse and being five months post-partum which may have contributed to her psychosis. It also stated that she had a history of unprovoked assaults, had recently attempted to overdose on heroin, had a recent motor vehicle accident thought to be deliberate, had been monitored for opiate withdrawal and had been opiate free since transfer to the Swanston Centre.

At approximately 1.30pm, EN Drayton introduced RN Verschuur to Ms Calleja. Ms Calleja appeared ‘vague, dismissive and made no eye contact’.

At approximately 4.30pm Ms Calleja approached the nurses’ desk carrying a clipboard and asked to use the telephone. RN Verschuur understood she first called her bank to check whether her mortgage payment had been made. After this call she appeared concerned and then called Mr Ho. RN Verschuur overheard her complaining to Mr Ho about the unpaid mortgage and ‘yelling’ at him. After the telephone call, Ms Calleja approached RN Verschuur

6 Decisions in relation to the observational category are made by the shift manager together with the primary nurse looking after the patient.

” Statement of RN Hayes (28 January 2016) Inquest Brief p 23.

5 Statement of RN Verschuur (4 February 2016), para [3], Inquest Brief p 28.

and asked if she could have a few puffs of a cigarette. She said her house was for her and her children, and appeared ‘irritable, flat and unhappy about her mortgage situation”.

At approximately 5.00pm Ms Calleja asked RN Verschuur for benzodiazepine medication.

After checking Ms Calleja’s medication chart, RN Verschuur refused but offered chlorpromazine tablets and nicotine replacement therapy instead, which was accepted. Ms Calleja then had her dinner.

At approximately 6.20pm reception advised RN Verschuur that Ms Calleja’s husband had arrived. RN Verschuur met Mr Ho in the foyer. He was casually dressed and holding a plastic A4 sized document folder which was zipped up. She expected the A4 folder contained mortgage documents given the content of their conversations earlier that day. Mr Ho was not searched nor asked to empty his pockets or open the folder.

RN Verschuur took Mr Ho to Ms Calleja who was in the lounge area. She monitored the way they greeted each other to ensure it was amiable. Ms Calleja appeared pleased to see her husband.

At 7.00pm Ms Calleja and Mr Ho approached RN Verschuur at the nurses’ station, and Ms Calleja asked if she could speak with her husband ‘in private’. RN Verschuur wanted to be able to continue visual observations and therefore directed Ms Calleja and Mr Ho to the ‘fish bowl’, a separate glassed room which was visible from the nursing station but offered some privacy as conversations were not audible from outside.

At 7.15pm RN Verschuur noticed that Ms Calleja and Mr Ho were no longer in the fish bowl.

She thought they may have gone to Ms Calleja’s room so she immediately checked the room and noted they were not there. She raised the alarm and staff commenced searching for Ms Calleja.

RN Verschuur searched the courtyard and reception area and then looked in Ms Calleja’s room again. She noted the ensuite bathroom door was closed and locked from the inside. She called out that she was a nurse and was coming in, then opened the door. Ms Calleja was lying on her right side in the foetal position on the floor next to the toilet. Her underpants down, there was a plastic spoon in her mouth and a plastic bag stuck to the right side of her face. An empty syringe and needle were hanging in her right inner elbow. She was not breathing and had no pulse. Cardio-pulmonary resuscitation was commenced and continued by the ‘code blue team’ who also administered naloxone (a synthetic opioid antagonist used for the treatment of opioid

dependence and to counter overdose) and adrenaline.

° I note that according to her family Ms Calleja did not have a mortgage, suggesting that RN Verschuur may have misheard or Ms Calleja was engaged in a ruse.

33:

39:

36;

RN Verschuur was directed to find out what Ms Calleja had taken. She looked for Mr Ho and found him in the toilet in the public foyer area. RN Verschuur told Mr Ho that Ms Calleja had collapsed and said they needed to know what she had injected. Mr Ho appeared distressed. He shook his head and said something to the effect of J told her not to have it’ before admitting Ms Calleja had taken heroin.

All resuscitation efforts failed and Ms Calleja was declared deceased at 8.06 pm.

Mr Ho was formally interviewed by police on 31 August 2015 and admitted supplying heroin, a syringe and needle to Ms Calleja while they were in the fish bowl. He said the items had been separately packaged in his pocket. He explained that she ‘was doing it very hard’ and kept asking and asking him to bring in heroin. He thought that maybe she was withdrawing and his intention was to make ‘her time easy’.

Mr Ho was subsequently charged with possession of heroin. He was convicted and fined for

that offence in the Geelong Magistrates Court on 10 November 2015.

Cause of death

Be

On 3 September 2015, Dr Gregory Young, Forensic Pathologist at the Victorian Institute of Forensic Medicine, conducted an autopsy on the body of Ms Calleja after reviewing a post mortem CT scan. The autopsy revealed fresh needle puncture sites in both arms (consistent with resuscitative intravenous cannulae insertion as well as use of a syringe) and features of a chronic injection site in the left arm. Her liver showed chronic hepatitis and there was pulmonary oedema in the lungs.

Toxicological analysis of post mortem specimens taken from Ms Calleja identified morphine and codeine (both consistent with the use of heroin), naxolone, diazepam! and its metabolite, chlorpromazine, olanzapine, a metabolite of risperidone, ziprasidone and zuclopenthixol (both used to treat schizophrenia and psychoses), and a metabolite of amitriptyline (an antidepressant).

After reviewing toxicology results, Dr Young completed a report, dated 15 October 2015, in which he formulated the cause of death as ‘1(a) combined drug toxicity’. He commented that heroin can cause death immediately (due to the injection itself), from overdose (leading to central nervous system depression) or as a complication of unconsciousness, leading to airway obstruction. He observed that drugs such as diazepam and amitriptyline can also cause central

nervous system depression.

'© Barwon Health records show that Ms Calleja was administered 10mg of diazepam at 12.50 am on 25 August 2015.

40. During his evidence Associate Professor Harvey accepted the reason for ascribing the cause of death to combined drug toxicity, but proffered his view that the immediate and predominant contributor to Ms Calleja’s death was her injection of heroin. He considered that although they were sedatives her prescribed drugs were unlikely to have interacted with the heroin!!.

41. I forwarded the transcript of Associate Professor Harvey’s evidence to Dr Young for comment.

Dr Young essentially agreed that the temporal relationship between Ms Calleja’s administration of heroin and collapse made it likely that her death was mostly due to the immediate effects of the heroin. He noted that her previous abstinence made her more vulnerable to a heroin overdose. However, given their known potential to interact with heroin (and each other), Dr Young considered that it was not possible to rule out contribution by the other drugs in her system”.

42. Given the presence of a number of potentially interacting drugs in her system, I am satisfied that Dr Young’s formulation of ‘combined drug toxicity’ is appropriate, however I propose to add the words ‘mainly heroin’ to reflect the fact that heroin was the main and immediate cause

of Ms Calleja’s death.

Identity of the deceased

43. The deceased was identified by her brother Joseph Calleja on 25 August 2015. Identity was not

in issue and required no further investigation.

Management of Mr Ho’s visit on 25 August 2015 by Barwon Health

Family concerns

44. Various members of the Calleja family provided a bundle of joint statements through their spokesperson Ellen Calleja (Joseph’s wife). In the statements the family expressed serious

concerns about the management of Mr Ho’s visit to Ms Calleja on 25 August 2015:

'! Transcript pages 20, 58 — 61.

? The eMIMS DrugAlert Interactions site states the following with regards to these drugs:

1. Both opioid agonists (such as heroin/morphine) and benzodiazepines (such as diazepam) may cause sedation and respiratory depression, hence concurrent use of these agents may increase these risks.

2. Coadministration of tricyclic antidepressants (such as amitriptyline) with opioid agonists (such as heroin/morphine) may cause additive CNS depressant effects.

3. Concurrent use of benzodiazepines (such as diazepam) and tricyclic antidepressants (such as amitriptyline) may lead to additive CNS depression including excessive sedation.

We were surprised to hear that the IPU allowed Jemi entry into the IPU given Natasha’s reaction to Jemi during their previous visit and as staff had previously recognised that he too required help for his drug use. We were also disappointed to hear that Natasha and Jemi were allowed to enter a private room to discuss matters with no supervision. We understand that the IPU [is] not a jail, and that inpatients need to be treated with dignity and respect, however given the circumstances and that staff were aware of Natasha and Jemi’s recent drug use and Natasha’s recent overdose and past drug use history, this arrangement of allowing Natasha and Jemi to meet together unsupervised did not seem safe especially since visitors are not checked to see if anything unsafe is being brought into the facility ... There were many errors in judgment within the IPU procedures and again, although we do recognise the IPU is not [a] jail, Natasha was an Involuntary patient and at risk to herself. Allowing Jemi access to Natasha without supervision was a critical error in judgment and one which has cost her

children and family dearly.

Hospital Procedures

The Swanston Centre procedures in relation to visitors were outlined in the statement of RN Christopher Fryar'* and in the statement and oral evidence of Associate Professor Harvey.'4 With minor changes the procedures at the time of Ms Calleja’s death are still current. Visitors are strongly encouraged because they are regarded as important to patient recovery. According to RN Fryar it would be rare for a visitor to be refused entry.

Visitors report to reception in the front foyer where they sign in and declare that they have received a ‘Visitor Information Sheet’. There are multiple copies of the Visitor Information Sheets next to the sign-in book.

The Visitor Information Sheets consist of a double sided A4 sheet of paper outlining the roles and responsibilities of visitors, including, at the relevant time: e ‘All belongings being brought onto the ward must be approved by nursing staff.’ e ‘The Swanston Centre Staff reserve the right to search belongings if it is believed there is a risk to the safety of others.’ And under the heading ITEMS NOT PERMITTED appears a list which includes: ‘ILLICIT SUBSTANCES - illicit substances found will be removed and disposed of by staff’

There was also a warning sign prominently displayed on the reception window which read:

3 Dated 8 January 2016, Inquest Brief p 36.

4 Dated 14 March 2017.

VISITORS - PLEASE NOTE

ON ENTERING THIS BUILDING, YOU MAY BE REQUESTED TO PRESENT ALL BAGS FOR A SEARCH BY BARWON HEALTH STAFF REFUSAL COULD RESULT IN A REQUEST TO LEAVE

NO ALCOHOL ILLICIT SUBSTANCES OR WEAPONS WILL BE PERMITTED.

Visitors are met in reception by the primary nurse of the patient being visited (RN Verschuur in this case) and taken into the secure area of the unit by that nurse. Interactions between visitors and patients are monitored on an individual basis with decisions about the level of monitoring depending on the state of the patient at the time of the visit. Visits occur in public areas; visits in rooms are not allowed.!>

According to RN Verschuur the first time, or first several times, a visitor comes to the unit, the nurses educate them about items not permitted, such as weapons, illicit substances, ligatures such as electrical cords, medication from the outside and caffeine. She expected that Mr Ho had already been given this information as he had visited Ms Calleja on previous occasions. !® Swanston Centre staff believe they have no ‘legal’ right to search visitors, but they can deny access to the unit. Barwon Health has a written procedure (current at the time) entitled ‘Searching of a Consumer and their Property/Belongings’ with the stated aim of describing search processes permissible by law which ensure clinical safety, while respecting consumer rights. Associate Professor Harvey said the goal is to ‘balance the dignity of family members and other visitors, and the therapeutic benefits of engaging them in the treatment process, against any risks to patients’.

This document contains a section headed ‘Visitors to the Acute Unit’ which discusses the need to balance the risk to patients and staff against the ‘level of intrusion or exclusion contemplated’. Although it could be better expressed, the section appears to stipulate that if a visitor brings in property for the patient, that property must be searched before the patient has

access to it. In relation to a visitor’s own property the section states:

'S Transcript page 36.

'6 Evidence in the brief indicated Mr Ho had visited on the 21 August 2015, and the 24 August 2015.

‘If it is suspected that visitors are bringing illicit substances or dangerous materials to the Acute Unit the unit/shift manager should be informed. Staff should not touch the contents but the visitor should be requested to remove the contents of their bags for inspection.

Searching can only occur with the express consent of the visitor. If a visitor refuses to consent to an inspection of his or her belongings, the visitor should be refused entry to the premises, and if necessary, asked to leave the facility.’ According to RN Verschuur staff exercise their discretion as to what property of visitors is searched before they enter the Swanston Centre. It was her practice to ask a visitor who was carrying a large bag, shopping bag or parcel what was in the bag or parcel. If the visitor refused to consent to a bag or parcel inspection, she could refuse entry. She said it was not the usual practice to inspect handbags or coats and staff had to balance privacy and dignity and staff rapport with visitors and patients against the risk of visitors bringing dangerous or illicit substances into the unit.

RN Verschuur said she had ‘no reason to believe or suspect that [Mr Ho] was bringing illicit or dangerous substances with him’. There were no concerns noted about him at handover or in the progress notes concerning Ms Calleja.

Associate Professor Harvey agreed with RN Verschuur’s interpretation and application of the procedure generally and on the day. He agreed that there is no ‘blanket rule’ that all visitors must be subjected to searches or a particular kind of search. In practice, staff will usually ask visitors about the content of their bags. If the bag contains items for the patient, staff will search the bag and give the items to the patient. This is done to prevent ligature risks, weapons, alcohol and illicit substances being brought onto the unit. However, if the bag and contents belong to the visitor, the search options are generally limited to asking what is in the bag and asking the visitor to show staff its contents.

Associate Professor Harvey confirmed that staff generally will not look in smaller items such as coats unless there is perceived to be a ‘specific risk’. They will not perform pat-down searches or ask visitors to remove clothing or shoes for searches as this would ‘go beyond what is reasonable and dignified treatment of visitors ... [and] create an environment that is not conducive to mental health recovery and would contradict the Mental Health Principles and potentially the Charter of Human Rights and Responsibilities Act 2006’.

Associate Professor Harvey also agreed with RN Verschuur’s assumption that Mr Ho would have been provided with the Visitor Information Sheet on his previous visits. He emphasised that information about what can and cannot be brought into the unit is also shown on the ‘highly visible’ sign at reception, that it is clear illicit drugs are not permitted, and visitors have

a ‘degree of responsibility’ in this respect.

58. In relation to the family’s contention that staff knew that Mr Ho was an illicit drug user, and therefore should have exercised more caution, Associate Professor Harvey was not certain whether that was the case. He explained that privacy considerations did not permit the searching of hospital records to obtain information about a visitor, so that even if there was institutional knowledge, individual staff members may not have known. In any event, Associate Professor Harvey explained that approximately 80% of Swanston Centre patients have substance use issues and it is assumed that their partners and visitors do also: ‘you have to

run from the assumption that everybody is a user’!’.

He said if this fact alone gave rise to a relevant suspicion under their search procedure, it would require the property of almost every visitor to be searched. Rather, the suspicion envisaged by the procedure requires more specific

evidence, such as a prior occurrence or a suspicious parcel in a bag.

Changes since Ms Calleja’s death

59. There have been some changes to Swanston Centre visitor procedures since Ms Calleja’s death:

The Swanston Centre administration has been relocated to the front reception area after

hours in order to strengthen the monitoring of all visitors signing in and out.

The sign in sheet has been augmented by a visitor badge that must be worn by visitors and returned at the end of the visit. Associate Professor Harvey observed there was some

doubt as to whether Mr Ho had signed in.

The Visitor Information Sheet now explains the requirement to wear a badge and the two

bullet points quoted above at paragraph [48] have been replaced with: ‘All belongings brought onto the ward will be searched by nursing staff and items of risk removed’.

Further the word ‘illicit’ has been replaced with ‘illegal’.

The unit is currently installing visitors’ lockers, and the ‘idea is that if visitors do not

want bags or belongings searched, they can place these in the locker before visiting patients’.

According to Associate Professor Harvey, apart from the badges, these improvements were part

of a ‘general review of processes’ and were not precipitated by Ms Calleja’s death.

7 Transcript page 15.

Possible preventative measures

él.

Associate Professor Harvey agreed that patients in the Swanston Centre are at particular risk of overdose from illicit substances because they have had a period of abstinence and it is possible the illicit substances may interact with their prescribed drugs (albeit he considered the latter risk small). He doubted that Mr Ho had ever been informed of this fact and postulated the desire to keep the message simple as the reason the Visitor Information Sheet did not explain it

either.

As to whether there should be more stringent search procedures Associate Professor Harvey pointed to the responsibilities of the hospital and its staff to comply with the Mental Health Principles set out in section 11 of the MHA, particularly the requirements to provide assessment and treatment in ‘the least restrictive way possible’, to promote ‘best possible therapeutic outcomes’, to respect and promote the ‘rights, dignity and autonomy’ of the patient and to respect, recognise and support visitors in their role as carers. He said the Swanston Centre has to rely on visitors to act responsibly and not bring in illicit substances. Measures such as requiring all visitors to agree to a search of their belongings or to empty their pockets as a condition of entry or requiring patients to provide lists of names or details of potential visitors may infringe the mental health principles by detracting from the freedom and dignity of the patient and the visitor, would possibly dissuade visitors from coming at all and ‘would

impair our ability to provide ... high quality, inclusive recovery oriented care’.'®

Significantly Associate Professor Harvey also doubted the efficacy of a stricter approach. He said that drugs can get into a hospital ward by many different routes. I accept the force of this argument. Visitors intent on bringing illicit substances into the Centre could easily circumvent a policy which mandated bag searches and emptying of pockets as a condition of entry by secreting the substances on their person. I also accept that such a policy would pose logistical difficulties considering the volume of visitors (probably hundreds a day!’) to the Swanston

Centre.

'8 Transcript page 18.

9 Transcript page 45.

FINDINGS

Having investigated the death of Ms Calleja and having held an inquest in relation to her death on

20 March 2017, at Melbourne, I make the following findings, pursuant to section 67(1) of the Coroners Act 2008 (Vic):

(a) the identity of the deceased was Natasha Calleja, born 18 January 1983;

(b) Ms Calleja died on 25 August 2015, at Barwon Hospital, Geelong, Victoria from

combined drug toxicity, mainly heroin;

(c) Ms Calleja’s death was the unintentional consequence of her consumption of drugs, in

particular heroin;

(d) the heroin was supplied to her by her de facto partner, Jemi Ho; and

(e) her death occurred in the circumstances described above.

COMMENTS

Pursuant to section 67(3) of the Coroners Act 2008 (Vic) I make the following comments connected

with the death:

The death of Ms Calleja graphically illustrates the potential harm of illicit substances to hospital inpatients. Although the magnitude of the potential harm is great, I am not satisfied that introducing compulsory searches as a condition of entry would achieve the desired result.

I am therefore not satisfied the benefits of such a policy would outweigh the disadvantages and accept that the discretionary nature of the existing procedure is appropriate. That said, in my view, the existing procedure would be enhanced by including the searching of pockets by consent. This can be achieved by a simple amendment, namely by adding the words ‘and their

pockets’ after the word ‘bags’, so that the procedure reads:

‘Staff should not touch the contents but the visitor should be requested to remove the contents

of their bags and their pockets for inspection’.

Further, I believe more could be done to educate hospital patients and visitors about the

particular risks posed by illicit drugs if taken after a period of abstinence and/or in combination

with hospital prescribed drugs. It is trite to say that people are more likely to comply with rules when they understand the reason for them. I accept Associate Professor Harvey’s evidence”?

that it would be counterproductive to talk about death to mentally ill patients and I also accept that many patients, for example Ms Calleja, may not be well enough to participate in such a discussion. However, this only reinforces the need to educate visitors on the topic. The message could be simply conveyed by amending the Visitor Information Sheet to include in

prominent typeface the following or similar:

HOSPITAL PATIENTS HAVE AN INCREASED RISK OF OVERDOSE FROM ILLICIT SUBSTANCES.

The nurse who signs the visitor in could supplement this statement by further explanation as he or she sees fit.

Finally, after the Inquest, Ellen Calleja wrote to the Court outlining her concerns that the Visitor Information Sheets and warning signs would not be understood by the many visitors with poor English literacy, such as Mr Ho. This point is well made. It is incumbent on the hospital to ensure these documents are available in other languages or otherwise understood by

all visitors to the Swanston Centre.

RECOMMENDATIONS

Pursuant to section 72(2) of the Coroners Act 2008 (Vic) I make the following comments connected

with the death:

Barwon Health’s Searching of a Consumer and their Property/Belongings procedure be amended in the manner outlined in Comment 1 of this finding so that it contains the words: ‘Staff should not touch the contents but the visitor should be requested to remove the contents

of their bags and their pockets for inspection’

The Swanston Centre Visitor Information Sheets be amended in the manner outlined in Comment 2 of this finding so that it contains the warning: ‘HOSPITAL PATIENTS HAVE AN

INCREASED RISK OF OVERDOSE FROM ILLICIT SUBSTANCES’.

Barwon Health take steps to ensure that the Swanston Centre Visitor Information Sheets and warning signs are available in other languages or otherwise capable of being understood by

persons with non-English speaking backgrounds or poor English literacy.

2° Transcript page 10.

PUBLICATION Pursuant to section 73(1) of the Coroners Act 2008, | order that this Finding be published on the

internet.

I convey my sincerest sympathy to Ms Calleja’s family and friends.

I direct the Register of Births, Deaths and Marriages be amended so that the cause of death on Ms

Calleja’s death certificate is: “combined drug toxicity, mainly heroin’.

I direct that a copy of this finding be provided to the following: Jemi Ho, senior next of kin The Calleja Family Barwon Health Office of the Chief Psychiatrist Register of Births, Deaths and Marriages

Signature:

CORONER ROSEMARY CARLIN

Date: 7 April 2017