Finding into death of Jackson Desmond David Stawicki

IN THE CORONERS COURT COR 2020 005110 OF VICTORIA AT MELBOURNE FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 63(2) Section 67 of the Coroners Act 2008 Findings of: Coroner Paresa Antoniadis Spanos Deceased: Jackson Desmond David Stawicki Date of birth: 7 March 1996 Date of death: Between 11 and 14 September 2020 Cause of death: 1(a) Haemorrhagic shock in the setting of a sharp force injury to the left arm Place of death: 97 Roslyn Road, Belmont, Victoria, 3216

INTRODUCTION

1. On 14 September 2020, Jackson Desmond David Stawicki was 24 years old when he was found deceased at home. At the time, Jackson lived alone in Belmont, Victoria, having recently moved out of a share house in Waurn Ponds.

2. Jackson was born in New South Whales and had a disrupted start to his childhood. At the time he was born, his biological father was in prison. Afterwards, Jackson and his parents moved to the Gold Coast. His parents separated prior to Jackson starting school and for a time he alternated between living with his mother and his paternal grandmother, Christina Stawicki.

3. In 2005, Jackson experienced further dislocation when his mother became unable to care for him. He moved to live with Ms Stawicki on a permanent basis and she became his main support. Thereafter, he only had sporadic contact with his parents.

4. Jackson attended several schools in the Geelong area. He had difficulty fitting in with his peers, and with his concentration and attendance. Despite his difficulties at school, Ms Stawicki recalled he was an “exceptionally intelligent child.”1

5. Jackson had a history of substance abuse that started at a young age. He was first referred to drug and alcohol services at Barwon Health in 2010, and had subsequent episodes of care in 2012, 2013, 2016 and 2017.

6. Throughout these episodes of care Jackson presented with depression, substance abuse, emotional dysregulation with suicide attempts and significant psychosocial issues. Periods of homelessness were also reported. The history of these presentations suggests Jackson would engage with services when in crisis before disengaging again when the crisis resolved.

7. In 2018, Jackson moved out of his grandmother’s house and lived across a number of houses with friends. He also stayed with his biological mother briefly for around three months.

Throughout this time, he remained in frequent contact with Ms Stawicki, and they continued to enjoy a strong relationship.

8. Ms Stawicki stated that Jackson reported self-harming and threatening suicide on many occasions. She believed these behaviours were often to seek attention.

1 Statement of Christina Stawicki dated 26 October 2021.

9. Jackson was in good physical health and did not have a regular General Practitioner (GP).

According to Medicare and Pharmaceutical Benefits Scheme (PBS) records obtained from Services Australia, in the 12 months leading up to his death, Jackson only attended Dr Olurotimi Orekoya on one occasion being 2 January 2020.

10. The evidence suggests Jackson did not have a history of underlying natural disease and was not prescribed any ongoing medications.

THE CORONIAL INVESTIGATION

11. Jackson’s death was reported to the Coroner as it fell within the definition of a reportable death in the Coroners Act 2008 (the Act). Reportable deaths include deaths that are unexpected, unnatural or violent or result from accident or injury.

12. The role of a coroner is to independently investigate reportable deaths to establish, if possible, identity, medical cause of death, and surrounding circumstances. Surrounding circumstances are limited to events which are sufficiently proximate and causally related to the death. The purpose of a coronial investigation is to establish the facts, not to cast blame or determine criminal or civil liability.

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

14. Victoria Police assigned Sergeant Benjamin Nash to be the Coroner’s Investigator for the investigation of Jackson’s death. The Coroner’s Investigator conducted inquiries on my behalf, including taking statements from witnesses – such as family, the forensic pathologist, treating clinicians and investigating officers – and submitted a coronial brief of evidence.

15. This finding draws on the totality of the coronial investigation into the death of Jackson Desmond David Stawicki including evidence contained in the coronial brief. Whilst I have reviewed all the material, I will only refer to that which is directly relevant to my findings or

necessary for narrative clarity. In the coronial jurisdiction, facts must be established on the balance of probabilities.2

BACKGROUND

16. Between 4 and 5 September 2020, Jackson was conveyed either by ambulance or Victoria Police to the University Hospital Geelong Emergency Department (ED) operated by Barwon Health. On each occasion, Jackson was apprehended and transported to the ED for a mental health assessment pursuant to section 351 of the Mental Health Act 2014 (Vic) (MHA).

17. Section 351 of the MHA permits a police officer to apprehend a person for the purpose of taking them to a hospital for mental health assessment where:

(i) The person appears to have mental illness; and (ii) because of the person's apparent mental illness, the person needs to be apprehended to prevent serious and imminent harm to the person or to another person.

First Presentation: 10.35pm 4 September 2020

18. On the evening of 4 September 2020, Jackson was at a share house in Waurn Ponds where he lived with several friends. Due to a dispute between Jackson and his housemates, the police were called and arrived at the address at about 9.20pm. When police arrived, Jackson appeared drug affected and was not making sense. He was apprehended under section 351 and, with the assistance of paramedics, was conveyed to the ED.

19. On arrival at the Geelong Hospital ED, Jackson was agitated and told clinicians he had used cannabis, methamphetamine and alprazolam. ED Clinician Dr Conor Kelly assessed him as having a mild behavioural disturbance without psychosis. Diazepam (and anxiolytic or antianxiety medication) and olanzapine (an antipsychotic) were administered to Jackson to deescalate his behaviour and calm his mental state.

20. The de-escalation strategies were effective and at 12.23am on 5 September 2020, Jackson was reviewed by mental health clinician nurse, Ms Amanda French. Although he presented as substance affected, Jackson was able to hold a reasonable conversation regarding his mental 2 Subject to the principles enunciated in Briginshaw v Briginshaw (1938) 60 CLR 336. 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.

health. He disclosed a history of long-standing depression, insomnia, anger management issues, a traumatic childhood and substance use since he was teenager. He further reported he that had been prescribed the antidepressant mirtazapine by his general practitioner but was not taking the medication.

21. He was assessed with having a history of cluster B personality traits3, attention deficit hyperactivity disorder, anxiety, depression, and polysubstance abuse. Jackson denied any suicidal intent, plan or thoughts.

22. Ms French contacted the on-call psychiatrist, Dr Emily Moriarty, and noted that “Jackson is currently presenting as substance affected. Despite this, he was able to hold a reasonable conversation about his mental health and accepted oral medication.”4

23. Jackson was assessed as not having active psychotic symptoms and being at low risk of suicide with cluster B personality traits and impulsive behaviour. He was also assessed as posing a moderate risk of harm to others. A plan was made to discharge Jackson with community follow-up from the Child and Youth Triage Team and he was provided with contact numbers for crisis and addiction service contacts.

24. Jackson was placed in a taxi to take him home. However, he became upset again and abusive towards the taxi driver and got out of the taxi. Police were called again and, after receiving confirmation from the hospital that it was appropriate to do so, returned Jackson to his current home at 1.23am on 5 September 2020.

Second Presentation: 4.50am 5 September 2020

25. At 2.17am, police returned to Jackson’s residence in Waurn Ponds due to further reports from his housemates that Jackson was damaging property. Jackson’s friend and landlord, Heath Tournier, told police he would arrange alternate accommodation for Jackson in Belmont to remove him from the current environment. Police left a short time later.

26. At 3.34am, police were contacted by Mr Tournier and asked to attend the new address in Belmont as Jackson made threats to harm himself. Police attended and observed Jackson to 3 Cluster B Personality traits is not a diagnosis. Cluster B is a general term used to describe a group of personality disorders. The DSM-IV classified antisocial personality disorder, borderline personality disorder, histrionic personality disorder and narcissistic personality disorder as Cluster B Personality Disorders.

4 Statement of Professor Steven Moylan, Clinical Director of Mental Health, Drugs and Alcohol Services, University Hospital Geelong, dated 3 September 2021.

be disorientated, fixated on objects, and climbing around the room. Attending members believed Jackson was a “danger to himself”5

27. Jackson was arrested once again under section 351 of the MHA and taken to Geelong Hospital Ed by an Ambulance Victoria crew with police assistance. Ambulance Victoria records noted Jackson was cooperative but was experiencing visual hallucinations and displaying bizarre behaviours. Paramedics administered olanzapine 10mg to reduce his manic symptoms.

28. When Jackson arrived at the ED at about 4.50am, he was behaving aggressively. He was restrained with shackles and clinicians administered the lorazepam (a benzodiazepine drug) and ziprasidone (am antipsycotic). Dr Kelly, who had assessed Jackson during his earlier presentation, opined that he was possibly experiencing a drug induced psychosis. A plan was made for Jackson to be reviewed by the mental health team once he had calmed down.

29. Jackson slept for several hours and when he woke, remained aggressive and agitated. He was reviewed by mental health clinician, Ms Andrea Sullivan who was hampered by Jackson’s ongoing abusive and aggressive demeanour. Ms Sullivan assessed that Jackson was no longer acutely substance affected and did not show evidence of acute psychiatric features. Jackson denied any suicidal thinking, intent or plan, and his suicide risk was rated as low.

30. Ms Sullivan discussed Jackson’s presentation with the rostered on-call psychiatrist, Dr Murray Anderson who did not consider that there were grounds for an involuntary compulsory treatment order under the MHA. Jackson was accordingly discharged and escorted from the ED by security guards. When he refused to leave, police attended at 12.39pm to remove him from the hospital.

Third presentation: 4.12pm 5 September 2020

31. On 5 September 2020, after being discharged from the ED for a second time, Jackson returned to the Waurn Ponds address. His former housemates contacted police again at 2.46pm in response to Jackson displaying erratic behaviour and allegedly threatening several of his housemates with a knife. When police attended, they noted Jackson appeared highly erratic and drug affected and apprehended him for a third time under section 351 of the MHA.

Jackson was taken to the ED by ambulance again, paramedics administering 5mg midazolam for its sedative effects during the trip to hospital.6 5 Statement of Senior Constable Sarah Boore dated 28 June 2021.

6 Midazolam is a benzodiazepine medication used for anesthesia and procedural sedation, and to treat severe agitation.

32. Jackson arrived at the ED at about 4.12pm on 5 September 2020. The triage nurse assessed him as confused and erratic, but able to follow commands and documented that this was his third ED presentation within 24 hours.

33. At 5.43pm, Jackson was reviewed by ED clinician Dr Anoushka Perera. On examination, his observations were normal, and he appeared awake, alert and time cooperative at the time. Dr Perera formed the view Jackson was no longer acutely substance affected. She noted evidence of previous cuts to both of Jackson’s arms. Jackson denied a wish to harm himself or others and claimed the scratches on both forearms were from a cat and not self-harm.7

34. At 6.22pm, Jackson was reviewed by mental health clinician nurse, Ms Margaret Kent.

Jackson remained in police handcuffs throughout the assessment. Ms Kent conducted a suicide risk assessment and Jackson again denied suicidal ideation, plan or intent. He also denied any perceptual disturbances.

35. Jackson acknowledged to Ms Kent that the cuts on his arms were the result of self-harm. Ms Kent did not believe that Jackson was displaying any psychiatric symptomatology and that he was a low acute risk of suicide. His history of previous suicide attempts was noted by Ms Kent and, in conjunction with his substance use and personality traits, she formed a view that Jackson was at a moderate risk of suicide on an ongoing basis.

36. According to Ms Kent, Jackson engaged well during the assessment, was pleasant and charming, and did not present with a thought disorder, mood elevation or psychotic symptoms.

Ms Kent believed it was likely Jackson substance affected to an extent during the assessment, but did not present as acutely affected.

37. Ms Kent formed the view that Jackson’s behaviour was predominately antisocial and did not meet the criteria under the MHA for a compulsory treatment order.8 Ms Kent contacted the on-call psychiatrist, Dr Anderson, who was also contacted in relation to Jackson’s earlier (second) presentation. Dr Anderson agreed with Ms Kent’s assessment that at the time Jackson’s presentation did not warrant further and compulsory treatment under the MHA.

38. The decision was made to discharge Jackson at 7.25pm with community care follow up. Dr Perera believed the decision to discharge was a collective decision between herself and the 7 Dr Perera was sceptical of the reasons Jackson provided for the injuries and Jackson later confirmed the injuries were the result of self-harm.

8 Statement of Margaret Kent dated 28 August 2022; Mental Health Act 2015, Part 4, Division 1.

mental health team. A diagnosis of mental and behavioural disorder due to multiple drug use and use of other psychoactive substances with withdrawal was made.

Post Discharge Movements and Engagement

39. Jackson was discharged on 5 September 2020 to the care of police. He was taken to Geelong Police Station where he was charged with making threats to kill his housemates and intervention orders were granted protecting them from Jackson.

40. On 6 September 2020, Jackson formally moved into accommodation at 97 Roslyn Road, Belmont, as arranged by Mr Tournier.

41. The initial discharge plan from Jackson’s first presentation, being engagement with the Child and Youth Triage Team (CYTT) remained unchanged throughout his subsequent presentations.

42. On 7 September 2020, CYTT sent Jackson a letter requesting he contact the community service. Barwon Health were unable to phone Jackson as they did not have a valid phone number in their patient administration system.9 Despite his multiple presentations to the ED, prior to his death, Jackson did not have any engagement with the CYTT.

MATTERS IN RELATION TO WHICH A FINDING MUST, IF POSSIBLE, BE MADE Identity of the deceased

43. On 22 September 2020, Coroner Byrne made a formal determination (Form 8) identifying the deceased as Jackson Desmond David Stawicki, born 7 March 1996, based on expert fingerprint comparison and analysis and the police report of death to the coroner (Form 83).

44. Identity is not in dispute and requires no further investigation.

Medical cause of death

45. Forensic Pathology Registrar Dr Joanne Ho, from the Victorian Institute of Forensic Medicine (VIFM), conducted an autopsy of Jackson’s body in the mortuary on 24 September 2020 and provided a written report of her findings dated 4 December 2020.

9 Statement of Prof Steven Moylan dated 3 September 2021.

46. The autopsy showed a wound complex consistent with a sharp force injury to the left antecubital fossa (inner elbow). There was a puncture to the brachial artery. Historical selfharm scars were present to the right and left sides of the neck and on the left arm.

47. There was no evidence at autopsy of any natural disease that could have caused or contributed to death.

48. Routine toxicological analysis of post-mortem samples detected flualprazolam10, etizolam11, cocaine12 and its metabolites, 3,4-Methylenedioxymethamphetamine13 (MDMA) and its metabolite, delta-9-tetrahydrocannabinol14, and pholcodine15.

49. Dr Ho provided an opinion that the medical cause of death was 1 (a) Haemorrhagic shock in the setting of a sharp force injury to the left arm.

50. I accept Dr Ho’s opinion.

Circumstances in which the death occurred

51. On 10 September 2020, Jackson spent the day with Ms Stawicki. He appeared talkative and excitable, and Ms Stawicki believed that he was drug affected at the time. The pair returned to Jackson’s home in Belmont where Jackson showed his grandmother drugs that he had in his possession.16

52. The following day, Jackson and Ms Stawicki spoke over the telephone. She described him as agitated regarding an issue with his bank. The evidence suggests this was the last time Jackson was known to be alive.

53. On 14 September 2020, Jackson’s landlord Mr Tournier received a phone message from a mutual friend of his and Jackson’s. The friend enquired about Jackson’s wellbeing as he had not been heard from for several days. Concerned for his friend, Mr Tournier headed to Jackson’s house in Belmont.

10 Flualprazolam is a benzodiazepine derivative and has no established therapeutic use.

11 Etizolam is a thienotriazolodiazepine derivative with amnesic, anxiolytic, anticonvulsant, hypnotic, sedative and skeletal muscle relaxant effects. Etizolam is not listed in the Australian Register of Therapeutic Goods.

12 Cocaine is an alkaloid found in the leaves of Erythroxylon coca. It is an indirectly acting sympathomimetic and is abused for its stimulant properties.

13 MDMA is a designer amphetamine also known as ecstasy 14 Delta-9-tetrahydrocannabinol (THC) is the active form of cannabis (marijuana).

15 Pholcodine is a semisynthetic opioid derivative indicated for cough.

16 Ms Stawicki’s statement dated 26 October 2021 was unclear as to what drugs Jackson showed her.

54. Mr Tournier arrived at around 10.00pm, knocked on the front door but did not receive a response. He unlocked the front door using a key, but the door was held in place by a security chain. Through the small gap between the door and the frame, Mr Tournier could see Jackson seemingly unresponsive, lying over a vacuum cleaner and covered in blood. He forced entry to the house and attended to Jackson who was cold to the touch. Mr Tournier contacted emergency services.

55. Ambulance Victoria paramedics and Victoria Police members concurrently arrived at the scene at around 10.40pm. Paramedics attended to Jackson and verified he was deceased at the scene. Resuscitation efforts were not initiated.

56. Police conducted a search of the scene and noted there was a significant amount of dried blood throughout the house. A large meat cleaver was found on top of a filing cabinet in the lounge room amongst a substantial amount of coagulated blood. A note was located placed on the floor near the entry of the house. The contents of the note were not suggestive of suicide and were largely unintelligible. An examination of Jackson’s body revealed a deep penetration injury to his inner left elbow.

57. Due to the nature of the scene, the on-call Homicide Squad was contacted by attending police.

Having investigated the circumstances surrounding Jackson’s death and provided the brief of evidence in relation to the same, Acting Sergeant Benjamin Nash concluded that there were no suspicious circumstances and that Jackson had ended his own life.

CPU REVIEW OF CARE

58. As part of my review, I obtained advice from the Coroners Prevention Unit (CPU) about the clinical management and care provided to Jackson during his last episode of care at the Geelong Hospital.

59. The CPU is staffed by healthcare professionals, including practising physicians and nurses.

Importantly, these healthcare professionals are independent of the health professionals and institutions under consideration. They draw on their medical, nursing, and research experience to evaluate the clinical management and care provided to the deceased by reviewing the medical records and considering any concerns raised by family or other parties.

60. Following a series of preliminary reviews of the matter, the CPU recommended a statement and Barwon Health policies be obtained from Professor Steven Moylan, Clinical Director of

Mental Health, Drugs and Alcohol Services. Statements were also requested and obtained from a number of the clinicians involved in Jackson’s care across his three ED presentations.

61. CPU considered all these statements as well as the medical records provided by Barwon Health, Ambulance Victoria records, the coronial brief and the court file.

Review of clinical care

62. The CPU considered that on each of the three presentations, the care provided in the ED was reasonable and appropriate. During each of his presentations, Jackson was referred for review by a mental health clinician once he was deemed medically suitable for review. During both the first and second presentations, a combination of benzodiazepines and antipsychotic medications were administered to suitably stabilise Jackson for a mental health assessment.

63. On each separate presentation, the various mental health clinicians appropriately contacted the rostered on-call consultant psychiatrist. This resulted in a discharge plan for community follow-up with the CYTT which remained after each presentation. The CPU considered the discharge plan was appropriate.

64. Further, the CPU found each mental health assessment met the requirements for a mental health service in response to a patient who presents having been apprehended under section 351 of the MHA.

Barwon Health Policy and Procedure

65. With respect to persons who present multiple times in a short period, in Professor Moylan’s initial statement he advised that it is expected “a person presenting for assessment will have their relevant history considered as part of their review.”17 Professor Moylan noted that during both Jackson’s second and third assessments, the multiple presentations were noted.

66. In a subsequent statement to the court provided in September 2022, Professor Moylan advised that the Barwon Health Mental Health, Drugs and Alcohol Services (MHDAS) was developing an Acute Intervention Service Delivery Framework (the framework). According to Professor Moylan, the framework aims to formalise processes already in place with clear guidelines and procedures.

17 Statement of Prof Steven Moylan dated 3 September 2021.

67. Professor Moylan advised that part of the framework will be to “articulate the availability of escalation options for consumers who attend in crisis on multiple occasions in a short time.”18 In Jackson’s case, his treatment was elevated to the on-call psychiatrists and with the intention for post-discharge engagement with the CYTT.

68. The CPU opined that the framework will likely provide clearer guidance for clinicians about escalation pathways. That said, it was not clear to the CPU whether guidance will be specific to the circumstances in which Jackson presented and whether escalation beyond consultation with the on-call psychiatrist would have occurred in his case if the framework had been in place.

Jackson’s Contact Details

69. Included with Professor Moylan’s subsequent statement was a copy of Barwon Health’s ‘Patient Registration and Update of Consumer Demographic Information Procedure (the procedure).’ The procedure states: In circumstances where the consumer, or their carer/family member, is not able to validate demographic information due to incapacity or clinical urgency, it must be verified and updated at the next consumer contact point.

70. The procedure lists the patient’s phone number as vital information and a mobile as essential information. The procedure includes a Patient Registration Form (PRF) which contains a section for telephone and home addresses to be filled in.

71. At no point across Jackson’s three presentations was a phone number obtained for Jackson.

The CPU did not identify any evidence that a current telephone number was sought from Jackson, or that a telephone number was sought and refused by Jackson. Further, his father was recorded as Jackson’s next of kin, whereas it was Ms Stawicki who was his main support.

72. Relevantly, there is also no evidence to suggest that Jackson did not have a valid phone number at the time of his presentations. According to Ms Stawicki, she and Jackson spoke on the telephone several days after his ED presentations.

18 Statement of Prof Steven Moylan dated 16 September 2022.

73. In his initial statement, Professor Moylan advised that the CYTT sent a letter to Jackson requesting that he contact the service as they “did not have a valid phone number in the patient administration system.”

74. The address recorded in Jackson’s medical records and patient registration was for his previous address in Waurn Ponds. As a result of the events that preceded his second presentation, Jackson’s landlord arranged for alternate accommodation in Belmont. This information was noted by Dr Kelly during Jackson’s second presentation.

75. The evidence suggests that Jackson never received the letter from CYTT dated 7 September 2020 and there is no evidence to suggest that Jackson attempted to contact the CYTT or any other Barwon Health service.

76. The CPU considered it reasonable to expect that contact details are verified when a patient is referred for follow-up as part of a discharge plan. When contact details cannot be verified, the discharge plan should be reviewed with this in consideration.

CPU Conclusion

77. Jackson experienced a change in his mental state and the contributing factors were the effects of the illicit substances and, potentially, a mood disorder. The CPU found the available evidence supported the collective decision that Jackson did not meet the criteria for compulsory treatment when assessed at each relevant occasion. There was no evidence of ongoing psychotic symptoms once Jackson’s drug intoxication subsided. Threatening, angry and abusive behaviours are not in themselves indicative of a psychiatric illness.

FINDINGS AND CONCLUSION

78. The standard of proof for coronial findings of fact is the civil standard of proof on the balance of probabilities, with the Briginshaw gloss or explications.19 Moreover, the effect of the authorities is that Coroners should not make adverse comments or findings against individuals or institutions, unless the evidence provides a comfortable level of satisfaction that they 19 Briginshaw v Briginshaw (1938) 60 CLR 336 at 362-363: ‘The seriousness of an allegation made, the inherent unlikelihood of an occurrence of a given description, or the gravity of the consequences flowing from a particular finding, are considerations which must affect the answer to the question whether the issues had been proved to the reasonable satisfaction of the tribunal. In such matters “reasonable satisfaction” should not be produced by inexact proofs, indefinite testimony, or indirect inferences…’.

departed materially from the standards of their profession and in so doing, caused or contributed to the death.

79. It is axiomatic that the material departure from applicable standards be assessed without the benefit of hindsight, on the basis of what was known or should reasonably have been known at the time, and not from the privileged position of hindsight. Patterns or trajectories that may be appreciated at a later time or may even obvious once the tragic outcome has come to pass are to be eschewed in favour of a fair assessment made.

80. The care provided by clinicians within the University Hospital Geelong across each of Jackson’s three presentations on 4-5 September 2020 was reasonable and appropriate.

Jackson presented as acutely drug affected on each occasion. By the time the effects of the drugs had worn off, Jackson did not display any evidence of psychiatric symptomatology.

81. However, Barwon Health staff and clinicians failed to obtain current contact details for Jackson, including an updated address and critically his mobile phone number. There is no evidence to suggest that Jackson refused to provide this information to Barwon Health staff.

The discharge plan for Jackson to engage with the CYTT was made following his first presentation. No phone number was obtained prior to the initial discharge and, despite an additional two presentations, Jackson’s contact details remained incomplete.

82. The CYTT ability to contact and engage Jackson was confounded by the unavailability of his phone number. The letter sent on 7 September 2020 was to a superseded address and likely never reached Jackson.

83. It is clear that Jackson needed help in the community to address his mood disorder and substance abuse. Suboptimal management of Jackson’s discharge by failing to obtain essential contact information rendered him vulnerable and without supports that might otherwise have been provided if he had engaged with the CYTT.

84. Pursuant to section 67(1) of the Coroners Act 2008 I make the following findings: a) the identity of the deceased was Jackson Desmond David Stawicki, born 7 March 1996; b) the death occurred between 11 and 14 September 2020 at 97 Roslyn Road, Belmont, Victoria, 3216; c) the cause of Jackson’s death was haemorrhagic shock in the setting of a sharp force injury to the left arm; and

d) the death occurred in the circumstances described above.

85. Toxicological analysis of post-mortem samples indicate Jackson was under the influence of several drugs proximate to his death. While the precise impairment on his mood and judgement cannot be known, his recent history of erratic and paranoid behaviour when acutely substance affected supports a finding that he was likely significantly judgment impaired when he died.

86. When no longer acutely substance affected, Jackson consistently denied suicidal thoughts or intent to mental health clinicians. It is noteworthy that no suicide note was discovered at the scene.

87. Considered in its totality, the available evidence supports a finding that Jackson self-inflicted the wounds that caused his death but that he did so without the intention of ending his life.

COMMENTS Pursuant to section 67(3) of the Act, I make the following comments connected with the death.

1. This case highlights the need for all staff in a clinical setting to ensure patient information, including mobile phone contact details and residential addresses are up to date. This is especially important when a discharge plan requires proactive contact by a community team for follow-up.

2. Barwon Health’s own policies reflect this important and simple principle. The ‘Patient Registration and Update of Consumer Demographic Information Procedure’20 establishes that it is the responsibility of all staff within the organisation to ensure patient information is accurately recorded and stored. Despite three separate presentations, Barwon Health failed to obtain a valid phone number and up to date residential address for Jackson.

3. Health care staff ought to be aware of their responsibilities to validate that patient contact details are current and correct. The inability of the CYTT to effectively reach Jackson to try to engage him in treatment highlights the importance of doing so.

20 Barwon Health, Patient Registration and Update of Consumer Demographic Information Procedure, last reviewed 28 April 2020.

Pursuant to section 73(1A) of the Act, I order that this finding be published on the Coroners Court of Victoria website in accordance with the rules.

I convey my sincere condolences to Jackson’s family for their loss.

I direct that a copy of this finding be provided to the following: Christina Stawicki, senior next of kin Barwon Health c/o Meridian Lawyers Office of the Chief Psychiatrist Sergeant Benjamin Nash, Victoria Police, Coroner’s Investigator Signature: ___________________________________ Coroner Paresa Antoniadis Spanos Date : 28 July 2023 NOTE: Under section 83 of the Coroners Act 2008 ('the Act'), a person with sufficient interest in an investigation may appeal to the Trial Division of the Supreme Court against the findings of a coroner in respect of a death after an investigation. An appeal must be made within 6 months after the day on which the determination is made, unless the Supreme Court grants leave to appeal out of time under section 86 of the Act.