Coronial Findings 2022

Response from Respect received 23 August 2023.

In response to the first recommendation, I recommend that all facilities using mobility hoists review their maintenance schedules to ensure that they are serviced at intervals which are appropriate to detect and prevent failure of the components, the following has occurred:
 Review of policy and process.
 Review of the preventative maintenance process indicated that monitoring of schedules could be improved, thus improvement has been facilitated by the introduction of an electronic recording and monitoring system, replacing the previous paper-based system.
Following trial, this system is being rolled out throughout the organisation.

In response to the second recommendation, I recommend that technicians responsible for servicing mobility hoists use thread locking adhesive (such as Loctite) and/or split pins to provide additional. security to critical, load-bearing nuts and bolts, the following has occurred:
 Respect have consolidated service agreements for preventatve maintenance of hoists to have two service providers over three states. Discussions with service providers has indicated that technicians are unwilling to make any changes to the manufactured structure of hoists given that they may be accountable for liability of any failure. Additionally, warranties would be voided.
 To mitigate the risk of further incidents in addition to regular external annual service and checks the internal Respect maintenance staff undertake monthly checks of all hoists with particular attention to nuts and bolts.
 Servicing of hoists continues to be undertaken as per the manufacturer’s recommendations..

NOTE: THIS IS NOT A CORONIAL RECOMMENDATION

Ruling in relation to the matter of Paul George Hunt, Paul James Reynolds, Simon Graham Darke, and Robert Anthony Cooke.

Response from Veterinary Board of Tasmania received 4 September 2023

The VBT recently declared revised veterinary service standards and guidelines.

https://nre.tas.gov.au/Documents/Tasmanian%20VSS%20-%20Standards%20and%20Guidance%20Notes.pdf

On page 42 the Guidelines state the following with respect to storage of Pentobarbital:

Pentobarbital

Appendix D of the Poisons and Therapeutic Goods Regulation 2008 (Regulation) lists Schedule 4 substances (prescription-only medicines) that have common therapeutic uses, but are also liable to abuse, misuse and diversion, warranting more stringent controls on possession and supply. These substances are commonly referred to as Schedule 4 Appendix D (S4D) medicines. S4D substances must be stored in a locked container and kept securely when not in immediate use. The Board expects that Pentobarbital be stored in an S8 safe to prevent unauthorised access.

Response received from  StateWide Mental Health Services  21 February 2023

Statewide and Mental Health Services (SMHS) has considered this matter and has taken a number of steps to advise staff of the risk’s attendant on discharge to the community post a high-risk event.

In my capacity of Executive Director Medical Services, I have circulated a memo to staff as attached providing guidance around this process.

The issue and your recommendation have been discussed at the SMHS Quality and Safety Meeting and the Mortality and Critical Incident Review Committee meeting. These two committees and attendant meetings are the peak bodies that consider safety and morbidity/mortality matters within the service footprint.

Changes are being made to a currently being developed document, called the Comprehensive Care Plan that will replace the Discharge policy.

Matter notes (NOT a  response to Coronial Recommendations):

This is the s58 decision in relation to the matter of Eden Jayde Westbrook.

Coroner Olivia McTaggart handed down her findings on 30 September 2016.

Mr and Mrs Westbrook made an application under s58 of the Coroners Act 1995 to have the investigation into the death of their daughter Eden re-opened and finding re-examined on 5 August 2020.

Chief Magistrate Catherine Geason considered the matters raised and gave reasons on 1 April 2022 as to why the investigation would not be re-opened.