Inquest into the death of Roy Roberts

Case Number: 2019/269131

Findings Date: 3 February 2023

Magistrate: Derek Lee

CORONIAL LAW | cause and manner of death, diagnosis of primary epilepsy; seizure-like episode; methadone toxicity; opioid substitution therapy; unprescribed drug use; care and treatment; refusal of medical assessment and investigations; Aboriginal Health Worker; inmate patient confidentiality

Responses

Recommendations

The Chief Executive Justice Health and Forensic Mental Health Network

1. I recommend that, in consultation with Corrective Services New South Wales, appropriate steps be taken to ensure that adequate education and guidance is provided to Justice Health clinicians so that they may inform inmate patients of:

(a) the confidentiality requirements that attach to provision of any health information by an inmate to a clinician; and

(b) the ability to request a consultation with a clinician in the absence of a Corrective Services New South Wales officer, subject to any safety and security considerations that may attach to such a request.

2. I recommend that consideration be given to providing ongoing education and training to all nursing and medical clinicians regarding the clinical features and identification of primary epilepsy.

3. I recommend that a review be conducted to ensure that Aboriginal Health Worker positions in New South Wales correctional centres are sufficiently staffed to provide inmate patients with access to culturally appropriate healthcare.

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