Inquest into the death of Dushyanthan Visvanathan

Case Number: 2019/00302386

Date of Findings: 5 September 2025

Magistrate: Deputy State Coroner, David O'Neil

CORONIAL LAW - Death in custody; alcohol withdrawal; inadequate information; level of care provided. 

Responses

Recommendations

To Justice Health and Forensic Mental Health Network

1. That the drug and alcohol substance withdrawal monitoring form used by Justice Health be amended to incorporate, firstly, guidance regarding the frequency of observations recommended for patients in alcohol withdrawal, and secondly, a field which can be used by practitioners to indicate the plan for the frequency of observations for the patient.
2. That consideration be given to sending out or publishing a short communication to Justice Health staff which emphasises the importance of proper ventiliation during CPR.
3. Consideration be given to seeking an allocation of funding from the Ministry of Health, for the staffing of drug and alcohol remote offsite and after-hours medical service shifts until 11pm with an on-call service to continue to be provided from 11pm onwards.