Inquest into the death of Frank Dwayne Coleman

Case Number: 2021/196736

Date of Findings: 22 October 2025

Magistrate: State Coroner, Magistrate Teresa O’Sullivan

Catchwords: CORONIAL LAW – Death in custody – s 23 – Long Bay Correctional Facility – First Nations – methadone – overdose

Responses

Recommendations

To the Chief Executive Justice Health and Forensic Mental Health Network NSW (Justice Health) / the Commissioner, Corrective Services NSW

1. Justice Health, in coordination with Corrective Services NSW, review the models of care and resourcing of Drug and Alcohol assessments for the commencement of opioid agonist therapy (OAT), with a view to increasing access and capacity, and;
   a. Produce a joint report estimating unmet need in the public jail system and outlining the optimum wait time.
   b. Produce a joint mapping report indicating what resources would be necessary to achieve the optimum wait time (including staffing and infrastructure needs)
2. Justice Health, in coordination with Corrective Services NSW:
   a. assess the viability of Drug and Alcohol reviews being conducted via telehealth, including in-cell, and if deemed viable
   b. trial providing Drug and Alcohol reviews by in-cell telehealth