Inquest into the death of JC

Case Number: 2021/19652

Date of Findings: 22 January 2026 

Magistrate: Coroner, Deputy Chief Magistrate Sharon Freund

Catchwords: CORONIAL LAW – deliberate self-poisoning, Care and Treatment, Calvary Mater Hospital, Newcastle. Benzodiazepine withdrawal

Responses

Recommendations

To the Murrumbidgee Local Health District:

1. That the coronial findings be drawn to the attention of the NSW Ministry of Health by the Hunter New England Local Health District (HNELHD) in support of the case, when further advanced, for the funding and establishment of a Behavioural Assessment Unit within the Emergency Department at Calvary Mater Hospital (CMH) Newcastle, in order to provide more effective care and treatment to patients presenting with episodes of deliberate self harm within the Local Health District. 
2. That CMH and the HNELHD:
   a) provide training and education to clinicians involved in assessing patients presenting to the Emergency Department (ED) with Deliberate Self Poisoning (DSP) concerning the “red flag” of potential benzodiazepine addiction and withdrawal; and
   b) Provide training and education that encourages clinicians to seek advice from addiction medicine specialists when assessing patients presenting with benzodiazepine dependence and at high risk of withdrawal at discharge from the Emergency Department.
3. That the CMH require mental health clinicians assessing patients in the CMH Emergency Department to compete Mental Health Outcome and Assessment Tool (MH-OAT)(A1) psychiatric assessment form, and that CMH require mental health clinicians assessing patients in the CMH general hospital wards to complete MH-OAT(A1) form when an admission is required to a mental health unit. 
4. That the HNELHD ensures that the coronial findings in this matter are reviewed and taken into account by the Committees that next determine the appropriate “Scope of Practice” of Mental Health Nurse Practitioners who work in the CMH ED, including but not limited to:
   • whether it is appropriate for the Mental Health Nurse Practitioner (MHNP) to conduct assessments of patients presenting after an episode of DSP where a risk of benzodiazepine withdrawal after discharge has been identified;
   • requirements to use MH-OAT forms (or their equivalent) when assessing patients in the ED.
5. That CMH and the HNELHD take action to ensure that clinicians in the ED have a clear understanding of roles and responsibilities for the timely completion of discharge documentation in cases of multidisciplinary care.  
6. That, as identified by the clinical heads during the inquest, the following aspects of policy be reviewed by CMH:
   • The Suicidal Behaviour policy in relation to who is responsible for the conduct of mental health assessments in the ED;
   • The Suicidal Behaviour policy in relation to the circumstances in which a patient with DSP is to be “admitted under Toxicology”;
   • The Deliberate Self Poisoning “Toxicology Pathway” in relation to who is to be contacted in connection with mental health assessment following toxicology clearance.