Coroner Criticises Lack of Medical Treatment Before ‘Preventable’ Death at Clarence
The death of a 29-year-old man at Clarence Correctional Centre was preventable if he had been given proper medical treatment, a coroner has found.
The inquest into the death of Dictor Dongrin in mid-2022 found that his treatment by prison health staff was “wholly inadequate”, and that he was unattended to for 21 hours.
Dongrin was suffering from alcohol withdrawal when he died in a medical unit at the prison, the day after he had been incarcerated.
The coroner found that “timely and adequate medical intervention could have prevented death”.
They recommended that the medical staff in the prison who did not treat or monitor Dongrin should have their conduct reviewed by professional councils.
“There is evidence of systematic complacency and incompetence,” Deputy State Coroner Rebecca Hosking said.
Lawyer Ian Fraser, who represented Dongrin’s family, said the man’s death happened in a “system of apathy which created a lack of responsibility”.
“The cruel irony is Dictor Dongrin died in a clinical observation cell where no clinical observations were taken,” Fraser said.
Inquest Into Death of Man at Maryborough Prison Concludes
A coronial inquest into the death of Glen Francis at Maryborough Correctional Centre in late 2021 has finished.
Francis died from a rare bacterial condition after he was bed-ridden for weeks.
The inquest looked into the level of medical care provided to him, and if there was a failure to see how unwell he was.
It heard that Francis had asked for medical help five times in the three weeks before his death.
His pain was dismissed as “drug-seeking behaviour”, the inquest heard.
Coroner’s findings are expected to be released later this year. About Time will provide an update.
Findings Handed Down on Death of Man on Remand in Victoria
A Victorian coroner has released findings on the death of Phi Long Dang at Fulham Correctional Centre in 2024.
The man was on remand at the prison for drug-related offences.
The coroner found that drugs were smuggled in to him across multiple visits, and that he had died of a drug overdose after ingesting a balloon containing methylamphetamine.
Coroner Criticises Lack of Medical Treatment Before ‘Preventable’ Death at Clarence
The death of a 29-year-old man at Clarence Correctional Centre was preventable if he had been given proper medical treatment, a coroner has found.
The inquest into the death of Dictor Dongrin in mid-2022 found that his treatment by prison health staff was “wholly inadequate”, and that he was unattended to for 21 hours.
Dongrin was suffering from alcohol withdrawal when he died in a medical unit at the prison, the day after he had been incarcerated.
The coroner found that “timely and adequate medical intervention could have prevented death”.
They recommended that the medical staff in the prison who did not treat or monitor Dongrin should have their conduct reviewed by professional councils.
“There is evidence of systematic complacency and incompetence,” Deputy State Coroner Rebecca Hosking said.
Lawyer Ian Fraser, who represented Dongrin’s family, said the man’s death happened in a “system of apathy which created a lack of responsibility”.
“The cruel irony is Dictor Dongrin died in a clinical observation cell where no clinical observations were taken,” Fraser said.
Inquest Into Death of Man at Maryborough Prison Concludes
A coronial inquest into the death of Glen Francis at Maryborough Correctional Centre in late 2021 has finished.
Francis died from a rare bacterial condition after he was bed-ridden for weeks.
The inquest looked into the level of medical care provided to him, and if there was a failure to see how unwell he was.
It heard that Francis had asked for medical help five times in the three weeks before his death.
His pain was dismissed as “drug-seeking behaviour”, the inquest heard.
Coroner’s findings are expected to be released later this year. About Time will provide an update.
Findings Handed Down on Death of Man on Remand in Victoria
A Victorian coroner has released findings on the death of Phi Long Dang at Fulham Correctional Centre in 2024.
The man was on remand at the prison for drug-related offences.
The coroner found that drugs were smuggled in to him across multiple visits, and that he had died of a drug overdose after ingesting a balloon containing methylamphetamine.
Coroner Finds Corella Place Failures Contributed to Preventable Death
This section is written by Alison Harding.
A Melbourne coroner has found that Corrections Victoria failed to support a man in his rehabilitation and failed to treat him with dignity and due respect, given his acquired brain injury and ADHD.
Coroner Audrey Jamieson said “a plethora of missed opportunities and failings” contributed to the man’s death from mixed drug toxicity. She said the man did not intend to take his own life, and that his death in May 2020 was preventable.
The coroner described the man, who cannot be named, as a vulnerable and isolated person, who should have been better protected against the clear dangers caused by the stockpiling of a “staggering” quantity of methadone tablets, as well as the trade of prescription and non-prescription medication, at Corella Place in Ararat.
Managed by Corrections Victoria, Corella Place 228 is a gated post-sentence residential facility that houses people who have committed serious sex offences. The man was under an order that required him to live at the facility and subjected him to other restrictions.
At the time of the man’s death, he was under COVID-19 quarantine, restricted to his unit and a small deck for 23 hours a day, with one hour allowed out for exercise.
The coroner said the man had a difficult childhood and adolescence. He was diagnosed with ADHD as a child and later removed from his family home due to his behaviours and cannabis use. He was diagnosed with an acquired brain injury after an assault in 2009.
A neuropsychological assessment in 2010 found that the man’s intellectual functioning was in the upper end of the borderline range. In her finding, Ms Jamieson said that experts had recommended the man would benefit from residential drug rehabilitation.
Before the pandemic, Corella Place residents could go on regular community outings, usually with a monitored ankle bracelet and supervised by case workers. Community outings were suspended from 21 March 2020.
Independent expert, a clinical forensic medicine and addiction medicine consultant, Edward Ogden, said the boredom, isolation and hopelessness inside Corella Place was a “perfect storm” for drug use.
“In (Professor Ogden’s) experience treating patients, particularly those on court orders or who had been incarcerated, drug use was often a way to pass the time, and to make life more tolerable,” the coroner said.
She found that a significant factor contributing to the man’s death was “his access to and ingestion of methadone”.
“There is clear and cogent evidence that he had access to, or in some other way obtained methadone tablets at Corella Place 228,” she said.
She found a direct link between the cause of the man’s death and Corella Place’s failure to properly monitor and control methadone entering the facility, its distribution, and undertake risk minimisation strategies.
The coroner said that the death “was not an intentional act of self-harm but the unintended consequence of his intentional use and abuse of illicit and prescription drugs, in circumstances where he felt trapped, hopeless and powerless”.
She found that Corrections Victoria failed to support the man in his rehabilitation, failed to adhere to the recommendations of its own expert psychologist and failed to provide needed mental health supports.
The coroner made 18 recommendations, with 16 directed at the Department of Justice and Community Safety. Three recommendations were made regarding residents’ ability to control their own prescribed medications.
The coroner also recommended allowing for more family visits, and mandatory training to assist residents with disabilities, and to recognise signs of drug misuse and overdose.
About Time asked the Department of Justice and Community Safety several questions about the findings.
A Department spokesperson responded: “We thank the Coroner for their findings and are continuing to carefully consider the recommendations before responding in due course.”
Under the Coroners Act 2008, a public statutory authority or entity who receives a recommendation from a coroner has three months to respond in writing stating what action, if any, has or will be taken.
Coroner Finds Corella Place Failures Contributed to Preventable Death
This section is written by Alison Harding.
A Melbourne coroner has found that Corrections Victoria failed to support a man in his rehabilitation and failed to treat him with dignity and due respect, given his acquired brain injury and ADHD.
Coroner Audrey Jamieson said “a plethora of missed opportunities and failings” contributed to the man’s death from mixed drug toxicity. She said the man did not intend to take his own life, and that his death in May 2020 was preventable.
The coroner described the man, who cannot be named, as a vulnerable and isolated person, who should have been better protected against the clear dangers caused by the stockpiling of a “staggering” quantity of methadone tablets, as well as the trade of prescription and non-prescription medication, at Corella Place in Ararat.
Managed by Corrections Victoria, Corella Place 228 is a gated post-sentence residential facility that houses people who have committed serious sex offences. The man was under an order that required him to live at the facility and subjected him to other restrictions.
At the time of the man’s death, he was under COVID-19 quarantine, restricted to his unit and a small deck for 23 hours a day, with one hour allowed out for exercise.
The coroner said the man had a difficult childhood and adolescence. He was diagnosed with ADHD as a child and later removed from his family home due to his behaviours and cannabis use. He was diagnosed with an acquired brain injury after an assault in 2009.
A neuropsychological assessment in 2010 found that the man’s intellectual functioning was in the upper end of the borderline range. In her finding, Ms Jamieson said that experts had recommended the man would benefit from residential drug rehabilitation.
Before the pandemic, Corella Place residents could go on regular community outings, usually with a monitored ankle bracelet and supervised by case workers. Community outings were suspended from 21 March 2020.
Independent expert, a clinical forensic medicine and addiction medicine consultant, Edward Ogden, said the boredom, isolation and hopelessness inside Corella Place was a “perfect storm” for drug use.
“In (Professor Ogden’s) experience treating patients, particularly those on court orders or who had been incarcerated, drug use was often a way to pass the time, and to make life more tolerable,” the coroner said.
She found that a significant factor contributing to the man’s death was “his access to and ingestion of methadone”.
“There is clear and cogent evidence that he had access to, or in some other way obtained methadone tablets at Corella Place 228,” she said.
She found a direct link between the cause of the man’s death and Corella Place’s failure to properly monitor and control methadone entering the facility, its distribution, and undertake risk minimisation strategies.
The coroner said that the death “was not an intentional act of self-harm but the unintended consequence of his intentional use and abuse of illicit and prescription drugs, in circumstances where he felt trapped, hopeless and powerless”.
She found that Corrections Victoria failed to support the man in his rehabilitation, failed to adhere to the recommendations of its own expert psychologist and failed to provide needed mental health supports.
The coroner made 18 recommendations, with 16 directed at the Department of Justice and Community Safety. Three recommendations were made regarding residents’ ability to control their own prescribed medications.
The coroner also recommended allowing for more family visits, and mandatory training to assist residents with disabilities, and to recognise signs of drug misuse and overdose.
About Time asked the Department of Justice and Community Safety several questions about the findings.
A Department spokesperson responded: “We thank the Coroner for their findings and are continuing to carefully consider the recommendations before responding in due course.”
Under the Coroners Act 2008, a public statutory authority or entity who receives a recommendation from a coroner has three months to respond in writing stating what action, if any, has or will be taken.
