Deaths In Custody

27 Sep 2007 questionsarchive

I seek leave to make an explanation before asking the Minister for Mental Health and Substance Abuse a question about a death in custody.

The Hon. J.M.A. LENSINK: The Coroner has inquired into the death of Michael Philip Cockburn, who, late in 2002, was detained at Glenside and transferred to the Royal Adelaide Hospital, where he passed away. The inquest report into the death was tabled a couple of weeks ago. In the report the Coroner found that one of the potential contributing factors to this gentleman’s death was the fact that he had an adverse reaction to particular anti-psychotic medications, which were referred to in his Glenside clinical records.

Unfortunately, these records did not accompany him to the Royal Adelaide; instead, someone else’s drug chart was transported with him to the Royal Adelaide. When he was administered such medications, he deteriorated significantly and he was unable to be revived.

One of the Coroner’s recommendations is that Glenside implement measures to ensure that substitution of one patient’s documents for that of another does not happen again. Can the minister advice what changes to the practices at Glenside have been implemented to ensure that the chances of this type of incident occurring is minimised in the future?

The Hon. G.E. GAGO(Minister for Mental Health and Substance Abuse): I thank the honourable member for her important question. Indeed, this was a tragic accident. The matter has been before the Coroner, and I understand that he has handed down his findings and that he has expressed his concerns relating to the incident. In the case of all Coroner’s inquests, we look very carefully at any recommendations or concerns that are raised in the report and, in due course, we respond comprehensively to those findings. We are currently considering the Coroner’s report and putting together a response, and that will be tabled in parliament in due course.