Deceased
Gary Hietanen
Demographics
45y, male
Coroner
Coroner Darren Bracken
Date of death
2017-08-08
Finding date
2020-12-23
Cause of death
Combined drug toxicity (methadone, amitriptyline, gabapentin, paracetamol)
AI-generated summary
A 45-year-old male prisoner died in custody from combined drug toxicity after ingesting methadone, amitriptyline, gabapentin and paracetamol. He had a documented history of hoarding and misusing prescribed medications to achieve a euphoric effect. He was admitted to hospital on 21 July 2017 after deliberately overdosing on gabapentin/pregabalin, then discharged to prison six days later. Critical information about his drug-hoarding behaviour was not communicated from the hospital to prison management. The prison's 'trap-to-trap' medication dispensing method (medications passed through cell door traps) provided inadequate supervision for identifying and preventing drug accumulation. Evening lockdown procedures did not reliably establish that prisoners were conscious and responsive. The coroner identified systemic failures in health information sharing between hospital and correctional services, inadequate medication dispensing protocols, and insufficient prison staff protocols for assessing prisoner wellbeing, rather than any single medical error.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Court Reference: COR 2017 3888
FINDING INTO DEATH WITH INQUEST . Form 37 Rule 63(1) Section 67 of the Coroners Act 2008 (Amended pursuant to section 76 of the Coroner’s Act 2008 as at 19 February 2020)*
Deceased:
Findings of:
Delivered on:
Delivered at:
Hearing date:
Appearances:
Counsel assisting the Coroner:
*Refer to Schedule of Correction of Errors at page 38.
23 December 2020
Coroners Court of Victoria
Kavanagh Street, Southbank
20 to 23 August 2019
Ms N. Hodgson appeared on behalf of St Vincent’s Correctional Health Services and St Vincent’s Hospital
Mr R. Harper appeared on behalf of G4S
Ms V. Katotas appeared on behalf of Ms J. Camilleri Mr King Taylor
Identity of the Deceased - section 67(1)(a) of the Coroners Act 2008 Cause of death - Section 67(1)(b) of the Act
THE INVESTIGATION, THE INQUEST & CONTROVERSIES The Investigation The Inquest and Controversies
CONCLUSIONS AND FINDINGS Conclusions Findings
On8 August 2017 Mr Gary Hietanen was 45 years old when he was found in his cell in the Borrowdale Unit of Port Phillip Prison (“the Prison”) after having passed away.' Mr Hietanen had entered custody at the Melbourne Assessment Prison on 3 February 2011 after having been convicted of manslaughter and sentenced to 10 years imprisonment with a non-parole period of seven years; this term of imprisonment was Mr Hietanen’s first.
Mr Hietanen was a Muslim Indigenous Australian with a long-time partner with whom he had one son, who himself had two children, both of whom were born while Mr Hietanen was in gaol.
The Borrowdale Unit of the Prison is a ‘security unit’ used to’ accommodate prisoners who are security risks or like Mr Hietanen, prisoners against whom threats had been made.?
The Prison is operated by G4S Custodial Services Pty Ltd (“G48”). St. Vincent’s Hospital provides medical services to prisoners on site at the Prison via St. Vincent’s Correctional Health (“SVCH”) and at St. Vincent’s Hospital Melbourne in Fitzroy via a security ward, St. Augustine’s (““SVHM”).
The Victorian correctional system, including G4S, utilises a series of ‘alerts’ allocated to prisoners to signify assessments undertaken by custodial staff in relation to the
prisoners’;
(a) propensity for violence (V rating),
(b) placement considering the prisoner’s vulnerability to imposition by other prisoners (T
rating),
(c) psychiatric condition (P rating),
' Port Phillip Prison is a maximum-security male prison privately operated by G4S Custodial Services Pty Ltd under contract to the Department of Justice and Regulation.
2 JARO report: Review into the death of Mr Gary Hietanen at Port Philip Prison on 8 August 2017 dated 20 April 2018 p24 of 30; CB.
(d) medical condition (M rating),
(e) security status, taking into classification? (Al, A2, B rating); and
(f) suicide and self-harm rating (S rating).
(a) V3 acknowledging his history of significant violence,
(b) P3 acknowledging that his psychiatric state was stable but required regular or ongoing
treatment; and
(c) M2 acknowledging that his medical condition required regular or ongoing treatment.
harm himself.
anticipation of release on or about 24 January 2018.
Mr Hietanen had a long history of illicit drug use and of improperly using prescription medication, both medication which had been prescribed for him and which he had obtained from other prisoners. Mr Hietanen had admitted to hoarding prescribed medication so that he could take a bigger than prescribed dose and experience an
increased effect.*
searched more often, screened more often for drugs and his contact visits being limited.
3 Classification is the process of determining the level of security for the prisoner. Prisoners will be placed in
accommodation or correctional facility which serves that classification.
4 Exhibit 2 and T.8.
5 For a total of three years during the time he spent in prison.
Such prisoners are also actively encouraged to participate in reviews to discuss their drug or alcohol treatment. with a view to minimising the harm that their substance abuse may cause. On 2 April 2015, Mr Hietanen was accorded IDU status 3BR° which remained current until the week before his death when it was altered to ‘neutral’ as a result of Mr Hietanen not having been involved with further illicit use of drugs;’ it remained at that
level until 8 August 2017.
Mr Hietarien had an extensive medical history including asthma, high blood pressure, hepatitis C, gastric reflux, constipation, poly substance abuse and he was a heavy smoker. He was prescribed a long list of medications to deal with his complex health issues including anti-depressants, anti-coagulants, pain relief and blood pressure medication. When he died Mr Hietanen weighed 135 kilograms and had a BMI of 40.3 that placed him in the morbidly obese category.
On 8 August 2017, Mr Hietanen was found in his single cell by prison staff conducting
the morning muster after having passed away.
13, Mr Hietanen’s death constituted a ‘reportable death’ pursuant to section 4 Coroners Act 2008 (Vic) (the Act); his death occurred in Victoria and was one or more of unexpected or unnatural. Further, Mr Hietanen was a person under the care control or custody of the Secretary to the Department of Justice® and pursuant to section 52(2) of the Coroners Act
(2008) because Mr Hietanen was in custody when he died, an inquest is mandatory.
possible, to find:
6 The 3 in 3BR is irrelevant for these purposes. The B signifies that the prison had been involved in minor trafficking offences involving small amounts of drugs, possession of non-prescribed or illicit drugs (other than cannabis), consuming alcohol or a drug of dependence (other than cannabis) and refusing to submit to or interfering with drug testing. The R signifies a review of the prisoners who had committed B offences and the
reintroduction of contact visits and an eligibility to access the Drug-Free Incentive Program (DFIP).
77.535,
8 Section 4, Coroners Act 2008.
(a) The identity of the deceased;
(b) The cause of the death; and
(c) The circumstances in which the death occurred.’
death.
determine disciplinary matters.
preventable deaths in the community and Coroners may:
(a) Report to the Attorney-General on a death;!
(b) Comment on any matter connected with the death including matters of public health
or safety and the administration of justice;!4 and
(c) Make recommendations to any minister or public statutory authority on any matter comnected with the death, including public health or safety or the administration of
justice.
9 See Coroners Act 2008 (Vic) preamble; s 67 10 Coroners Act 2008 (Vic) s 67()(c).
'! Keown v Khan [1999) 1 VR 16.
2 Coroners Act 2008 (Vic) s 69(1).
3 Coroners Act 2008 (Vic) s 72(1).
'4 Coroners Act 2008 (Vic) s 67(3).
1S Coroners Act 2008 (Vic) s 72(2).
weight of evidence commensurate with the gravity of the finding, and effect."*
Such a description should interpreted in the context of the coronial jurisdiction being
inquisitorial and having nothing to do with guilt or innocence.
Identity of the Deceased - section 67(1)(a) of the Coroners Act 2008
16 (1938) 60 CLR 336, pp. 362-363. See Domaszewicz v State Coroner (2004) 11 VR 237, Re State Coroner; ex parte; Minister for Health (2009) 261 ALR 152 [21]; Anderson v Blashki [1993] 2 VR 9, 95.
! Qantas Airways Limited v Gama (2008) 167 FCR 537 at [139] per Branson J but bear in mind His Honour was referring to the correct approach to the standard of proof in a civil proceeding in a federal court with reference to section 140 of the Evidence Act 1995 (Cth); Neat Holdings Pty Ltd. Karajan Holdings Pty Lid (1992) 67 ALJR 170 at pi 70- 171 per Mason CJ, Brennan, Deane and Gaudron JJ.
18 Anderson v Blashki [1993] 2 VR 89, following Briginshaw v Briginshaw (1938) 60 CLR 336, referring to Barten v Williams(1978) 20 ACTR 10; Cuming Smith & Co Lid v Western Farmers Co-operative Ltd [1979] VR 129; Mahon v Air New Zealand Ltd {1984] AC 808 and Annetts v McCann (1990) 170 CLR 596.
!9 Briginshaw v Briginshaw (1938) 60 CLR 336, at pp. 362-3 per Dixon J.
2 Briginshaw v Briginshaw (1938) 60 CLR 336, at pp. 362-3 per Dixon J.; Cuming Smith & CO Ltd v Western Farmers Co-operative Ltd [1979] VR 129, at p. 147; Neat Holdings Pty Lid v Karajan Holdings Pty Ltd (1992) 67 ALJR 170 at p! 70-171 per Mason CJ, Brennan, Deane and Gaudron JJ.
Cause of death - Section 67(1)(b) of the Act
death was “1 (a) Combined drug toxicity”?! I accept Dr Young’s opinion.
THE INVESTIGATION, THE INQUEST & CONTROVERSIES The Investigation
and from SVHM in reply to G4S submissions.
nominated as issues of controversy as;
(a) SVCH and SVHM sharing prisoner health information with G48,
(b) A safe and efficient method of dispensing medication in Borrowdale Unit; and
2! Medical Examination Report of Dr Gregory Young dated 9 November 2017; Coronial Brief p. 76-88.
22 Section 89(4) Coroners Act 2008.
23 St. Vincents Hospital Melbourne (“SVHM”) and St. Vincent’s Correctional Health (““SVCH”).
24 Mr Hietanen’s partner.
(c) Evening lockdown procedure at the Prison — observance of positive signs of life and well-being of each prisoner incorporating the ‘toast run’ and what constituted a
verbal response.
The Inquest and Controversies
(a). SVCH, SVHM Sharing Prisoner Health Information with G4S
followed.
The 2015 Policy
Form St. Augustine’s Mental State and Risk Assessment” form (“Returning Form’).
have access to prisoners’ medical histories.
25 “Closing Submissions of Ms Camilleri” [13]. Correctional provider in this case is G4S.
26 Attachment to Exhibit 23, This document purports to have been last reviewed in July 2015.
27 CB Pp. 191-199.
28 CB Pp. 316-320.
29,
SVCHS staff did and do have access to prisoners’ medical history (including any Discharge Summaries and Returning Forms) from which they were required to complete a form known as the, “Prisoner Health Information Form” setting out the prisoner health information that SVCHS staff considered relevant to be provided to G4S. Prisoners are asked to sign completed “Prisoner Health Information Form[s]’ consenting to the
information in it being provided to G4S.
That principles of privacy and medical confidentiality dictate that not all prisoners’ medical information gleaned by St. Vincent’s Hospital, whether as SVHM or SVCHS should be passed on to G4S is uncontroversial. That some such information may bear on the secure running of the Prison is also uncontroversial, Careful assessment of information, balancing of rights, obligations and needs is required to decide what of
prisoners’ medical information should be appropriately passed onto G4S.
When Mr Hietanen was discharged from SVHM on 27 July 2017, the Discharge Summary referred to Mr Hietanen having been admitted to hospital because he had saved-up pills, perhaps four or five, and taken them all at once to reach a ‘happy state’ and to him having done that on a number of previous occasions. Such information according to Mr Vale was information relevant to the security of the prison, including to Mr Hietanen’s management, safety and well-being”’ and so should have been included
on the Prisoner Health Information Form; it was not.
I note that when Mr Hietanen returned to the Prison on 27 July 2017 the practise was that a psychiatric nurse would complete the Prisoner Health Information Form; no staff had been specifically trained to complete this form. Mr Hietanen’s Prisoner Health Information Form was completed by a SVCHS staff member on 27 July 2017, although despite enquiries,*! the identity of the staff member remains unknown. Mr Hietanen signed the form consenting to its content being provided to G4S staff??; The form
contained scant information; there was no reference to:
2 7.86.
31 Exhibit 22.
32 pp.314-315 Vol. IL CB.
i. The cause of Mr Hietanen’s admission to SVHM on 27 July 2017,
ii. Of him allegedly hoarding his medication and taking doses in excess of that
which were prescribed to reach a ‘happy state’ or iti. Of him having admitted to having hoarded medication on other occasions; and
iv. Of an unknown mixture having been found in his room.
Whilst there is tension between what health-information should be provided-to G48 and
what must remain confidential, | note that the completed “Prisoner Health Information Form” could have included the information in the Discharge Summery to which I referred in paragraph 31 above, and Mr Hietanen could have been asked for his consent that this information be provided to G48. There is no evidence about why this material
was not included in the Prisoner Health Information Form.
Dr Smith, an employee of SVHM, gave evidence that she believed that the information
in the Discharge Summary was provided to G4S.*3
When Mr Hietanen returned to the Prison on 27 July he was also reviewed by Dr McLaren, an employee of SVCHS. Dr McLaren read the Discharge Summary from SVHM but didn’t pass its contents onto G4S believing that G4S would have already known that information.*4 Further, Dr McLaren considered that the “Prisoner Health Information Form” ought to only contain information in relation to a prisoner being
violent.
Evidence of Dr Belinda Smith
Dr Smith was a visiting medical officer and Director of Physician Training at
SVHM. Two written statements made by Dr. Smith were tendered.**
on 21 July 2017 by ambulance from the Prison because prison staff had noticed him to
have a reduced level of consciousness, an erratic heart rate and normal blood pressure.
37.7 -8.
36 Exhibits 1 & 2.
i]
Mr Hietanen underwent an echocardiogram and was reviewed by the cardiac registrar because his troponin levels had ‘risen minimally’. Subsequent cardiac monitoring did not raise any concern and Mr Hietanen’s gabapentin was recommenced. On 27 July 2017, Mr Hietanen was discharged back to the Prison — with arrangements being made for a psychiatric follow-up, and a thallium stress test?’ to be followed by an
appointment in the outpatient clinic at the Prison when the test results were available.
Dr Smith was taken to the notes made by the ambulance staff who brought Mr Hietanen to SVHM and the notes by Dr Leader, the doctor who first saw Mr Hietanen in the emergency department.*® Dr Smith explained that when Mr Hietanen arrived at the hospital, staff had concerns about him having taken an overdose of gabapentin or
pregabalin®? or both.” Dr Smith said that:
(a) She first became aware that Mr Hietanen had taken extra gabapentin from Dr Christiansen the overnight registrar."!
(b) She spoke to Mr Hietanen and he told her that he had taken ‘extra’ of his prescribed gabapentin tablets to ‘lift his mood’, to ‘feel good’ and that he was shocked that he became unwell because, he said, it was not uncommon for him to self-medicate with
Gabapentin to make himself ‘feel good’.
(c) Mr Hietanen told her about having taken ‘extra’ gabapentin or pregabalin, she
wasn’t sure which.”
37 Such a test checks how well blood flows into the heart under exercise.
38 At 12.03am 22 July 2017 CB.204, T.13.
39 Not a drug that was prescribed to Mr Hietanen.
40 Both. drugs and any combined effect and perhaps an altered conscious state T.14-15.
3 T30-31; Exhibit 2 p.2.
Dr Smith was unable to recall which drug Mr Hietanen referred to and was not confident of the contents of the notes. Dr Smith ordered a psychiatric review which did not occur at the hospital and despite an intention that it occur at the Prison neither did it occur
there.“* Mr Hietanen was given a reduced dose of his prescribed gabapentin.
Dr Smith gave evidence that she believed that the Prison was aware that Mr Hietanen
had taken extra medication in the past.
Dr Smith gave evidence that after prisoners are treated at SCVH the hospital prepares a ‘Discharge Summary’ to accompany each prisoner back to where-ever they are being
held.”
Despite ambulance notes*® that Mr Hietanen told ambulance staff that he had taken 600mg of Lyrica, and that he had taken from another prisoner possibly together with extra gabapentin was no reference to that in Mr Hietanen’s “Discharge Summary” and so was not available to the- person at the prison who filled in the Prisoner Health
Information Form.
The Prisoner Health Information Form, the process for its completion and the lack of adequate training in its use“? were reviewed after Mr Hietanen’s death, and the “Communication between Health Service and Correctional Provider / Clinical Services” policy ‘became the “Communication of Health Information Between SVCHS and Correctional Services” policy. The new policy facilitated a greater scope of information being provided to SVCHS and being made available to G48. This new policy specifically contemplated health information management issues seperately from safety from violence (security) issues and detailed relevant training for those completing
associated forms as set out in Mr Vale’s*° and Mr Castle’s°! evidence.
5718
467.17.
77.6,
48 Extra Material Tab 3 p.88.
4 7.458, 468.
50 Exhibits 22 & 23.
43, Given the evidence of Mr C and Ms F, canvassed below, even if they had been aware of:
(a) IDU,
(b) History of hoarding; and
(c) Diverting of drugs.
Subsequent trap-to-irap distribution of medication to Mr Hietanen and the ‘evening muster’ may not have been conducted differently and Mr Hietanen may have died as he
did anyway.
(b) Lockdown Procedures and Morning Muster Procedure at the Port Phillip Prison
A final muster or ‘Lock Down’ of all prisoners is performed each day in Borrowdale Unit at the evening lockdown. This usually commences at about 7.30pm.
‘Lock Down’ is a check to make sure that all prisoners are in their allocated cells and
alive; it is considered a ‘welfare check’,>? before the Unit is ‘locked down’ for the night.
The staff performing the final count are required to attend each cell and sight the prisoner through the trap and record their presence in the unit on the daily master sheet. In doing so, they are required to pay attention to the prisoner's well-being. The final muster also
requires correctional officers to perform other security activities.
Prisoners in the Borrowdale Unit spend up to 23 hours of every day alone in their cells.
They are allowed out for at least an hour to exercise, generally alone. Any effect of such a draconian regime on prisoners is not within the scope of this inquest, albeit that the regime may have influenced Mr Hietanen’s drug abuse. I note that Mr Hietanen was not resident in the Borrowdale Unit because he posed a security risk but was there for his
own protection.
Correctional officers Mr C and Ms F provided statements and gave viva voce evidence,
during which they each described, conducting the ‘Lock Down’ in the Borrowdale Unit
3! Exhibit 26.
27 542-543.
3 Volume 2, p45; CB.
54 Exhibit 6;7;8; 11 and 12.
in the late afternoon / evening on 7 August 2017. Given the regime of the Borrowdale Unit, the need for such ‘welfare checks’ is obvious. Mr C and Ms F also gave evidence of the method by which medication is dispensed to prisoners in the Borrowdale Unit, and Mr C gave evidence of finding Mr Hietanen in this cell on 8 August 2018 having passed
away.
Evidence of Correctional Officer Mrc
Mr C provided the court with written statements dated 8 August 2017,°° 13 October 2017°° and 19 August 2019.57 He gave viva voce evidence on 21 August 2019.
Prior to his statement dated 19 August 2019 being tendered, Leading Senior Constable Taylor (LSC Taylor) asked him whether there was anything that he wanted to change (in his statements) to which Mr C replied:
“Um, just um, I’ve recently recalled that um Mr Hietanen was snoring um when — I
did the truck [sic] count....yeah the night shutdown, yeah....on the 7", yes.” 8
“Um, I’ll be honest with you, on Monday after speaking with the solicitors, I went back home and my wife was snoring and it just brought back a memory of that and
for some reason it triggered — it triggered that in my head”.
(a) On that day when things were freshest in his mind.
(b) That Mr Hietanen’s death was the first death in custody in which he was involved.
55 Exhibit 7.
56 Exhibit 6.
57 Exhibit 8.
587,152.
37.152,
(c) He was conscious when he typed the statement that it was very important that he record all of the detail that he could possibly remember because there was going to
be an investigation and, in all likelihood, he would have to give evidence.
(d) He knew that him discovering Mr Hietanen’s death was significant and that an
investigation was to ensue.
(e) That the document should contain his best recollection of precisely what went on,
on the same date as the event.”
Mr C gave evidence that he thought that that report was meant to only refer to what occurred on 8 August 2017,” that the purpose of the form was to record the events of
what occurred on that day.”
(a) At that time, he was aware that Mr Hietanen’s death was a very serious matter being
investigated by police.
(b) He was conscious that it was particularly acutely significant that he tell investigating
police everything he remembered.
(c) After police had written out the statement, he read it. Mr C seemed to
obfuscate when asked if he read it carefully but subsequently agreed that he did.
(d) Police who ‘took the statement’ asked him if the document was an accurate
description of what he had told them.
(ec) He was aware that the statement dealt with a very important matter — Mr Hietanen’s
death in custody.
3 7234, 4 7.212.
(f) He was asked to initial each page of the statement and to sign it at the end.
(g) He signed the statement as being accurate.
(h) If there was anything inaccurate, he would have told the police to change it and he would have made sure that they did, but that he didn’t then think there was anything
he needed to change.® 54, Ms Katotas asked Mr C further questions:
“... ‘Sprightly in the mornings’. You don’t refer to seeing him_breathing in_that
paragraph? I wasn’t asked that question at the time by the police.
Well, I'll ask you_now, do vou remember seeing him breathing or hearing him
breathing? Yes.
You recall hearing Gary breathing? Hearing him snoring, yes.
No, no, that’s not my question, I'll get to the snoring. Do you hear Gary, do you hear
him breathing on the evening muster on 7 August? Yes.
Do you see his stomach moving up and down? Yes.
Do you hear him snoring? Yes.
You don’t mention any of those things in paragraph 8 or indeed of that particular
statement taken by the police on 13 October? I didn’t realise I needed to be that
specific. ”°”
Mr C agreed that the statement does not refer to him hearing or seeing Mr Hietanen breathing or hearing him snoring, and said that this was because he was not asked by the
police who ‘took the statement’ about these issues** Ms Katotas continues:
“You don’t think that that was important to tell the police officer? It wasn’t
questioned at the time.
6 7.212.
6 Questions asked are underlined.
6 7164; T165 Underlined sections are questions put to Mr C.
8 1164-165.
i7
THE CORONER: That wasn’t the question, Answer the question, if you would? Ah,
it may have been important to raise that at the time, yes, but I didn’t.
Now you can answer that question, Mr C? Can I hear the question again please?
Didn’t you think it was important that you tell the police that you saw his chest or
stomach rising and falling when you spoke to them on the morning of the 8?
MS KATOTAS: 13". Well, this statement was taken on 13 October.
THE CORONER. 13", I’m sorry, yes? I—I didn’t think it was important to note it at the time. JI didn’t realise that — that it would be — that — that it would be that
important.”
seeing Mr Hietanen breathing to which Mr C replied: “J didn’t realise that I needed to be that specific.””
changes and signed it.”
evening of the 7"), he saw Mr Hietanen’s face. Mr C responded:
“I do not recall whether Mr Hietanen spoke to me but I am sure I received some sort of verbal or physical acknowledgement or sign of life (such as chest rising falling, sounds of breathing or snoring or physical movement) from him to complete the
welfare check because I would not have moved on otherwise.
6 T165.9-T165.28 Underlined sections are questions put to Mr C.
70 As he was giving evidence.
7 Bxhibit 8.
So_he says Iam sure I received some sort of verbal or physical acknowledgement.
You don’t. say, do you, that you heard him breathing and snoring. It says sounds of
breathing or snoring or physical movement. Do you agree that that’s what the
statement says? That’s what the statement says.
It doesn’t say, does it, that on 7 August muster, when you did the welfare check, that
you heard him breathing or that you heard him snoring. It says that it was ‘or’, you
either heard or saw him breathing o7 snoring. It’s not @ confirmation that youl saw or
heard him breathing? I wouldn’t have moved on had I not received a confirmation of life.
THE CORONER: That wasn’t the question. Answer the question please? Could you
repeat the question?
MS KATOTAS: The paragraph, and I'll read it to you again, ‘I do not recall whether
Mr Hietanen spoke to me but I’m-sure I received some sort of verbal or physical
acknowledgement or sign of life (such as chest rising and falling, sounds of breathing
or_snoring, or physical movement).’ Do you agree that you don’t say in that
statement that you heard him breathing or vou saw him breathing or you heard him
snoring, it was J either, I either heard him snoring or breathing. It’s an or, it’s not an
and, do you agree? It could be interpreted that way.
So what is your evidence then now, today, on 2] August 2019?
THE CORONER: Can I just stop you there. Can we go back one step. Have you got paragraph 26 in front of you? Yes.
You don’t say in that statement I heard him snoring, do you? No.
Thank you. Nor do you say I heard him breathing, do you? No.”
Thank you. I’m sorry to interrupt, Ms Katotas. 74
snoring of the evening of 7 August 2017.
«Do you want to alter your evidence at all in relation to your memory? Well I—I
had a recollection on, like I said, on Monday night after meeting with the solicitors
7 T166.9-T167.16 Underlined sections are questions put to Mr C.
and reading the statement. My wife was snoring in bed and it reminded me of that day, that night, that evening when I dropped the trap and did muster. It brought a memory back to me that Mr Hietanen, Gary was on his bed, he was snoring,
breathing.
Two years later, two years later, your wife is snoring. Has she not snored in the last
two years? She has
Or_was Monday the first time in the last time that you heard your _wife_snoring?
No”.
«received some [unspecified] sort of verbal or physical acknowledgement or sign of life”
not including it “...didn’t make much sense.”
Mr Hietanen.®° When asked about what he saw Mr C said:
« ..He was snoring. His chest was rising and falling. Or his belly, chest area was
rising and falling.”
7 T 167.17-167.29 Underlined sections are questions put to Mr C.
1 T.217; Exhibit 8 para. 26.
7] Exhibit 8 para. 26.
That's not what the statement says, though, is it? No, sir.
That’s not referred to in any of the other documents that you compiled, is ii? No, sir.
Why not? I don’t know, sir.
You don’t know. Even if — you say that you had seen his chest rising and falling, and
you heard him snoring? Yes.
How is it that you were satisfied that that was sufficient as a welfare check? He could
easily have been unconscious or under the influence of some drug, couldn’t he? I
know that now. Um, I didn’t at the time. I didn’t think that he was under the
influence at the time.
So_a sign of positive ~ let me rephrase that — a sign of life that’s satisfactory to yout
was the rising of the chest and the snoring? I thought that he was asleep.
Possibly, yes. Jt could equally be that, as J say, he was under the effect of some sort
of drug or in fact unconscious or dying? I know that now, sir. I didn’t at the time.
You didn’t think that at the time you needed a little bit more in the way of positive sign
of life? _I didn’t think there was any cause for concern at the time, which is why
On the basis of what?...’Cause he was alive and breathing, sir.”®!
“heard...the...the prisoner making sounds behind the door. 783
81'T218.2 — 218.27 Underlined sections are questions put to Mr C.
82 F180. and T182.
837 180.29-.30.
When I asked Mr C further questions about this, explicitly directing him to the issues in
the question, he agreed that he did not obtain a ‘verbal response’ .**
This response was different from the one he provided to Ms Katotas when she asked him
questions about whether he had obtained a verbal response.®®
Mr C described not recalling if Mr Hietanen spoke to him during the ‘lock down’, but of believing that he saw some sort of verbal of physical acknowledgement because if he
had not (seen such a sign), he would not have moved on.®°
Ms Katotas explained to Mr C that on 21 July 2017, Mr Hietanen had been found in his cell and was not able to be awoken by Mr Sullivan, and so Mr Sullivan called the assistance of other officers and went into Mr Hietanen’s cell to try to wake him.
Mr Sullivan called a ‘code black’. Ms Katotas asked Mr C that if he had known of this event on 7 August would he have woken Mr Hietanen during the ‘lock down’ check.
Mtr C said “...possibly yes”.®7
When asked about how he could be sure that his evidence of the recollection he had on 19 August 2018 was of hearing Mr Hietanen snoring on 7 August 2017, Mr C said that he could not be sure that his memory was of Mr Hietanen snoring on 7 August 2017, although he went on to say that the memory triggered was of hearing Mr Hietanen snoring on 7 August 2017.°8
Mr C agreed that his recollection of Mr Hietanen snoring on 7 August 2017 was a very
significant event, and when asked about whether he told his solicitors on 20 August 2018
of this recollection, he said that he had didn’t because:
(a) “...I didn’t realise the substantiation of, of that evidence.”*° Then later,
85 7180-181.
877.185.
89°7229.1-.2.
(b) “I thought it, I thought it was covered in what I had written, which is why I didn’t...
Then later still,
(c) “I thought that it was covered in s.26 of my statement.””!
«No, I haven't. No, she no longer works at Port Phillip Prison.
(a) Maybe in February 2019 at a pub in Werribee.
(b) They had never discussed their recollections about what had happened or the statements that they had made.
(c) He did talk to Ms F about the event.
(Q) He couldn’t recall discussing the events with Ms F.%
(e) He saw her at work after Mr Hietanen’s death and might have discussed the events with her, albeit that Ms F didn’t tell him at any time that she had included in her statement that she had heard Mr Hietanen snoring during the ‘lock down’ on
7 August 2019.%
907 229.4-.5.
91'1233.6.
7 .219-220.
95 7221.28.
(f) He may have spoken to Ms F about the events surrounding Mr Hietanen’s
death?’ but didn’t talk to her about their recollections of events.”
(g) He didn’t speak to her about the events of the night, nor the content of their
statements at work.”
door with the cell key. Mr C says: “. [I] unlock the trap with my key and put my face down to the trap.
...And if you see my hand movement there, I ~ I’m knocking the door with a key to get a response from Gary and then I advise the supervisor F to put him down for
toast.
So at that stage you were concerned you didn’t get a response...I knocked on the
door, um...to obviously get a — a better response from him, um, by the look of it, it
was obtained and J initiated the toast for Ms F to write down
Well having watched the video then, does that _-.can you explain to His Honour why
it is that you appeared to have spent a longer time at Gary’s cell door than, say, the
other_checks vou did that evening? Um maybe I was trying to get a — a further
response from him um and just to make sure that he was safe for the evening.
...Well it’s a muscle memory thing. I left the flap, have a look, drop, drop the trap and put my head in. I, I drop the trap on, on all of those counts to ensure that I
have a, an interaction with the prisoner behind the door. 201
asked of him unless explicitly re-directed to it. | After having seen
987 .230.5.
100 Exhibit 28.
‘01-7207. Underlined sections are questions put to Mr C.
Mr C in the witness box and having heard all his evidence, my impression is that Mr C
. was an intelligent, thoughtful man who did not always directly answer questions put to
him not because he misunderstood them or didn’t understand them at all, but rather he preferred to answer another question. Further, I formed the view that some of his evidence was at least implausible. When for example, Mr C was directed to answer Ms Katotas’ question about whether he thought it was important to tell police on 13 October 2017 that he had seen Mr Hietanen breathing and snoring, when he conducted the “lock down” on 7 August 2017 — the night before he found him in his cell having passed away, Mr C said that:
“I didn’t think it was important to note it at the time. I didn’t realise that -that it
would be — that — it would be that important.”'
I find it at least very surprising that Mr C made no mention in his Officer’s report of 8 August 2017, of allegedly having seen Mr Hietanen breathing when he checked him in his cell on 7 August 2017 (the previous night) because he said that the report only dealt with events of 8 August 2017.'% His assertion that in his report of 8 August, Mr C didn’t refer to having allegedly seen Mr Hietanen alive some 12 hours earlier seems at least odd. This is especially so when Mr C was concerned about the circumstances surrounding Mr Hietanen having been found in his cell having passed away:
«_ a crime scene and maintaining that crime scene.’ |
I take into account that Mr C found discovering Mr Hietanen in his cell having passed away was confronting for him and perhaps all the more so because Mr C said that Mr
Hietanen resembled his, Mr C’s recently deceased father. !°°
I found Mr C’s evidence that the day before he gave evidence he remembered hearing
Mr Hietanen snoring on a specific night some two years prior and that this memory was
102 1149-1234,
104 166.
106 Exhibit 8 p.2.
triggered by having heard his wife snoring the night before he gave evidence frankly, implausible. His evidence that he definitely did not discuss hearing Mr Hietanen snoring with Ms F was not explicitly supported by Ms F’s evidence; she was uncertain about whether she discussed this matter with Mr C.!°7 Ms F’s reference in her statement of November 2017 to Mr C looking into Mr Hietanen’s cell and she hearing Mr Hietanen snoring at least provides some consistency to her evidence that she heard Mr Hietanen snoring on 7. July 2017, albeit that in her. statement of 16 August 2019. she refers to ‘...believing...’ that she heard Mr Hietanen, said there to be a known loud snorer, snoring. This evidence does not necessarily support Mr C having remembered in 2019
that he heard Mr Hietanen snoring in 2017.
1 am not satisfied that Mr C heard Mr Hietanen breathing or snoring, or that he saw his chest or stomach moving up and down when he conducted the final count on 7 August
Nor am I satisfied that he, Mr C, “...received some sort of verbal physical acknowledgement or sign of life (such as chest rising falling, sounds or breathing or snoring or physical acknowledgement’® from Mr Hietanen when he conducted the
count on 7 August 2017.
Evidence of Correctional Officer Ms F
i2
work she did not discuss the evening of 7 August 2017 with him.! She later gave
107 7.252.
109 Exhibit 11.
110 Exhibit 12.
My 252.
122-7.252,16,
79,
evidence that she “...can’t recall if I did’,'° but that she was concerned about
Mr C’s welfare because he was distressed about that day.!!4
Ms F told LSC Taylor that when police took her second statement on 3 November 2017 they had “...our reports that I collated from that day...”!5 She told LSC Taylor that she knew that Mr Hietanen was a drug “...diverter...who would try to acquire other people's [drugs].” Ms F gave evidence that she had a memory of the ‘trap muster’ on 7 Atigiist' 2017 arid of remembering hearing Mr Hietanen snoring from outside the cell’
when the trap was opened.'!®
Ms F gave evidence that she was not aware of a ‘code black’ having been called in
relation to Mr Hietanen in July 2017.1”
Ms F gave evidence that on morning of 8 August 2017, she saw Mr Hietanen “...pretty
much sitting on the bed, legs over the edge, facing the tv area which was the desk.”'"*
Ms F gave evidence that she and Mr C heard Mr Hietanen snoring:!!
THE CORONER: “Just_a couple of things, if I may. How did you know that Mr C
heard him snoring? We may have spoken about it but, again, I - I can't recall.
Again, sir, I - I honestly can't remember.
You may have spoken to Mr C about that? We may have, um...
Mr C's given us some evidence about having spoken to you on a couple of occasions.
£i
One, shortly after this event about welfare issues? Yep.
Do you remember that? No, sir.
You don't remember that? No.
"14 *7.252.18-252.22,
Healso said that he's seen you at work a number of times afier the event before you
finished? Yep, yep.
Could it have been during that period when you and he spoke about the snoring
issue? Maybe, but again I can't recall ‘cause again a lot of things have happened in
that time.
Yes. He also mentioned meeting you_a couple of times socially in relation to
American football at a hotel I think, in was it Werribee or something like that? Yep,
yes, On two occasions? M'hmm.
Could you have spoken to him there about the snoring? No. We don't talk about
work outside of work.
But you could have spoken to him at some point in time about the snoring? I could
have but I can't 100 per cent guarantee I did.!”°
occurred on the 8" of August 2017.
was aware when she was making it that it was being taken for the inquest into
120 270,12- T271.8 Underlined sections are questions put to Ms F.
Mr Hietanen’s death, a very important issue." She agreed that the statement made on 16 August 2019'75 makes no reference to the conversation that she said that she had with Mr C as they inspected Mr Hietanen on 7 August 2017. Ms F also agreed that her statement taken 3 November 2017!*° makes no reference to that conversation and when
asked she could not say why.!?”
In answer to questions from Ms Katotas, Ms F said that had she known on 7 August 2017 that on 21 July 2017 Mr Hietanen had beeii the stibject to a ‘code black’ and he went to hospital as a result of an overdose on medication, she would have done something
different on the night of 7 August 2017 and checked on him.'”8
When she gave evidence, Ms F had little if any direct memory at all of the events of 7 and 8 August 2017 and, she said, of any discussion she had with Mr C shortly afterward, perhaps unsurprising given that those events were two years earlier. Any subsequent discussion she may have had with Mr C was certainly more recent, albeit her recollection of that or those discussions was at best vague. Her evidence about having moved on to another cell after having checked Mr Hietanen on 7 August 2017 was more consistent with her having believed that she or Mr C had perceived signs of life in Mr Hietanen because they moved on rather than them having actually seen or heard such a
sign or signs and so moved on. Mr C’s evidence had a similar tenor.
Having viewed the video of the ceil check of 7 August 2017, Mr C can be seen to be closer to Mr Hietanen’s cell and the open trap door, when Ms F says that she heard Mr Hietanen snoring. Absent Mr C having some hearing difficulty, of which there is no
evidence, if Mr Hietanen was snoring Mr C may have been able to hear him.
The alternative is that Mr Hietanen wasn’t snoring, and Ms F was incorrect or mistaken
in her statements of November 2017 and August 2019 and so was Mr C in his later
triggered memory.
25 Exhibit 12.
126 Exhibit 11.
Hietanen down for ‘toast’.!2?
alive when he, Mr C looked into the cell on the evening of 7 August.
Hietanen, but at no point in his evidence does he explain what that interaction was.
for toast.!3!
Mr C and Ms F checked him during the ‘lock down’ on 7 August 2017.
(c)_ Dispensing Drugs to Prisoners in the Borrowdale Unit
(a small door), a part of the main door of each cell located below the window in the door
130'7207.29.
‘tT 180-182.
about waist height from the floor. The pharmacy assistant identifies the prisoner and passes the prisoner’s medication through the trap door to the prisoner.
The correctional officer watches this and then via the window in the cell door, watches the prisoner take the medication. The prisoner is then asked to open his mouth so that the correctional officer can see (through the window) that the medication was consumed.
Evidence is that the officer cannot see the medication all the time from when it is handed to the prisoner through the trap until when it goes into-his mouth..'3?. Mr C described this process as “...offen not ideal...”.'°> Later in his evidence, Mr C is referred to his statement made on 19 August 2019 and explained that using this process, it is not “...as
easy to conduct observations”.'**
Mr C gave evidence that other methods had been tried, including taking prisoners from their cells to the medical room in Borrowdale or opening the cell doors so that correctional officers can better see prisoners consuming medication. Mr C too referred
to methadone that is dispensed only from the medical room.'**
Mr C explained that medication can be dispensed up to three times per day in the Borrowdale Unit. In mainstream units, medication is dispensed to all prisoners from a central point in their unit. Mr C explained that when a prisoner is to take prescribed methadone, he is taken from the cell to the Opioid Substitution Therapy Program Room (“the medical room”) in the Borrowdale Unit and provided with the medication. Prison officers then stand next to the prisoner and have a clearer view of consumption of the
medication. '°7
133-7.158.13.
136-7159.
Mr C gave evidence that a particular prisoner having an IDU rating would make no
difference to the diligence with which he supervised his drug dispensation.*
Ms F gave evidence to similar effect.19
Mr Sellman adopted Mr Castle’s statement and in particular, gave evidence that an IDU 3B status would not have changed the way that Mr Hietanen was managed in the
Borrowdale Unit, other than the specific effects of the attribution of the IUD 3B status.
Mr G, another prison officer gave evidence that dispensation ‘of all medication in Borrowdale could be conducted at the “medical room” window which would allow correctional officers to see the prisoners taking their medication better.'*° Mr G referred to a very limited trial of this alternative method of dispensation having been
undertaken!“! but could provide only a very little evidence of the results.
Ms. Mizzen, a health services manager for G4S at the Prison, gave evidence of the operation of the trap-to-trap dispensation of medication. She referred to some prisoners receiving medication out of their cells and of G4S giving some consideration to ‘trap-to-
trap’ dispensation of medication:
“ought to be changed permanently but for the reasons set out above which are largely staffing levels, time constraints and commercial issues it was decided not to.
Ah in addition to that it was the drug screening as well which didn’t show any improvement, Other witnesses spoke about trials of medication dispensation by other than trap-to-trap
method,'’ one reference was made to a trial over a weekend. 44
138 193,
39-7 245,
140 7.306.
142 7.530.
144-7504.10-.13.
100.Mr G gave evidence that dispensing medication through the trap in Borrowdale Unit and making sure that it is consumed is quite difficult, and had he known a particular prisoner was hoarding medication he would have paid more. attention to making sure that they
were taking the drugs provided to them. ‘4°
101.Dr Joseph, the medical director of St. Vincent’s Correctional Health Service agreed that dispensation of medication in Borrowdale Unit through cell door traps is less than perfect and that if medication were dispénsed otitside the medical room that gaps in supervision of consumption would be less likely. Dr Joseph asserted that a balancing exercise needs to be undertaken between “...che commercial effects and the management effects...”.
Dr. Joseph gives evidence that he does not know if hoarding or overdoses involving Lyrica at the Prison is contributed to by the way that the drug is dispensed.'° Dr Joseph explained that when prisoners take a number of central nervous system supressing drugs,
the combined effect of all the drugs must be carefully considered!”
Conclusions
St. Vincent’s Hospital Melbourne — St. Vincent’s Correctional Health Services & G4S
Sharing Health Information.
102.Mr Vale’s ‘concession’ that with ‘hind-sight’, Dr McLaren should have told G4S staff of Mr Hietanen’s history of stockpiling medication, suggests a problem with an individual when the problem with communication was an underlying management and protocol deficit. The problem experienced by Dr McLaren was the lack of an explicit and functioning practice and process whereby SVHM and SVHCS could inform G4S staff of material in a prisoner’s medical file that effected the safe operation of the prison. Such an issue is not one that only becomes clear with the benefit of hindsight, but rather a
fundamental structural requirement. Dr. McLaren should not have been required to rely
on ‘reasonable expectation’ or a ‘belief that G4S staff knew that Mr Hietanen had been subject to the ‘Code Black’.
Ina similar vein Dr Medis should not have been obliged to rely on what she ‘would have
believed’ or ‘assumed’ or indeed what she understood was ‘usually reported’.!”?
103.The Policy and Procedural changes set out paragraphs 34 — 40 of St. Vincent’s written submissions appear to deal with the underlying deficient management and structural problem to which I have referred. Adequacy of such structural change ought to be
monitored and audited.
A Safe and Effective Method of Dispensing Medication in the Borrowdale Unit
104.Trap-to-trap distribution in the Borrowdale Unit involves, at the very least, the potential for prisoners to accumulate prescribed drugs. Such conduct is not unknown in the Prison particularly when prisoners believe that a larger than prescribed dose will provide a desirable effect. The danger posed by accumulation of, particularly central nervous
system depressants is that a larger than prescribed dose may be fatal.
105.As I have set out G4S staff all gave evidence in notably similar terms, that regardless of a prisoner’ having IDU rating, history of hoarding or diverting of drugs, the trap-to-trap medication distribution would not have been conducted any differently. The exception to this was Mr G and Ms F who referred to them possibly acting differently if they had been aware of the ‘Code Black’ in which Mr Hietanen had been involved in on 21 July.° Further still, this position was maintained when questions were put about whether they would have more closely monitored dispensation of medication to Mr Hietanen had they known that he had told medical staff of hoarding medication, and taking doses in excess for an enhanced effect.>! This is disturbing. Axiomatically prisoners with histories of such conduct may be usefully subjected to heightened scrutiny
when drugs are distributed.
“8Paragraph 18 Written Submissions by St. Vincent’s Hospital.
'49 Paragraphs 22-25 Written Submissions by St. Vincent’s Hospital.
106.Such an apparent unwillingness to recognise particular problems with particular
prisoners and deal with them is concerning.
The custodial officers’ response — to the effect that regardless of the prisoner’s history or circumstances supervision of medication, that distribution is at least unhelpful and ignores the difficulties of trap-to-trap medication distribution and the potentially fatal effects of prisoners accumulating drugs, especially central nervous system depressants.
Custodial staff should be made awaré of prisoners’ illicit’ drtig usé histories and any proclivities to hoard medication and take those histories and proclivities into account
when overseeing medication dispensation.
107.As at 18 August 2017 a large percentage, 75 — 80%!*? of prisoners in the Borrowdale Unit were taking prescribed medication. Evidence at the Inquest was replete with
3 Ensuring each prisoner
references to drugs being hoarded and diverted by prisoners.'° consumes the drugs he is prescribed according to the prescribing doctor’s orders is an essential task for custodial management. The effect of failure is at least ill health and
possibly death.
108.Dispensation of drugs to prisoners with a history of hoarding medication should be more assiduously supervised and may only be effective if not undertaken ‘trap-to-trap’.
‘Commercial and management issues’ in particular staffing levels of the Borrowdale Unit, must clearly bear on how Borrowdale is run but such issues must be balanced with
the dangers posed by hoarding medication.
The ‘Lockdown’ Process at Borrowdale
109.Mr Hietanen’s management may not have been any different had G4S staff known of his drug hoarding history and proclivity, including the ‘Code Black’ from July 2017 subject to what Ms F,'5* Mr G5 and Mr C° said. Such knowledge should have made a
difference to his management.
Instructions to staff undertaking lock-down in the Borrowdale Unit would usefully be
reiterated specifically required a spoken response from each and every prisoner. Such
reiteration may be as simple as clarifying the obvious; a verbal response is a spoken one
and not snoring nor hearing breathing.
Findings
110.Pursuant to section 67(1) of the Coroners Act 2008 find that:
{a) (b)
(c)
The identity of the deceased was Gary Hietanen born 4 May 1972.
Mr Hietanen’s death occurred on 8 August 2017 in the Borrowdale Unit of Port Philip Prison 451 Dohertys Road Truganina, Victoria 3029 from combined drug toxicity.
In the circumstances set out in paragraphs 103-109 above.
111.Having considered all the circumstances I am satisfied that Mr Hietanen’s death was the
inadvertent result of him intentionally ingesting a number of drugs including methadone,
amitriptyline, gabapentin and paracetamol.
112.Pursuant to section 72(2) Coroners Act 2008) recommend that:
medication to prisoners in the Borrowdale Unit of Port Phillip Prison incorporating
consideration of:
a) ‘Trap-to-trap’ dispensation and alternatives including but not limited opening cell
doors to dispense medication,
b) Dispensing medication directly to prisoners form a central point in the Unit; and
c) Whether different dispensation methods ought to be used for different prisoners
taking into account the nature of the medication being dispensed and each
prisoner’s history of medication and drug use and abuse.
verbal, spoken response must be obtained from each and every prisoner. If such a
response is not forthcoming from an enquiry made through the ‘trap’, the cell door is
to be opened and a verbal response then obtained from the prisoner.
Coroners Court of Victoria website in accordance with the rules.
114.1 direct that a copy of this finding be provided to the following:
(a) (b) () iG) () ( (g) (h) (i)
Signature:
Ms Joanne Camilleri, senior next of kin;
Ms Jan Seaton, mother of the deceased;
Mr Hugh Middleton, Martin & Richard Lawyers;
Ms Michelle Gavin, Justice Assurance Review. Office;
Ms Trish Sellman, General Manager Port Phillip Prison;
Ms Deborah Coombs, Victorian Government Solicitor’s Office;
Ms Ingrid Nunnink, Marsh & Maher Richmond Bennison,
Mr Mark O’Sullivan, Minter Ellison; and
Detective Leading Senior Constable Frank Fierro, Coroner’s Investigator, Victoria Police.
Date: Z — -* :
ee, H2/.
Paragraph 22, which read:
“On 10 August 2017 Dr Gregory Young, Forensic Pathologist practicing at the Victorian Institute of Forensic Medicine, performed an autopsy upon Mr Hietanen’s body. Dr Young provided a written report in which he opined that the cause of Mr Hietanen’s death was “Mixed drug toxicity (heroin, alcohol, diazepam)”. I accept Dr
Young’s opinion” has been changed to read:
“On 10 August 2017 Dr Gregory Young, Forensic Pathologist practicing at the Victorian Institute of Forensic Medicine, performed an autopsy upon Mr Hietanen’s body. Dr Young provided a written report in which he opined that the cause of Mr
Hietanen’s death was “I (a) Combined drug toxicity”. I accept Dr Young’s opinion.”
Paragraph 22; footnote 21 which read: “Medical Examination Report of Dr Melissa Baker dated 16 January 2018; Coronial Brief p 177” has been changed to read:
“Medical Examination Report of Dr Gregory Young dated 9 November 2017; Coronial Brief p 76-88”
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