An organised exercise regime and more rigorous checking at jail muster times are among the recommendations of a coronial inquest into the methadone death of Indigenous man Steven Freeman at Canberra’s jail.
Mr Freeman, who was 25 at the time of his death in May 2016, had been on the methadone program at the Alexander Maconochie Centre for only two days when he died.
The cause of death was identified some time ago as aspirational pneumonia secondary to methadone toxicity.
His death sparked a major inquiry in the ACT, with a report making wide-ranging recommendations about health care at the prison.
A key recommendation of the report suggests adopting national standards with random urine and blood tests to check for opiate use among prisoners.
Mr Freeman’s mother, who sat through the inquest, said this issue went beyond race.
“I don’t want it ever happen to another mother, no matter what culture they are,” Narelle King said outside court.
“I never want to pick up a paper and see a mother go through what I went through in the past 22 months, no matter what colour they are or what nationality.
“We’re all mothers and I’m going to carry this burden for the rest of my life for not being there for my son when he wanted me.”
Ms King insisted her son “was never a heroin addict”, and the question of exactly why Mr Freeman had been given methadone in the first place when he was not an opiate user was a key part of the inquest.
The court heard it was well known that methadone can be lethal for a non or low-level user.
No one person to blame, coroner says
But coroner Robert Cook said Mr Freeman had told Dr Luke Streitberg, who prescribed the methadone, that he was using heroin in jail and intended to keep using it.
Mr Cook did not find any particular individual was to blame and said he was satisfied that nursing staff and Dr Streitberg, who prescribed the methadone, had not contributed to his cause of death.
There had also been an incident where Mr Freeman was caught in possession of an opiate, although urine testing close to the time of his death showed no drugs in his system.
Mr Cook did take aim at the jail’s mustering system, because Mr Freeman was marked as present, at a time when he would have been dead.
A prison officer believed Mr Freeman had responded with a movement of his foot at the muster call into his cell, and no-one realised he was dead until mid-morning.
“[The foot movement] should no longer be deemed to be satisfactory compliance for establishing a detainee’s health and wellbeing,” Mr Cook said.
He also suggested the need for more daily structure for prisoners, suggesting a physical education and training regime to prevent them from staying in bed for long periods.
The report also called for agencies to share their information on individuals, saying that may have helped Dr Streitberg.
Death a ‘great tragedy’, Minister says
Corrections Minister Shane Rattenbury said the Government had already addressed a number of concerns raised by Mr Freeman’s death.
“Steven Freeman should not have died in our custody — it’s a great tragedy that he did,” he said.
“From my first look at them, a number of things that have been recommended, we have already started to make progress on, and those that we have not, we will look carefully at now.
“ACT Health has already put in place a number of changes relating to the methadone program.”
However, he said more work would be needed before the Government would commit to random blood and urine testing of prisoners.
“The coroner’s made a very specific recommendation, which we’ll need to look at the legality of, the human rights consideration of, the privacy considerations of individuals, they are the sort of factors we’ll need to weigh up now,” he said.
Mr Rattenbury said changes to how musters were conducted had already been implemented, so that face and name recognition was required four times per day.