The system failed Paul Fennessy, when it allowed him to slip through the cracks, become a successful doctor-shopper, and finally administer himself a deadly cocktail of drugs, a coroner has found.
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Mr Fennessy, 21, died outside near a fence on January 6, 2010.
He had survived an overdose that day, one of many in his past. Once revived from unconsciousness by CPR and a dose of Narcan, he told staff at The Canberra Hospital he didn't care if he lived or died.
But that afternoon he was allowed to leave the hospital.
"Don't get wasted!" was a reminder he had written himself, found in a notebook near where he had died, a man so hopelessly addicted to drugs he was unable to help himself.
On Friday, the findings of a coroner following an inquest into his death were handed down. Coroner Margaret Hunter concluded the system failed Mr Fennessy when it allowed him to access prescription drugs from a myriad of sources, without those people fully aware of the potent combinations he was administering on himself.
"... Mr Fennessy just fell through the cracks despite the efforts of treating clinicians. In my view, it is the system at the time that allowed this to occur not a particular person or agency."
He had a history of mental health problems and overdoses. And though he tried, he failed repeatedly to rehabilitate himself.
Despite this, he was left alone to manage his rehabilitation.
"It appears to me Mr Fennessy was a person who was clearly unable to look after himself or make any considered decisions about himself in relation to his addiction.
"Yet he was required to self-refer for appointments to alcohol and drug services or rehabilitation clinics on numerous occasions."
His mother, Ann Finlay, who worked at the hospital, had repeatedly approached professionals, warning them her son was at risk of harm.
The Coroner found a Canberra pharmacy had administered him two doses of methadone on the day he died, when he had only been prescribed one, a mistake at the dispensing pharmacy.
Ms Hunter also found it was not unreasonable for medical staff to have discharged Mr Fennessy from Canberra Hospital on the night he died, given they believed they had no mechanism to detain him.
A question for the inquest was how the mental health clinician who assessed Mr Fennessy on the day he died, had found him not to be at risk of self-harm and not mentally ill. Such a finding would have empowered staff to keep him at the hospital.
The emergency department notes made earlier that day, where someone had written down that Mr Fennessy "did not care if he died or not", were not available to the clinician, the inquest heard.
It was evident at the time that there were significant concerns Mr Fennessy would overdose again, and very soon, Ms Hunter said. He had no ability to manage lifestyle or organise safety, food or shelter.
"Given these concerns, there does not appear to be any evidence that a plan to thwart that situation was devised by any of the medical staff."
Ms Hunter said changes have already been made to address the system failure. For example, the government has created an umbrella agency which shares information on a person's involvement with mental health, drug and alcohol and justice agencies.
She made two recommendations: That the government implement real-time monitoring systems, so doctors and pharmacists can be alerted if someone was doctor-shopping or prescription-hunting.
And that all medical files, including mental health records, in relation to a patient being treated at a Canberra public hospital be made available to all clinical staff at the hospital when required.
