Losing Paul: Paul Fennessy's mother battles against the system

Ann ran outside to see flames trapping her son in the shed. She remembers seeing the lawnmower, a petrol can. The image of her son, severely burned across his face, arms and chest, as he warned her away from the fire, etched into her memory. "I imagined the whole street going up in flames," she says.

Paul was intubated and flown to the specialist burns unit at Concord Hospital in Sydney with blisters across 37 per cent of his body. Three weeks later and still recovering, he was discharged with prescriptions for Endone and Tramadol. Paul was not, as far as Ann knows, quizzed by a doctor about his mental health or prescription drug problem before being prescribed the powerful opioids.

His family believe the accident was a key turning point for Paul, one that exposed him to a new suite of drugs that would exacerbate his existing mental health issues and undo attempts to rein in his existing prescription drug problem.

Seven years later, Coroner Margaret Hunter concluded the system had 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.

After the accident Paul was no longer able to play his piano or cello and the injuries brought back painful memories from the Canberra bushfires when he was about 14. As the fire consumed a neighbour's house and the surrounding trees, Ann tried the hose, but there was no pressure. The rush to the car, the engine that wouldn't start. "I remember thinking, well at least, if we die, at least we die together."

Before the accident, Paul's life had shown signs of improvement. He had been in and out of rehab that year, but was working at a cafe in Civic that night and had only one hospital admission in seven months. But his physical injuries gave him even more access to drugs - many of the ones he and his mother had been trying to get him off. The burns moved his dual diagnosis of mental health problems and drug abuse to a "triple diagnosis". He now had the trifecta of mental illness, physical trauma and addiction.

Despite the inquest finding Paul had been unable to make considered decisions regarding his addiction, "he was required to self-refer for appointments to alcohol and drug services or rehabilitation clinics on numerous occasions".

Three months after the accident and a series of overdoses later, police knocked on Ann's front door.

There were meetings after Paul died, lots of them.

With health officials and lawyers; sometimes even judges. Ann was told again and again that Paul had left the hospital of his own accord.

"He wanted to go, Ann," she remembers health staff saying. So much so, she almost gave up searching for answers. She believed them. But her years of experience in the health system still told her something had gone wrong.

"I said time and time again, in these meetings, just read that last note in my son's file and tell me that that's okay," Ann says. "That's all I wanted them to say. Look, that's not okay, that's not okay, that's not okay, and we'll do something about it."

There were letters too.

One, sent almost three years after Paul's death, Coroner Peter Dingwall wrote to Ann saying he saw "no basis" for hearings into Paul's case. A clinical review of Paul's treatment at the hospital that day found "no systemic issues" health authorities believed warranted addressing and changes had also been made to the mental health system since. Paul's case was about to join the hundreds of other deaths in the ACT that are "dispensed with" without a hearing every year.

But Ann was not convinced. More letters, more meetings. Another 11 months went by.

In late 2014, Chief Coroner Lorraine Walker decided Paul's case did raise "matters of public interest". Coroner Margaret Hunter, a former nurse, took on the case. But the ACT's chronically under-resourced Coroner's Court meant another year passed before hearings would be held, in December 2015.

Ann was preparing for the inquest when she met her lawyer to go through the folders and folders of documents finally released to them. In one, a hospital incident report showed Paul was actually escorted from the hospital that day, having been found rifling through medical supplies.

Ann felt deceived. It may have been an innocent oversight. ACT Health was approached on several occasions but declined to answer The Canberra Times' questions about the document, instead sending a lengthy statement. But it was significant in the minds of his family.

"He was just taken off the premises," Paul's uncle Philip Hillsdon says. "You don't expect hospital staff to say, well, we're over you now, go away. I know you've got no phone, no money, nowhere to live, ID, but you know. On your bike."

To Ann's family, it was yet another sign of Paul being dismissed - like his mental health seemed to be when he was admitted for overdoses. Ann placed a lot of hope in the coronial process, but was disappointed.

While any inquest is difficult for all involved, Ann's lawyer in the inquest, James Sabharwal said part of the struggle was because the health system closed ranks. Inquests are not supposed to be adversarial. But the legal resources governments bring to bear often far outweigh what a grieving family can afford.

"You're going against the system, whereby everything was geared to protect the system," Mr Sabharwal said.

January 6, 2010, AM:

Paul is at the Cooleman Court pharmacy in Weston, to get his daily dose of methadone, a powerful opioid his GP had just days earlier put him on a program to receive.

1226 hours:

An ambulance responds to a call from "a friend" of Paul's. He's overdosing. Paramedics administer four shots of 0.4mg of naloxone, reviving him.

1300 hours:

The ambulance arrives at Canberra Hospital. Paul is admitted to ED, stabilised and monitored. He says he has been feeling depressed and "doesn't care if he dies".

1645 hours:

Mental health nurse Bill Bailey starts assessment of Paul. Ann tells him Paul had presented twice to hospital in the last week, that he could not stop overdosing. He had access to huge amounts of prescription medication, she says, and nowhere to go. She urges the nurse to put him in detox or involuntarily detain him, but he does not. Mr Bailey writes that Paul has "no ability to maintain his lifestyle or organise safety, shelter and food", that he will "re-present" soon. The ED notes from earlier are not read. No suicide risk assessment is completed.

1710 hours:

Paul is not formally discharged, but, Ann is told, he leaves the hospital.

Unknown time:

Paul is back at the pharmacy, getting a second dose of methadone, despite already receiving his prescribed dose.

1840 hours:

Ann arrives home to find Paul on the trampoline in the backyard, but tells him he cannot stay and seeks help from police, exasperated, asking officers at the station to take him into custody.

2000 hours:

Police receive a call. It is Ann, trying to get help to find her son.

2020 hours:

Another call comes in. Paul's body has been found.

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Correction: This article previously stated Paul received four shots 400mg of naloxone. It has been corrected to state it was four shots of 0.4mg.