Death in custody inquest paused after new witnesses, documents emerge

Mr Freeman, 25, was found dead in his cell at the Alexander Maconochie Centre about 11am on May 27, 2016. He had been admitted to the prison methadone program two days earlier.

Over five days this week, the inquest examined the entry of Mr Freeman, an Indigenous inmate, onto methadone and the quality of care and supervision he received in those following days.

The cause of death at autopsy was found to be aspiration pneumonia as a result of methadone toxicity, the inquest heard.

On Friday, Luke Streitberg, the prison doctor who prescribed methadone to Mr Freeman, took the stand for a second day.

He was grilled by Bernard Collaery, who is representing Mr Freeman's family, on the steps he took to verify the prisoner's claims he was using heroin and dependent on the drug.

The inquest has heard there is no record of Mr Freeman using opiates, save for a positive test to buprenorphine in 2015, and that he may have mislead the doctor about his heroin use.

The doctor said he was always suspicious detainees would lie about using heroin to get on the methadone program, but there was almost nothing available to check those claims.

"There is no magic test for verifying opioid dependency," he said.

The doctor agreed he had not recorded withdrawal symptoms from an objective clinical scale, such as pulse, pupils, running nose, tremors, anxiety and sweating, in the medical notes, though he said these formed part of his general assessment when concluding Mr Freeman was suffering mild opiate withdrawal.

He said he made that conclusion based largely on the history Mr Freeman gave him and the prisoner's clinical presentation. Urine tests were not useful at induction, he said, because neither positive nor negative results would go to proving dependence.

The doctor agreed under questioning that the inability to accurately assess tolerance - as a certain dose of methadone can have vastly different effects depending on the person - made it important to supervise the reaction of first time users.

The doctor has explained there are several doctors who share the prison roster and so in general, he told the inquest, follow-on care for prisoners was taken up by nurses, and the centre's whole medical staff.

The inquest has heard Mr Freeman may have been displaying signs of methadone toxicity in the afternoon and evening before his death, though there is also contradictory evidence.

It emerged during Dr Streitberg's cross-examination on Friday there was a document relating to Mr Freeman's death that was not before the inquest. This related to notes or minutes taken at a morbidity conference with the prison medical staff, including Dr Streitberg, in the weeks after Mr Freeman's death.

The inquest has also heard the prison medical centre's clinical director, as well as the assistant director of nursing, were relevant to the inquiry and so would need to be called to give evidence.

There were no records to suggest the centre took steps, from the time Mr Freeman requested methadone, to his prescription six weeks later, to verify his claims, the court has heard.

As he adjourned on Friday for the witnesses and document to be brought before the inquest, Coroner Robert Cook warned the parties the matter was still at inquiry, and there had been no finalisations and no conclusions.

"Don't speculate, don't form a view. Nothing is concluded at all at this point in time," the coroner told the court.

Dr Streitberg, who was mid-cross examination, will return to continue being questioned in March. He will then be questioned by counsel assisting the coroner, James Lawton.

The next hearing day is scheduled for March 20.