On 16 July 2014, the Coroners Court of Victoria released its findings in the inquest into the death of Shannon James Lees. 

At the time of his death, Mr Lees was an involuntary patient at the Sunshine Mental Health Facility.  Mr Lees absconded from the facility by jumping a fence with the assistance of a chair.  It appeared that Mr Lees obtained methadone through an acquaintance he met after he absconded.  Mr Lees was found to have died from a drug overdose including tramadol and methadone.

While it was found that Mr Lees was a risk of absconding, he was not deemed to be a risk of harm to himself or others.  Therefore, it was not incumbent for the facility to increase security.  Coroner Jamieson was satisfied that Melbourne Health had undertaken sufficient measures to prevent absconding.

However, Coroner Jamieson was critical of the takeaway methadone program and looked at previous inquests where deaths had resulted from this process.  Coroner Jamieson considered there to be a systemic failure in the regulation of client access to takeaway methadone after identifying 127 potential deaths in Victoria between 2010 and 2013 which involved diverted takeaway methadone.  The frequency of overdose had greatly increased with the corresponding increase in access to takeaway methadone. 

Coroner Jamieson recommended, among other things, that the Department of Health reconvene an Advisory Group for Drugs of Dependence to review Mr Lees’ death and the current framework and policies for takeaway dosing. 

To view the findings, click here.