An intellectually disabled man who died from an accidental drug overdose while in the care of a high-profile disability services provider might still be alive today if he was placed in “an appropriate and secure environment”, the New South Wales deputy coroner has found.
David Veech died of an accidental fentanyl overdose while staying in a support home run by disability services firm Lifestyle Solutions in Goulburn in NSW last year.
On Thursday, the deputy state coroner Harriet Grahame found Veech’s death was “preventable”, and the result of “extremely significant failings” by Lifestyle Solutions which “created the environment of risk in which he died”.
She rejected the findings of an autopsy report that suggested Veech’s death was “apparent suicide”, saying there was “absolutely no evidence” the death was “intentionally self-inflicted”.
“Had he been placed in an appropriate and secure environment, without access to Schedule 8 drugs, he may be alive today,” she found.
Grahame has recommended NSW Health give “urgent consideration” to the “need for increased capacity for residential drug and alcohol rehabilitation beds in NSW”.
She found there was a particular need for “places that are suitable for patients exiting the criminal justice system with a history of aggression, ambivalent response to treatment or known lack of insight, and for patients with a mental health diagnosis”.
Veech, who was 35 when he died, suffered from “a mild intellectual disability” and had a number of criminal convictions and a history of violence and aggression. He also had a “serious and longstanding” history of multi-drug abuse, including an addiction to heroin, of which Lifestyle Solutions were “well aware”.
In what Grahame described as “a recipe for disaster”, Veech was placed in a residential support home near Goulburn operated by Lifestyle Solutions last year, after being released on parole after a stint in prison.
Despite warnings from his psychologist that the facility – a five-bedroom house in a rural area outside Goulburn – would need increased staffing and security to handle Veech, Grahame found the care he received was “substandard and inappropriate” and that steps could have been taken to prevent his death.
In a damning assessment of the care given by Lifestyle Solution, Grahame details “numerous extremely significant failings” by the organisation which “created the environment of risk in which he died”.
She found that staff were “completely ill-equipped to understand the severity” of Veech’s substance abuse issue and had “no training in dealing with drug seeking behaviour”.
“Nobody appears to have had even the most basic training in relation to drug and alcohol issues,” she stated.
“On the evening of David’s death he was identified by a staff member as lethargic or drowsy; this should have triggered concern.”
She found that carers at the facility were “isolated” and “fearful” of Veech, and that he had threatened some members of staff with violence, leading to supervision that was “clearly lacking”.
He was not seen for 12 hours before his death, a “clear violation” of his care program, and the staff member on duty had “real concerns for her own safety” because she had been threatened with violence by Veech.
Lifestyle Solutions is a Newcastle-based not-for-profit organisation that cared for about 1,200 disabled adults and 300 foster children across the country last year.
In March, Four Corners revealed the firm was under review by both the Victorian government and the NSW Ombudsman after a series of deaths of its clients and reports about abuse and neglect of people in its care.
In 2014 four of Lifestyle Solutions’ clients died amid practice failures which were only identified later.
During the inquiry Katrina Hyland, Lifestyle Solutions’ practice improvement specialist admitted the company had “failed its staff [and] failed David Veech”.
The company says it has instituted a number of policy changes as a result of Veech’s death. Grahame said that while she was “satisfied that Lifestyle Solutions understands the magnitude of its failings” it was “early days after such a tragedy” and a “demonstrated ongoing commitment to high-quality care is necessary to prevent further loss of life”.
In a statement, Lifestyle Solutions offered its condolences to Veech’s family and said it accepts the coroner’s findings and recommendations.
“While we genuinely tried to support and care for David, it is clear that there were a number of inadequacies in our policies, processes and staff training,” the firm said.
“Since that time, Andrew Hyland has been appointed as CEO and Lifestyle Solutions has a changed board. Under the direction of our new management team, we have and continue to implement changes that specifically address the coronial findings, including the need for long-term cultural change.
“We will ensure that the recommendations made by the coroner today are actioned in their entirety.”