Report – Coroner, 5 July 2023
FINDINGS, COMMENTS and RECOMMENDATIONS of Coroner Olivia McTaggart following the holding of an inquest under the Coroners Act 1995 into the death of: DAMIAN MICHAEL CRUMP
Conclusion
Mr Crump ended his life following a lengthy course of stealing dangerous drugs from Ambulance Tasmania (AT), his employer. He was a highly intelligent Intensive Care Paramedic who loved his work and enthusiastically imparted his clinical knowledge to many of his colleagues.
Unfortunately, he suffered long-standing mental illness and unresolved psychological issues.
His poor mental health was unrelated to his work at AT. Nevertheless, his practices and behaviour at work regularly exceeded appropriate boundaries and, in the weeks before his death, alarmingly so.
He was never adequately called to account for his behaviour by AT management, the spoken and unspoken view being “That’s just Crumpy!” Further, it was known amongst his colleagues and some managers of his longstanding intention to die by suicide before the age of 40 years.
This was not taken further as a welfare issue, despite his deteriorating mental state.
The coronial investigation highlighted severe resourcing deficits in the organisation, inadequate management of staff and a culture of tolerating unacceptable behaviour. These factors substantially contributed to Mr Crump’s behaviour and welfare not being dealt with and his drug thefts remaining undetected. He was therefore able to remain working as an operational Intensive Care Paramedic.
His manager and close friend took it upon herself to look after him, knowing of his mental illness and believing that he was honest with her. He was, however, dishonest about his medical treatment and his drug addiction. He treated her and other managers disrespectfully at times and was generally disrespectful of authority within the workplace. She became conflicted in her managerial role when she was required to report her belief that he had been stealing AT medication to police, and to initiate an internal investigation. There were no processes in AT to ensure that an internal investigation was progressed at all, and therefore Mr Crump was not formally identified as being responsible.
Numerous other opportunities existed for AT to properly deal with his behaviour and actions, including the serious ambulance incident nine days before his death. Appropriate intervention may have uncovered his addiction and thefts at that time.
Because of the unfeasibly large workload of AT managers and their lack of adequate training, there was no proper auditing of medication and there were no pathways to deal with Mr Crump’s behaviour or welfare. He was therefore able to remain at work and able to keep stealing Schedule 8 medications from the drug store.
The considerable work completed by AT in improving medication management is to be commended.
Resourcing has also been committed and comprehensive strategies developed in other critical areas of management and welfare.
AT has taken very significant steps to change the culture of the organisation in the years between Mr Crump’s death and today.
This change is ongoing, and remains heavily reliant upon sound planning and resourcing. It must be continued if AT is to overcome the cultural and systemic issues that have been highlighted in this investigation.
Formal findings required by section 28(1) of the Coroners Act 1995:
a) The identity of the deceased Damian Michael Crump, date of birth 4 September 1980.399
b) Mr Crump intentionally ended his own life by ingesting fatal quantities of drugs that he stole from the AT drug store in Hobart in the hours before his death; and the circumstances surrounding his death have been fully set out in these findings.400
c) Mr Crump died as a result of combined morphine, lignocaine amiodarone and midazolam toxicity.401
d) Mr Crump died between about 7.00pm on Friday 23 December 2016 and 2.00am on Saturday 24 December 2016 at Sorell in Tasmania.402
Recommendations
1. I recommend that Ambulance Tasmania implement random drug and alcohol testing for all employees as a matter of priority.
2. I recommend that Ambulance Tasmania implement any remaining recommendations from the December 2020 KP Health Medication Management Outcome Assessment as a matter of priority.
3. I recommend that Ambulance Tasmania conduct regular reviews of the operation of its policies relating to the management, storage, safekeeping, handling and accountability of drugs to ensure that the policies are effective and contemporary.
4. I recommend that Ambulance Tasmania provide regular training for all staff and managers regarding their obligations in respect of each policy relating to the management, storage, safekeeping, handling and accountability of drugs held by Ambulance Tasmania; and implement and maintain robust systems of accountability that ensure a high degree of compliance.
5. I recommend that Ambulance Tasmania implement a system of regular mandatory psychological assessments for its employees in order to identify mental health and psychological issues, and any changes, over the whole period of their employment with Ambulance Tasmania.
6. I recommend that Ambulance Tasmania continue to make efforts to reduce the span of control for duty managers and other managers.
7. I recommend that Ambulance Tasmania regularly review the ability of front line managers to undertake their duties of supervision adequately.
8. I recommend that Ambulance Tasmania provides regular training for all managers in managing staff generally and in responding to mental health issues.
9. I recommend that Ambulance Tasmania provides training for managers who are required to conduct or oversee investigations under a policy; this training to include knowledge of the policy, basic investigation skills, reporting requirements in SRLS or other electronic platform and identifying and managing conflicts of interest.
10. I recommend that Ambulance Tasmania complete any outstanding action items, of the 73 actions to which it has committed, from the Culture Improvement Action Plan July 2022.
11. I recommend that Ambulance Tasmania publish on its website a report setting out the progress of the 73 action items from the Culture Improvement Action Plan July 2022, indicating whether they have been completed or otherwise, providing details of those items that have not been completed, and providing a timeframe for their completion.
12. I recommend that Ambulance Tasmania complete and publish on its website updates at appropriate intervals of the Culture Improvement Action Plan, with the aim of promoting confidence and transparency.
13. I recommend that Ambulance Tasmania develop processes to provide timely assistance, where required, in a coronial investigation, including providing the coroner with relevant material to address matters pertaining to the scope of the inquest.
Footnotes
397 Doomadgee v Deputy State Coroner Clements[2005] QSC 357
398 See also Ruling in Xu and Davies, 3 May 2023.
399 C3 – Identification Affidavit & C14 – Affidavit of Alanah Eva Crump.
400 Coroners Act 1995, s 28(1)(b).
401 C5 – Post Mortem Report of Forensic Pathologist, Dr Donald Ritchey.
402 See especially: C15 – Affidavit of Kim Maree Fazackerley; C26 – Affidavit Jack Gary Steele; C27 Affidavit of Constable Douglas James McKinlay; C28 – Affidavit of Senior Constable Jeremy Paul Williams. See also the other evidence generally.
Read the full Coroner’s Report here: https://www.magistratescourt.tas.gov.au/__data/assets/pdf_file/0009/713817/Crump,-Damian-Michael-OMT-5.7.23.pdf.
Media release – Cassy O’Connor MP, 5 July 2023
Coronial Findings Demand Urgent Action on Paramedic Mental Health
The Coroner has effectively put the Rockliff Government on notice over the mental health of paramedics.
The Rockliff Government needs to commit to introducing regular a psychological assessment system for Ambulance Tasmania employees immediately, as recommended by Coroner Olivia McTaggart today.
Paramedics’ life-saving work, should not come at the cost of their own – nor their wellbeing.
Coroner McTaggart’s in-depth Inquiry into the tragic death of paramedic Damian Crump made thirteen strong recommendations that demand action.
The Greens welcome Ambulance Tasmania’s progress on many of the issues raised during the inquest, however, today’s findings highlight the need for a greater government focus on paramedic welfare.
It’s good to see improvement in paramedic support, but further reform is needed. Most critical is introducing regular psychological assessments to identify and respond to mental health issues quickly – a policy the Greens have long been calling for.
The stressful, and often traumatic, nature of paramedics’ work puts their mental health at risk daily. The Rockliff Government has a duty of care, and it should be doing all it can to support the people who are there when Tasmanians are in desperate need of help
Regular psychological assessments will help people before they reach a crisis point. They will create cultural change around accessing support. For those on the frontline this reform is crucial for their wellbeing – and could be life-saving.
The Greens have been strong advocates for regular paramedic mental health support, and took the policy to the 2021 State Election*. Regrettably, we are yet to see the government act. We trust today’s recommendations from the Coroner will drive real change and save lives.*
*’Paramedic Mental Health’ in the Health and Wellbeing policy.
