NSW deputy coroner Harriet Grahame made 15 recommendations after examining the deaths of two men inside publicly accessible hospital toilets.
NSW deputy coroner Harriet Grahame made 15 recommendations after examining the deaths of two men inside publicly accessible hospital toilets.

Coroner urges hospital toilet changes after mens' deaths

A coroner has recommended Liverpool Hospital conduct a feasibility study into a supervised injecting area following the deaths of two men in different Sydney hospital toilets.

NSW deputy coroner Harriet Grahame made 15 recommendations on Tuesday after the inquest into the deaths of Alan Bugden and Amaru Bestrin.

Both men were discovered in a public toilet with floor-to-ceiling doors that obscured views of them.

The toilets were in areas of high pedestrian traffic but outside a clinical area and beyond the direct line of sight of clinical staff who might have noticed if they were engaged for a prolonged period.

Neither man was immediately missed because they were not in-patients at the hospitals.

Mr Bugden wasn't discovered for 20 hours at Royal North Shore Hospital and in Mr Bestrin's case it took 10 hours before he was found at Liverpool Hospital.

"Both men died of conditions where earlier discovery could have made a favourable outcome more likely," Ms Grahame said.

"Both men died in circumstances where any checking or toilet monitoring strategies which were in place failed to assist discovery in a timely manner."

Neither toilet had a distress button, intercom, alarm, motion sensor or other technological devices which could have alerted staff to a crisis, the coroner found.

Mr Bugden, 66, died of pulmonary thromboembolism after suffering a stroke in the toilet in August 2015.

Mr Bestrin, 25, died of combined drug and alcohol toxicity in December 2016 after he injected heroin.

Ms Grahame said the inquest identified some "particularly high-risk" toilets on the concourse at Liverpool Hospital which were open 24 hours a day on a busy thoroughfare.

"They are well known to people needing a place to inject (drugs)," she said.

"The toilets have no emergency buttons and are completely enclosed and private."

There were six recorded collapses in the concourse toilets within a 12-month period.

"The risks are currently mitigated by a cleaning and security schedule that is not adequately audited," Ms Grahame said.

"In my view, at the very least, there is an urgent need to cost an interim solution such as shortening doors or placing a perspex panel in the door."

Ms Grahame recommended that both NSW Health and Liverpool Hospital create central registers of deaths or collapses in public and clinical toilets.

She also recommended Liverpool Hospital undertake an overall risk assessment of its public toilets and provide first aid training to all cleaners and security staff that focused on how to identify and respond to overdoses.



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