AMBULANCE Victoria has been convicted and fined $400,000 after the overdose death of an ambulance officer in Heywood.
AV pleaded guilty in the Warrnambool Magistrates Court on February 2 to two charges relating to breaching the Occupational Health and Safety Act.
Clive Hawkes was found dead at the Heywood ambulance station by his wife and son on January 20, 2015.
He was surrounded by drug paraphernalia, including open vials, and died of toxicity due to painkillers morphine and fentanyl.
In sentencing on Thursday, Warrnambool magistrate Cynthia Toose said AV ought to have known about improper access to the painkillers, the possible consumption, the risk of death and should have taken measures.
She took into account AV’s plea of guilty, the extent of the failures, the level of cooperation with investigators and the implementation of changes.
Ms Toose said there was a check system in place at the time of Mr Hawkes’ death but it was inadequate and had many failures.
She said the system of disposing of morphine and fentanyl required unused drugs to be squirted on the ground, which was then to be entered in a register.
Those actions were to be witnessed but if there was an absence of another available officer, the system allowed the record to show no second officer available.
Ms Toose said that work system had significant deficiencies and it was common place for no second officer available to be recorded on registers.
External, internal AV and Independant Broad-Based Anti-Corruption Commission (IBAC) reports were considered in sentencing, and AV has now implemented strategies to greatly enhance its systems.
The IBAC report said Ambulance Victoria had been quick to respond and Ms Toose added that AV had cooperated at every level.
The new system includes random drug testing of AV employees at all levels, pharmacist are now involved in ordering, receiving, stocking and disposing of AV painkillers, there is a new audit process, fentanyl comes in smaller packs, there have been improvements in tamper proof packaging, AV has a professional conduct unit, security cameras have been installed at stations and a whistleblower hotline has been established.
The maximum penalty for each of the charges was a fine of $1.3 million.
The family does not receive any part of the fine although they are expected to take legal action.
At the previous hearing, defence counsel Tony Thomas said Mr Hawkes' death had prompted a complete overhaul of the way AV ordered, received, stored, administered, disposed of and audited the use of morphine and fentanyl.
An AV audit in August 2014 found a number of irregularities at the Heywood station, there were significant discrepancies and almost 40 per cent of morphine and fentanyl were not accounted for.
Mr Thomas said that at the time of Mr Hawkes' death AV now acknowledged that the systems in place were inadequate.
Mr Hawkes had conceded he had a problem, but didn't know where to turn for help.
Welfare officers have been appointed with a check system of non-pattern use of painkillers to be finalised by June this year.
Mr Thomas said the non-pattern use check system had already been successful and flagged an officer at risk.
The random drug testing of AV officers started in January this year and involved staff at Warrnambool, Port Fairy, Mortlake and Terang.
There were 23 tests conducted and only one non-negative result recorded which was due to cold and flu medication.
The aim is that this year 20 per cent of staff will be tested across the state with a higher than average rate of single officer stations staff involved.
Security cameras and intruder identification systems were also introduced at stations.