TRANSCRIPT OF PROCEEDINGS...2019/05/14 · 20 Richmond Valley’s rate exceeded the state average in 2017 and 2018. Commissioner, you will hear evidence today from Superintendent

.SPECIAL COMMISSION INTO ICE 14.5.19R1P-569

AUSCRIPT AUSTRALASIA PTY LIMITED ACN 110 028 825

TRANSCRIPT OF PROCEEDINGS

O/N H-1013551

MR D. HOWARD SC, Commissioner IN THE MATTER OF THE SPECIAL COMMISSION OF INQUIRY INTO THE DRUG “ICE” LISMORE 9.30 AM, TUESDAY, 14 MAY 2019 Continued from 13.5.19 DAY 6 MR N. KELLY appears with MR D. BEAUFILS as counsel assisting the Commission MR S. KETTLE appears for the Ministry of Health MR N. REGENER appears for the Commissioner of Police


THE COMMISSIONER: Good morning, everyone. This is the first day of public hearings of the Special Commission of Inquiry in the Drug Ice in Lismore. Could I take appearances, please. MR N. KELLY: Commissioner, Kelly. I appear with Mr Beaufils as counsel 5 assisting. THE COMMISSIONER: Thank you, Mr Kelly. MR S. KETTLE: Yes, Commissioner, my name is Kettle. I appear for the Ministry 10 of Health. THE COMMISSIONER: Thank you, Mr Kettle. MR N. REGENER: Commissioner, my name is Regener, and I appear for the 15 Commissioner of Police. THE COMMISSIONER: Thank you, Mr Regener. MR KELLY: Commissioner, just by way of housekeeping, an application for 20 authorisation to appear at today’s hearing was received overnight from the Department of Family and Community Services. Presently, there isn’t a representative here for that department. THE COMMISSIONER: All right. 25 MR KELLY: We do not oppose that application. THE COMMISSIONER: All right. Look, thank you, Mr Kelly. I’ve seen that application and read the basis for it and it seems perfectly appropriate, but I should 30 make an order:

(1) And I do so authorising the representative of the Department of Family and Community Services to appear at the regional hearings referred to in their application which is Lismore, Nowra, Dubbo, East Maitland and Broken Hill, and I make that order. 35

MR KELLY: Commissioner, there are also a number of summonses that were summonses to appear issued to persons last week. However, given the opportunity to consider the statements that we’ve received in some cases subsequent to those summons being served, I’d ask that the following persons be formally excused from attending pursuant to those summonses. 40 THE COMMISSIONER: All right. MR KELLY: That’s Mr Frank Potter, Ms Trish Kokny, that’s K-o-k-n-y.


THE COMMISSIONER: Yes. MR KELLY: Mr Rod Chenhall, C-h-e-n-h-a-l-l, Ms Jodie Scott and Mr Wayne McKenna, M-c-K-e-n-n-a. 5 THE COMMISSIONER: All right. So you would like those witnesses excused, and would you like the summonses set aside? MR KELLY: No, I think it’s appropriate that they just be excused. 10 THE COMMISSIONER: Just be excused. All right. All right.

(2) Well, in relation to those witnesses: Frank Potter, Trish Kokny, Rod Chenhall, Jodie Scott, Wayne McKenna, I excuse them from attending pursuant to the summonses issued to them.

MR KELLY: Commissioner, if I may start formally by tendering a bundle of 15 documents for the purposes of the Lismore hearings. It’s a bundle of documents titled Lismore Hearing Tender Bundle, volume 1 of 1 and it runs to 28 tabs. THE COMMISSIONER: Right. Thank you. 20 MR KELLY: I tender that. THE COMMISSIONER: Thank you. All right. Well, thank you, Mr Kelly. I’ll admit that as exhibit – an exhibit. Now, what are we up to with exhibit numbers? We had – this is our first day of public hearings. We had some private - - - 25 MS ..........: LE - - - THE COMMISSIONER: LE. Okay. Thank you. So this will be exhibit LF, L for Lismore, exhibit F. 30 EXHIBIT #LF LISMORE HEARING TENDER BUNDLE, VOLUME 1 OF 1 35 THE COMMISSIONER: Thank you. MR KELLY: Just one matter, Commissioner. In tab 8 which is the statement of Mr Angus Skinner - - - 40 THE COMMISSIONER: Yes. MR KELLY: - - - which was also tendered at the Sydney general hearing - - - THE COMMISSIONER: Yes. 45


MR KELLY: - - - I do not tender paragraphs 47 through 52 of that statement, consistent with the tender at the Sydney general hearing. THE COMMISSIONER: 47 through to 52 - - - 5 MR KELLY: Inclusive. THE COMMISSIONER: All right. Well, I’ll strike those out from the tender document if that’s suitable. 47 to 52. I just mark those as not tendered. All right. Thank you, Mr Kelly. 10 MR KELLY: Commissioner, I propose to start today with an opening which I anticipate will take about 30 to 45 minutes. THE COMMISSIONER: All right. Thank you. 15 MR KELLY: Commissioner, as you have already heard in other hearings in this Inquiry, the terms of reference for the Special Commission require you to investigate the nature, prevalence and impact of crystal methylamphetamine and other illicit amphetamine-type stimulants in New South Wales: specifically, the nature, 20 prevalence and impact of crystal methylamphetamine, or “ice”, and other amphetamine-type stimulants, which I will refer to as “ATS”; secondly, the adequacy of existing measures to target crystal methylamphetamine and illicit ATS in New South Wales; and thirdly, options to strengthen New South Wales’ response to such drugs, including through law enforcement, education, treatment and 25 rehabilitation responses. The Special Commission is sitting here in Lismore to hear directly about the impacts of ATS in this region. Through this hearing, we hope to assist you in gaining insight into the response to and management of ATS and associated harms across the 30 Lismore region. The Commission has travelled to Lismore, and will be travelling to other parts of the state, in recognition of the unique issues faced by people outside of metropolitan areas. As Senior Counsel assisting the inquiry outlined in her opening to the Inquiry in 35 March, recent data indicates that people living in rural and remote areas are 2.5 times as likely to use methylamphetamines as those in major cities. Nevertheless, rural, regional and remote access to alcohol and other drug services is limited. Where services are available, they are often not adequately resourced to provide services which are appropriate and accessible for their local communities and regions. 40 Recruiting and retaining appropriately qualified staff in those areas can be a significant challenge. Residential rehabilitation and detoxification facilities are particularly scarce, meaning that people who do need access to treatment often have to leave their family and community supports or may not be able to gain access to treatment when they need it. As you will hear, this is a familiar story to the people of 45 this region.


The work of the Inquiry in Lismore commenced yesterday, where evidence was taken in private from people who have lived experience with amphetamine-type stimulants. The Inquiry heard of the addictive nature of these drugs and the varied drivers that lead people towards problematic use of ATS, especially crystal methylamphetamine. These ranged from using for work to using to enhance sexual 5 experience. We also heard about the way stigma can stop those with problematic use from seeking treatment. On behalf of those assisting you, Commissioner, I would like to thank those witnesses for their courage and generosity in sharing their stories. In addition to hearing from those with lived experience, the Inquiry had the privilege 10 of consulting with members of the local Indigenous community. The inquiry heard about the frustration felt by Aboriginal people at the continuing lack of appropriate services to assist Indigenous and non-Indigenous people in getting the help they need to address problematic drug use. Despite this frustration, the members of the local Indigenous community expressed their hope that this inquiry can generate change, so 15 that future generations will have the help that they see lacking for those who need it right now. The town of Lismore is covered by the service areas of the Richmond Police District, which encompasses the Northern Rivers area, including the towns of Ballina, 20 Lismore and Casino. A map of the district appears at tab 3 of the bundle. The Northern New South Wales Local Health District extends from Tweed Heads in the north to Tabulam and Urbenville in the west and to Nymboida and Grafton in the south, which is an area of approximately 20,700 square kilometres. And, Commissioner, there’s a map of the LHD at tab 2. Finally, the North Coast Primary 25 Health Network, which is a Commonwealth-funded corporation, covers the combined geographical regions of the Northern New South Wales LHD and the Mid-North Coast LHD. And a map of the North Coast PHN, as I will refer to it, also appears at tab 2 of the bundle. 30 To give some indication of the demographics of the region, I will highlight some statistics relating to each of Lismore and neighbouring Ballina and Richmond Valley local government areas. Lismore and Richmond Valley LGAs have an employment rate higher than the New South Wales average. And the statistics relating to that from the most recent census appear at tab 1 of the bundle. The Ballina local 35 government area has a lower unemployment rate than the state average. The town of Lismore sits in the Bundjalung Nation, but there are a number of First Nations in the region. And there is a map depicting those First Nations by reference to the PHN area in the bundle at tab 1 on the page ending in seventy-eight. 40 As you heard in the opening of the Inquiry in March, Indigenous people are disproportionately affected by justice responses generally. This region is no exception. Lismore and neighbouring Richmond Valley and Ballina LGAs have a higher representation of Aboriginal and Torres Strait Islander people than the New South Wales average, at five, 7.2 and 3.3 per cent respectively. The New South 45 Wales average is 2.9 per cent. These figures can also be found at tab 1. However, according to a report published earlier this month by the Lismore City Council’s


Social Justice and Crime Prevention Committee, the members of Indigenous and non-Indigenous people incarcerated in these three LGAs are close to equal. I withdraw that. In the Lismore and Ballina LGAs are close to equal, whereas in the Richmond Valley LGA, there are twice as many Indigenous people incarcerated as non-Indigenous people. 5 Bureau of Crime Statistics and Research statistics for the Lismore LGA, which appear at tab 3, show stable trends in possession and use of amphetamine charges over the 24 and 60 months to 2018. Trend information was not collected in the Richmond Valley and Ballina LGAs due to the total numbers being lower than the 10 statistical threshold. However, notwithstanding the stability in these trends, the rate per hundred thousand for these charges is consistently higher in the Lismore LGA than the state average. The rate for possession and use of amphetamine charges in Richmond Valley was 15 lower than the state average until 2018, at which point it was above that average. The rate has remained consistently lower than the state average in the Ballina LGA. The rate of use and/or possession of ecstasy charges is consistently lower than the state average in the Ballina and Lismore local government areas. However, Richmond Valley’s rate exceeded the state average in 2017 and 2018. 20 Commissioner, you will hear evidence today from Superintendent Toby Lindsay, Commander of the Richmond Police District, about the police’s experience with trends in ATS use, the police response to ATS in this region and the challenges faced by police in carrying out that response. 25 In 2016, the North Coast Primary Health Network had the second highest rate in Australia of people aged 14 years or older who had used at least one of 16 illicit drugs in the previous 12 months. That rate was 22.8 per cent, compared to the New South Wales rate of 14 per cent. 30 In a community survey conducted by the Primary Health Network in 2018, the Lismore LGA had the highest community health concern in the PHN about alcohol and other drug misuse, and that report can be found at tab 7. The cohorts of respondents who have tended to rate alcohol and other drug misuse as a top 35 community health concern included young people aged 15 to 24 years, people with alcohol or drug misuse challenges, Aboriginal respondents, LGBTQI respondents and people with a personal mental health challenge. You’ll hear evidence from Ms Liz Davis, Senior Manager of Mental Health, Suicide Prevention, Alcohol and Other Drugs Innovation and Strategy Branch of the PHN who can speak to that report. 40 There are a number of hospitals within the LHD including regional referral hospitals at Lismore Base Hospital and the Tweed Hospital. These hospitals each have an inpatient mental health unit that receives ATS related presentations. Recent data shows that methamphetamine related hospitalisations are higher than the state 45 average in both the PHN and the LHD, and they – those statistics appear at tab 2. The New South Wales HealthStats website notes that this data – which is the source


of that information, notes that the data reflects a substantial increase in the harms associated with methamphetamine use since 2009/10 most likely related to the increased purity, frequency of use, form of methamphetamine being the crystal form and mode of administration. 5 However, it is important to note that the date relates to hospitalisations directly attributable to methamphetamine related diagnoses such as poisoning by methamphetamine or mental and behavioural disorders due to use of methamphetamine. This means the statistics may not accurately reflect the rate of all methamphetamine related hospitalisations. In 2017, the PHN and the LHD had 10 higher levels of people in high or very high psychological distress than the state average. This is at tab 2. This is significant as data from 2016 indicated that, nationally, levels of high or very high psychological distress had increased significantly since 2010 amongst recent methamphetamine and ecstasy users. To speak to the effect of ATS use on the local frontline health system, you will hear 15 evidence from Mr Paul Millard, paramedic, Dr Rob Davies, Director of Emergency at the Tweed Hospital, and Dr Edward Wims, Clinical Director Mental Health Richmond to Clarence. The Local Health District runs the Riverlands Drug and Alcohol Centre, a 20 multifunctional service located in Lismore. The centre has a 16-bed inpatient detoxification unit as well as providing clinical liaison and outpatient services. In 2014/15, 11.7 per cent of clients at Riverlands identified methamphetamine as their primary drug of concern. The proportion of consumers seeking assistance with methamphetamine use at Riverlands has risen significantly since 2010/11. As at that 25 point, only 3.1 per cent had reported that methamphetamine was their principal drug of concern. You will hear evidence about the LHD’s drug and alcohol services from Dr David Helliwell, Clinical Lead Alcohol and Other Drugs, Dr Bronwyn Hudson, Advanced 30 Trainee Addiction Medicine, and they will give evidence today. And, tomorrow, if we have time at this stage for Mr Mitch Dobbie, Service Manager, Tweed, Ballina Drug and Alcohol service. You will also hear evidence from Ms Deirdre Robinson, General Manager Northern New South Wales LHD, Mental Health and Drug and Alcohol Services, about matters including the challenges of treating patients with a 35 dual diagnosis of mental illness and substance use disorders. Socioeconomic indexes suggest that the region is generally more socially disadvantaged than the national average with higher than average poverty rates and proportions of households in rental stress, and this information can be found at tab 7. 40 As a whole, the north coast has a higher rate of children in out of home care compared to the New South Wales average. Those figures can be found at tab 1. You will hear evidence during tomorrow’s hearing from Ms Judith Townsend from the Department of Family and Community Services on the impacts of ATS on families within the region which include exposure to violence and neglect. I 45 anticipate that Ms Townsend will give evidence that ATS and polysubstance abuse


feature in possibly up to 50 per cent a risk of significant harm reports and removals of children in the region. As to local responses to crystal methamphetamine in particular, in May 2015, Northern New South Wales Ice Symposium was held as a joint initiative of the 5 Primary Health Network, Bulgarr Ngaru Aboriginal Medical Corporation and the LHD. The symposium was attended by 42 participants from the community health and social service sectors and led to an action plan to progress the objectives of the Commonwealth Government’s National Ice Action Strategy within the context of local priorities, community understanding and service capacity. 10 In October 2015, Bulgarr Ngaru Aboriginal Medical Corporation and the north coast PHN initiated and jointly funded the Crystal Methamphetamine Project in response to community concerns about the impact crystal methamphetamine was having on families, individuals, communities and services in northern New South Wales. The 15 Crystal Methamphetamine Project was overseen by the regional substance misuse taskforce which was made up of high-level local representatives from New South Wales Health, New South Wales Polices, Family and Community Services, Aboriginal Medical Services, the primary network, New South Wales Ambulance and the Department of Education. 20 The final report of the Crystal Methamphetamine Project which appears at tab 7A details a number of impressive outcomes and outputs achieved as part of the project including the development of a project led based learning alcohol and other drug program that included a lived experience component with the Department of 25 Education, in consultation with Headspace, New South Wales Police and Tweed Shire Council. This was piloted with 58 year 9 and 10 students from two high schools with very positive results according to the report. The PHN has also recently published results from a community survey conducted in 30 2018 as part of its alcohol and other drug needs assessment in order to explore issues around access to alcohol and other drug services. The PHN engaged the Australian Institute of Health and Welfare to produce modelling to determine the impact of a single characteristic such as age, gender, disability, etcetera, on access to alcohol and other drug services and this needs assessment appears at tab 7. The key findings 35 from this modelling were younger people and older groups were less likely to report AOD services as being difficult to access compared to people who are aged from 25 to 64 years. Those reporting alcohol or drug use as a personal health challenge were less likely to 40 report access as being difficult than those who didn’t have such a challenge. Those who reported – however, those who support – those who reported supporting someone with AOD health issues were more likely to report access as being difficult. Those respondents identifying as LGBTQI were more likely to report that it was difficult to access AOD services compared to respondents that were heterosexual. 45 When the effect of each characteristic was examined separately, it revealed that


being LGBTQI resulted in the highest odds of reporting that access to AOD services was difficult. Further modelling commissioned by the PHN to examine the effect of stigma as a 5 barrier to treatment demonstrated that people with a mental health challenge were 43 per cent more likely to report stigma and shame as an issue for them when trying to access AOD services compared to those who did not report having a mental health challenge. The analysis also found that women were 77 per cent more likely to report stigma and shame as a challenge compared to men. 10 However, the most significant finding was that people identifying as LGBTQI were 142 per cent more likely to report stigma and shame was a challenge when trying to access AOD services when compared to heterosexual respondents. You will hear evidence about the particular usage patterns and support needs of the local LGBTQI 15 community from Mr Michael Tizard, regional manager, Northern Rivers, ACON, and Mr Derek Teece, substance support counsellor, Northern Rivers, ACON. The primary residential rehabilitation facilities in the region are the Buttery and Namatjira Haven, both of which are run by non-government organisations. The 20 Buttery is a therapeutic community with residential programs that can run for up to nine months. Following completion of these programs, individuals can move to a halfway house. The Buttery also offers community outreach services, including those specific to young people, families and those with comorbid mental health and drug and alcohol problems. The Buttery also has a private facility run as a social 25 enterprise. And you will hear evidence about these matters from Ms Leone Crayden, CEO of the Buttery. Namatjira Haven is a residential program for Aboriginal men aged over 18 years, with some capacity for non-Aboriginal men. Other drug-and-alcohol-specific 30 services in the region include Byron Private, which is a private residential facility located in Byron Bay with 12 beds and a six-week program. Rekindling the Spirit is a service created by Aboriginal people for Aboriginal people located in Lismore. This service offers assessment and referral, counselling and support plus a range of other services and programs. Rekindling the Spirit is partnered with Lismore’s 35 Aboriginal medical service, Jullums. As to prior investigations into local alcohol and other drug issues, the Health and Community Services Committee of the Legislative Council visited Lismore in June 2018 as part of its investigation into the provision of drug rehabilitation services in 40 regional, rural and remote New South Wales. This inquiry considered the types of rehabilitation services available, accessibility to these services and gaps in service delivery, amongst other things. Witnesses from government and non-government organisations gave evidence at 45 public hearings in Lismore, noting the difficulties in recruiting and retaining appropriate staff to the region and vast gaps in services. This included places for


residential rehabilitation as well as diversionary programs such as MERIT, Drug Courts and services within correctional facilities. Options for women and families were noted as being particularly scarce, as was that this accessibility challenge is compounded for Aboriginal women. 5 The New South Wales Government has supported the Committee’s recommendations to implement a state-wide drug and alcohol service planning tool; will consider expansion of the Drug Court and MERIT program; and will consider how accessibility to residential rehabilitation can be improved. In terms of those services that were investigated by the Community Services Committee, you will also 10 hear evidence from Mr Robert Lindgren, acting senior manager for MERIT in the Northern New South Wales Local Health District. Finally, on 10 April 2018, Lismore City Council resolved that council bring together a group of key community stakeholders to form a Social Justice and Crime 15 Prevention Committee aimed at identifying the needs and demand in the region for a Drug Court, a further residential rehabilitation centre, a youth and adult Koori Court and justice reinvestment initiatives. The Committee was constituted by councillors and local representatives from the health and justice sectors. 20 The Committee’s report, completed earlier this month, found that there is a local need and demand for those services it was tasked with investigating as well as, amongst other things, a need for culturally and gender-appropriate residential rehabilitation services for Aboriginal and non-Aboriginal women and children and for individuals with a dual diagnosis of AOD and mental health issues. 25 The Committee found a need for a youth detoxification service and for expansion of the MERIT program to address overwhelming demand and extend the program locally to individuals with alcohol issues. The Committee’s report appears at tab 6 of the bundle. You will hear evidence this morning from the chair of that Committee, 30 Councillor Eddie Lloyd. Commissioner, that concludes my opening. THE COMMISSIONER: Thank you very much, Mr Kelly. That’s a very helpful and comprehensive outline of what we will be hearing. And that’s very helpful to me. Just pardon me a moment. Good. Thank you, Mr Kelly. 35 MR KELLY: Before I commence with the first witness, Commissioner, could I inquire through you whether there are any representatives here from Family and Community Services at this stage. 40 THE COMMISSIONER: Any representatives from FACS, Family and Community Services, today? MR KELLY: I call Superintendent Toby Lindsay. 45 THE COMMISSIONER: And what tab is that - - -

.SPECIAL COMMISSION INTO ICE 14.5.19R1P-579 T.C. LINDSAY XN MR KELLY

MR KELLY: It’s tab 9 of the bundle, Commissioner. <TOBY CHRISTOPHER LINDSAY, SWORN [10.01 am] 5 <EXAMINATION BY MR KELLY THE COMMISSIONER: Thank you. Please sit down. 10 MR KELLY: Could you please state your full name, rank and station. MR T.C. LINDSAY: Toby Christopher Lindsay, L-i-n-d-s-a-y, Superintendent attached to Richmond Police District, Lismore Police Station. 15 MR KELLY: Superintendent, have you been provided with a copy of the expert witness code of conduct? MR LINDSAY: I have, sir. 20 MR KELLY: Yes? MR LINDSAY: I’ve got that with me. 25 MR KELLY: And have you read that? MR LINDSAY: I have. MR KELLY: And do you agree to be bound by it in giving your evidence? 30 MR LINDSAY: I do, sir. MR KELLY: And have you prepared a statement in this matter dated 9 May 2019? 35 MR LINDSAY: I have, sir. MR KELLY: Do you have a copy of that statement with you? MR LINDSAY: I do. 40 MR KELLY: Do you wish to make any changes to that statement at this stage? MR LINDSAY: I do, if possible, please. 45 MR KELLY: You do?


MR LINDSAY: One amendment. Paragraph 22. Northern Rivers communications are not serviced by a Koori Court. They’re serviced by circle sentencing and MERIT programs. MR KELLY: Thank you. 5 THE COMMISSIONER: So we will just correct that. “Northern Rivers communities are” – and then insert “not”. MR LINDSAY: Not. 10 THE COMMISSIONER: “Not serviced by a Koori Court”. MR LINDSAY: Correct. 15 THE COMMISSIONER: And then just continue on. MR LINDSAY: That’s correct. There’s circle sentencing and MERIT program. THE COMMISSIONER: Just so I’m clear, they’re not serviced by circle sentencing 20 or MERIT. Or do you mean to say that they are - - - MR LINDSAY: They are, in fact, serviced by circle sentencing - - - THE COMMISSIONER: Yes. 25 MR LINDSAY: - - - and MERIT, Commissioner. THE COMMISSIONER: Thank you. 30 MR LINDSAY: Thank you. MR KELLY: And in preparing that statement, did you receive briefings from Richmond Police District intelligence staff, senior management team, the State Crime Command and members of the community? 35 MR LINDSAY: I did, sir. MR KELLY: And you commenced duties with the police force in May 1994; is that right? 40 MR LINDSAY: That’s correct. MR KELLY: Yeah, and since that time, where have you undertaken your service. 45


MR LINDSAY: Predominantly uniform service in regional areas with some stints in Sydney as well. In the main, southern region, but also through metropolitan commands. MR KELLY: And how long have you been in this command? 5 MR LINDSAY: Since August last year and substantively as a district commander in December last year. MR KELLY: And do you hold any other roles in this area? 10 MR LINDSAY: I’m also the LECOM which is under local emergency management arrangements, the local emergency operations controller for the Lismore, Kyogle and Richmond Valley LGAs. 15 MR KELLY: And you heard, in my opening, describe the police district? MR LINDSAY: I did, sir. MR KELLY: Yep, and that’s correct? 20 MR LINDSAY: It is. MR KELLY: And the main towns in that area are - - - 25 MR LINDSAY: There are three. MR KELLY: Yes. MR LINDSAY: Ballina, Casino and Lismore. 30 MR KELLY: And are there stations in each of those towns? MR LINDSAY: There is. 35 MR KELLY: And other stations around the district? MR LINDSAY: There are. There are 13 in total with three main stations which are 24-hour facilities. 40 MR KELLY: Are there any drug specific offices in the district? MR LINDSAY: We have a drug; it’s a small drug unit. That strength changes dependant on the - - - 45 MR KELLY: So how many are there presently in - - -


MR LINDSAY: Three. MR KELLY: Three, and what are the main role – what are the main tasks that that unit undertakes? 5 MR LINDSAY: Covert and overt disruption operations relative to drug supply. MR KELLY: And how long has that unit been operating? MR LINDSAY: I can’t answer that. I’m sorry. 10 MR KELLY: That’s fine. I want to ask - - - MR LINDSAY: A number of years, certainly. 15 MR KELLY: What’s that, sorry? MR LINDSAY: A number of years, certainly. MR KELLY: Number of years. I want to ask you some questions around local use 20 of amphetamine-type stimulants which - - - MR LINDSAY: Sure. MR KELLY: - - - you’ve dealt with in your statement. If you start at paragraph 7 of 25 your statement, you mention there some trends. So you say that you detect – you note detections and legal actions recorded in WebCOPS. Could you explain what WebCOPS is. MR LINDSAY: WebCOPS is New South Wales Police Force’s operational 30 repository of information. It’s both criminal intelligence and crime data. MR KELLY: And you say there that the detections and legal actions related to methamphetamine and other amphetamine-type stimulants increased from 2014 and peaked sharply during 2016; is that right? 35 MR LINDSAY: That is correct. MR KELLY: Do you have any information about why that might have been? 40 MR LINDSAY: I don’t, at this stage. I can make an assumption or provide an opinion based on the data that I’ve reviewed - - - MR KELLY: Yes. 45 MR LINDSAY: - - - as a result of this. Certainly, our WebCOPS based methylamphetamine and MDMA detections increased from 2014 through to 2016


where they spiked locally, and that’s consistent with both northern region and New South Wales trends per information that I received from the chief statistician of our police force. I can say, locally, that our strike force activity which is the overt and covert investigative activities around reducing supply also spiked in 2016. They increased from 2014. 5 MR KELLY: I see. So the local operations increased in 2016 from - - - MR LINDSAY: They peaked in 2016. 10 MR KELLY: Right. So it may be that the detections that you’ve described could be a result of increased police activity. MR LINDSAY: That’s correct. 15 MR KELLY: You also make reference in paragraph evidence to – paragraph 7 of your statement of anecdotal evidence of an ice drought. What period are you talking about there? MR LINDSAY: It fell sharply in 2017, late 2017 into 2018. When I say it fell 20 shortly, I’m talking about WebCOPS detection incidents that recorded and then climbed back up into 2018. MR KELLY: And the anecdotal evidence that you’re referring to there, what’s that? 25 MR LINDSAY: So not only the data that I’ve just discussed. Also information received from senior management team, intelligence officers and personnel within the district. MR KELLY: I see. And what proportion would you say methamphetamine 30 accounts for in terms of illegal drug detections within the district? MR LINDSAY: So excluding cannabis, it would be one of the highest. MR KELLY: Are you able to put a number on that at all? 35 MR LINDSAY: I can’t quantify that now. Can certainly provide that, take it on notice. MR KELLY: And are there other illicit drugs that are particularly noteworthy in 40 terms of detections? MR LINDSAY: There are. MDMA and, also recently, pharmaceuticals. MR KELLY: Which pharmaceuticals? 45 MR LINDSAY: It’s a range. I don’t have that with me.


MR KELLY: Do you have any information about amphetamine-type stimulant pharmaceuticals MR LINDSAY: I don’t. 5 THE COMMISSIONER: Superintendent, just in relation to the pharmaceuticals, you say that’s been a recent trend. Is there a reason for that or is it something that perhaps wasn’t on the radar before or it’s being looked at now or – I’m just wondering what’s behind that. 10 MR LINDSAY: I can’t talk for this district - - - THE COMMISSIONER: Yes. MR LINDSAY: - - - as I’ve only been here a short period of time, but, certainly, in 15 my operational experience, I’m aware of medications such as fentanyl have become identified and an issue for the New South Wales Police Force. THE COMMISSIONER: Right. And - - - 20 MR LINDSAY: So I can’t explain why, locally, they - - - THE COMMISSIONER: Yes. MR LINDSAY: - - - became a drug of choice or detected drugs, but, certainly, the 25 increase has been significant. THE COMMISSIONER: And can you give me a rough idea as to when that was noticed, that increase? 30 MR LINDSAY: Certainly. So that – in essence, there was a 45 per cent increase in detections recorded from 2014 through to 2018. That’s locally. That’s for the Richmond Police District only. THE COMMISSIONER: Right. Good. Thank you. 35 MR KELLY: And according to police and information, what are – what is the indicative cost of methamphetamine in this region? MR LINDSAY: In relation to cost, I’ve referred to that as well. 40 MR KELLY: In paragraph 11 of your statement. MR LINDSAY: Yeah. Thank you. This is based on local intelligence experience from officers. It’s also consistent with statewide information. It’s approximately 45 $50 a street deal, a point, $400 per gram, and MDMA is between $15 and $30 per pill.


MR KELLY: Are you able to speak at all to the common features of the persons that police are engaging with who are detected with and use crystal methamphetamine in particular? MR LINDSAY: So, certainly, local police information is there’s no one identifiable 5 user group. In the main, users of low socioeconomic means. MR KELLY: I see. And is there any difference between those who police are encountering as users and those who police are encountering as dealers? 10 MR LINDSAY: Yes, there is. MR KELLY: And what are the differences there? MR LINDSAY: The differences is in relation to affectation. So in the main – the 15 mid-level suppliers would not be what I would classify as a addicted user, per se. It’s a business for those people. MR KELLY: I see. And in terms of those demographic descriptors that you’ve just used around the users being those predominantly of low socioeconomic status, do 20 you – does this – what is – what are the demographic features of the dealers that you’re observing? MR LINDSAY: I don’t have that data. 25 MR KELLY: And in terms of the geographic location of the police – of users, where is it that police are predominantly seeing users across the region? MR LINDSAY: Unfortunately, it’s across the district. It’s not centred on the main towns, the three main towns. It’s also evident in the smaller townships as well. 30 MR KELLY: I see. And how many of those smaller townships are there in a district? MR LINDSAY: A number. I don’t have that distinctly offhand, but - - - 35 MR KELLY: Yep. MR LINDSAY: - - - there’s a number. 40 MR KELLY: And in terms of the way that these users are administering the drugs, what information do police have around that? MR LINDSAY: Yeah, certainly, the combination of ingesting and injection. Initial users, I’m advised by senior managing intelligence staff, utilise ingestion, progress 45 through to inhalation, then injection.


MR KELLY: I see. MR LINDSAY: Whilst we’re not medical personnel, that’s based on information provided to us by users. 5 MR KELLY: And the users that you’re encountering, are they solely methamphetamine users? MR LINDSAY: In the main, no, is the intelligence and information I’ve received. It’s a combination. 10 MR KELLY: I see. So the users that you’re encountering, police information is that they’re using more than one drug; is that right? MR LINDSAY: Correct. 15 MR KELLY: Yeah. THE COMMISSIONER: Superintendent, you say in paragraph 10 of your statement that further information exists that novice users escalate consumption of 20 the illicit drug from cannabis to cannabis laced with methylamphetamine and then progress to methylamphetamine in its own right. What’s your information that that statement is based on? MR LINDSAY: That came from a briefing from my crime manager - - - 25 THE COMMISSIONER: Right. MR LINDSAY: - - - who has significant drug related experience in this command and Northern Rivers down to Coffs Harbour. 30 THE COMMISSIONER: Right. Do you know if – has there been any experience by the police of people using what they think is cannabis that has been laced with methamphetamine by dealers? 35 MR LINDSAY: I don’t have that information to hand. It’s certainly plausible. THE COMMISSIONER: All right. And I suppose the fact that both of those substances can be smoked and mixed together in a pipe, perhaps, makes that a genuine possibility. 40 MR LINDSAY: Correct, sir. THE COMMISSIONER: Yes. Okay. Thank you. 45


MR KELLY: I asked you some questions about the geographic spread of users. In particular I just – do you have any information about the time spread? So are there any periods where police see an increased amount of usage? MR LINDSAY: So in the main we looked at that in reviewing for this Commission. 5 We don’t find holiday seasons or peak days or nights. It’s spread across the week per se. What we did find was that increase in detection rates through a number of music festivals but they are certainly limited to the ..... MR KELLY: And how many music festivals are there in this - - - 10 MR LINDSAY: We currently have none. Last year we had a number of approved and non-approved events that occurred. MR KELLY: And when you say that there’s an increase in detection around those 15 music festivals, what drugs specifically is there an increase in detection of? MR LINDSAY: There has been a combination. MR KELLY: A combination. Is there an increase in methamphetamine detection? 20 MR LINDSAY: No. Per se it would be MDMA and other tablets. MR KELLY: In terms of – I want to ask you some questions now about the impacts of use. Can we start first of all with the do you see other offending being committed 25 in conjunction with methamphetamine use? MR LINDSAY: Unfortunately, yes. There’s a correlation. MR KELLY: And what are the types of offences that you’re seeing being caught 30 that correlate with methamphetamine use? MR LINDSAY: Locally clearly violence against others – violence against the person, property crime, road-related offences – risky driving behaviour – would be the top three from my perspective. 35 MR KELLY: And are you able to distinguish between user types within each of those offending groups at all? MR LINDSAY: I can’t, no. 40 MR KELLY: In your statement you say at paragraph 13 use of ice has – and methamphetamine has been observed as binge-type use and is causing a high dependence outcome on users. So in that context of use, as in a binge-type use, are you able to say at all whether there’s any particular type of offending associated with 45 that type of use?


MR LINDSAY: Violence and property crime would be the main. MR KELLY: And when you say violence and property crime, can you elaborate on those – on that a little bit? 5 MR LINDSAY: Assaults on a person; property crime in relation to break, enter and steals; steal from motor vehicles and steal from person type offences. MR KELLY: You also say that the impact includes extreme behaviour violence and criminality with little obvious care, concern or restraint by users for self or others; is 10 that right? MR LINDSAY: Yes. MR KELLY: And that description, does that relate to all of the type of offending 15 that you’ve described or one particular type of offending? MR LINDSAY: I don’t understand the question, I’m sorry. MR KELLY: No, that’s fine. So that extreme behaviour – violence and criminality 20 with little obvious care, concern or restraint by users for self or others – has that been observed in the context of binge-type use and high dependence outcomes? MR LINDSAY: Correct. 25 MR KELLY: And you say also that these crimes, as in crimes of violence and against property, are, on the face of it, attributable to users during these periods of affection and withdrawal; is that correct? MR LINDSAY: That’s correct. That’s what I’ve been briefed. 30 MR KELLY: Yes. And so is it the case that when – are police seeing this type of offending by users who are intoxicated at the time of the offendings? MR LINDSAY: They are. 35 THE COMMISSIONER: Superintendent, is there anything that sort of stands out in your experience that’s different about crystal methamphetamine and behaviour that it gives rise to in terms of criminal behaviour such as you’ve been describing? Is there anything that’s distinct or different from what you may have seen in relation to other 40 drugs in the past? MR LINDSAY: The duration of that affectation, the extreme strength that police report in relation to people that are affected by that particular drug and the significant risks around engaging people at that level of affectation as well. 45


THE COMMISSIONER: So that would be more emphatic than perhaps the case with drugs that you’ve had previous experience dealing with in relation to offenders such as opiates or heroin or cannabis? MR LINDSAY: That’s correct. 5 THE COMMISSIONER: All right. Thank you. MR KELLY: Superintendent, we have a statement from Mr Angus Skinner of the New South Wales Police Association. Have you had the opportunity to review that 10 statement? MR LINDSAY: I did yesterday. MR KELLY: Yes. Do you have a copy of that statement? 15 MR LINDSAY: I do have one with me. MR KELLY: It’s in tab – behind tab 8 of the bundle at this stage. Could I ask you first to turn to paragraph 9 of that statement. 20 MR LINDSAY: I’ve got that now. MR KELLY: Yes. I understand that’s consistent, that statement there about the interactions with persons affected by ATS is consistent with the evidence that you’ve 25 just given the Commissioner in that ATS can make an individual aggressive, incredibly strong and slow to tire. MR LINDSAY: Paragraph 9 represents my perspective and my view on the matter. 30 MR KELLY: Yes. And Mr Skinner also says at the same time police are unable – sorry, users are unable to comprehend the communication by police and attempts by police to de-escalate the situation. Is that consistent with your understanding? MR LINDSAY: That’s consistent with my observations as well. 35 MR KELLY: Yes. And he also says that that inability to comprehend communication makes attempts to resolve interactions between police and the offender very difficult and that the usual methods of resolution that police have available to them, which include verbal communication and de-escalation, use of 40 appointments and methods of apprehension and restraint, he says that they can be rendered less effective. Is that also your observation? MR LINDSAY: That’s an accurate statement. 45 MR KELLY: Can you explain with methods of apprehension and restraint in custody – sorry, I withdraw that. What does use of appointments mean?


MR LINDSAY: We have a number of appointments that are issued to us. They’re less than lethal options such as OC spray, handcuffs, expandable batons, to name a few. MR KELLY: Yes. So those – it’s your understanding that use of those 5 appointments can be rendered less effective in the context of these highly agitated users. MR LINDSAY: That’s correct. 10 MR KELLY: And, similarly, methods of restraint and custody. MR LINDSAY: Correct. MR KELLY: And what methods of restraint are available to police in this context? 15 MR LINDSAY: So besides verbal communication in attempts to de-escalation there are weaponless control tactics which are taught to police as part of their mandatory training that are also utilised. 20 MR KELLY: And Mr Skinner also says that the inability to use these tools – if I can use that word – places officers in significant danger. They are at far greater risk of being assaulted due to aggression and irrationality and difficulty in resolving the interaction and restraint of the ATS individual – is that – affected individual. Is that also consistent with your - - - 25 MR LINDSAY: That’s an accurate statement. MR KELLY: Yes. Mr Skinner then goes on to say one of the ways to get around these difficulties is to ensure that a large number of police officers respond to the 30 incidents. Is that also consistent with your information and experience? MR LINDSAY: Where available. MR KELLY: What’s that, sorry? 35 MR LINDSAY: Where available. MR KELLY: Available – what does that mean? 40 MR LINDSAY: So in terms of deployment. MR KELLY: Yes. MR LINDSAY: Large numbers of police in regional areas aren’t always available. 45


MR KELLY: I see. So do you agree that sometimes the way to get around those difficulties is to deploy more police? MR LINDSAY: I agree. 5 MR KELLY: And your answer is that that has been your experience in this district; is that right? MR LINDSAY: Correct. 10 MR KELLY: But only where those officers are available. MR LINDSAY: Correct. MR KELLY: And then Mr Skinner says that he has reports that apprehending an 15 ATS-affected individual will often require at least double the number of officers that would be required when ATS is not involved. Is that consistent with your experience in this district? MR LINDSAY: It is, sir, and I’ve also provided a recent case study which 20 highlights that. MR KELLY: Yes, I have that. And that as many as 10 officers may be needed to apprehend one ATS-affected individual? 25 MR LINDSAY: I’ve not seen that in my policing experience. MR KELLY: Mr Skinner also says that these incidents can take a lot longer to resolve than incidents that don’t involve ATS. Is that also consistent with your experience? 30 MR LINDSAY: It’s dependant on the incident. MR KELLY: Yes. And then Mr Skinner says that taking all of that into account those factors have the potential to compromise the ability of police to respond to 35 other urgent calls. Do you have anything to say about that? MR LINDSAY: Those challenges are daily challenges and not distinctly isolated to ATS usage. 40 MR KELLY: And in terms of those challenges being a daily occurrence, are they more so in a regional district than perhaps a metropolitan district? MR LINDSAY: Potentially. There’s less support services here in terms of specialist units but the police have minimum staffing requirements that we adhere to. 45


MR KELLY: Mr Skinner also says – just while we’re on his statement and in relation to what you’ve said at paragraph 13 – at paragraph 27 of Mr Skinner’s statement he refers to at all points of the process where multiple emergency services agencies are required there is – to coordinate resources there is the potential for delay. 5

For example, when police detain a person under section 22 of the Mental Health Act then the ideal next step is for the person to be transported in an ambulance to a health facility. However, ambulance resources, health facility staff and bed capacity are not always immediately available which means 10 police officers must transport the person in a vehicle that is not fit for that purpose.

Is that consistent with your experience in this district? 15 MR LINDSAY: Somewhat. So certainly ambulance and health staff are staffed as an on-a-needs basis and I can’t talk to their staff deficiencies or excesses - - - MR KELLY: Yes. 20 MR LINDSAY: - - - but I could certainly say that the ideal transportation mode for a person under mental health conditions would not be a police vehicle and we have MOU in place for that. MR KELLY: And, lastly, at paragraph 46 Mr Skinner says that the resource-25 intensive nature of ATS-related incidents also means they are a significant drain on police capacity in regional areas. Would you agree with that characterisation? MR LINDSAY: So certainly they are a drain on resources at the time; significant, I couldn’t say. 30 MR KELLY: I see. THE COMMISSIONER: Superintendent, do you think you have enough officers in your district? 35 MR LINDSAY: A commander will never say yes, sir. I will always take more. THE COMMISSIONER: Well, now is your chance to tell me. What do you think? 40 MR LINDSAY: So certainly I have 185 sworn police in my district, sir. Across those 13 police stations I’ve got 16 support staff. The Commissioner has given us an undertaking to provide additional police to regional areas. I understand those allocations will be forthcoming. But certainly I would take more police, if offered, but we deploy the police we have available on a needs basis. It’s intelligence basis. 45 We also have those first response agreements that we comply with.


THE COMMISSIONER: Right. And do you have any idea what increase might be forthcoming if the Commissioner is - - - MR LINDSAY: I understand we are being allocated some staff. That’s yet to be confirmed. 5 THE COMMISSIONER: All right. Thank you. Good. MR KELLY: Just staying in the impacts at this stage of ATS in the region, if I could get you to turn to paragraph 18 of your statement and there you note a number 10 of impacts relating to families and the community in the district. MR LINDSAY: I’m with that now; yes. MR KELLY: In the second dot point you say in terms of domestic and family 15 violence impacts and data records there are some complexities which means that there’s no specific data entry fields relating specifically to ATS use. MR LINDSAY: That’s a correct statement. 20 MR KELLY: Yes. Do you have – and then you refer to information from domestic violence liaison officers. Is that – did you speak to a domestic violence liaison officer for the purpose of preparing the statement? MR LINDSAY: Not for the purposes of preparing my statement but I certainly 25 speak to those officers regularly. MR KELLY: And what do they tell you about ATS use? MR LINDSAY: It’s an element in relation to domestic and family violence locally. 30 MR KELLY: And how is that element manifesting? MR LINDSAY: In terms of significant violence to those at risk - - - 35 MR KELLY: Yes. MR LINDSAY: - - - during those high usage periods that I described earlier. MR KELLY: In your statement you say often an increase in violence in incidents 40 where ATS use has been identified; is that right? MR LINDSAY: Unfortunately, yes. MR KELLY: So is that that you’re seeing more violence across the board? 45


MR LINDSAY: No, we’re not. I’m saying when a person is affected to that high level, the potential for violence in the family setting increases. MR KELLY: I see. And the severity of the violence – do you have any information about whether severity - - - 5 MR LINDSAY: In some cases it can be severe. MR KELLY: It can be severe. 10 MR LINDSAY: Correct. MR KELLY: I see. Now, did you have the opportunity to review some portions of the transcript from the Sydney general hearing before today? 15 MR LINDSAY: No, I didn’t. MR KELLY: No. There was some evidence from Ms Mary Baulch who is the CEO of Domestic Violence New South Wales. 20 MR LINDSAY: I have that statement. MR KELLY: And she gave some evidence orally about a program called Safer Pathways and are you aware of that program? 25 MR LINDSAY: I am. It’s in effect in this district. MR KELLY: I see. Could you explain how that program works in this district? MR LINDSAY: Certainly. So it’s based on a safety action meeting. Police chair 30 that meeting in this district. That’s a detective chief inspector, our crime manager. It’s a multi-agency and support services coordination medium whereby every fortnight they come together and discuss at this – victims and high risk cases. It’s a coordination dispute resolution resource direction. 35 MR KELLY: I see. And do you ever sit on that meeting? MR LINDSAY: No, I don’t. MR KELLY: No. And do you have any awareness around the extent to which ATS 40 use is considered in the context of that particular meeting? MR LINDSAY: I don’t have that data. MR KELLY: No. 45


THE COMMISSIONER: Superintendent, is there any particular difficulty in arranging for there to be a data entry field in relation to ATS use at scenes of domestic violence? MR LINDSAY: That would probably be a question best put to the head of 5 profession, which would be the commander of digital technicalities innovation. THE COMMISSIONER: Yes. MR LINDSAY: I’m aware of the WebCOPS Working Group, which looks at 10 amendments or enhancements to our data repository and required fields. I’m also aware that New South Wales Police Force is looking to enhance the WebCOPS as it currently stands into a new platform. THE COMMISSIONER: Right. So just from an operational point of view – I’m 15 thinking of the constable at the scene, on the ground. Obviously there’s a limit, resource-wise, to how much he can record or he or she can put down on the entry. But if there were ATS use suspected by the relevant police officer on the scene, would it be expected that they would record that, either in a notebook or in the COPS entry or - - - 20 MR LINDSAY: Both. It would form part of the freeform narrative - - - THE COMMISSIONER: Right. 25 MR LINDSAY: - - - which is recorded by the officer. THE COMMISSIONER: Right. So if a researcher, for example, wanted to really drill down – even though there’s not a data field in the dataset specifically for ATS correlating with domestic violence incidents, a researcher would likely, if they got 30 access to the primary documents, being the COPS report or the police officer’s notebook, be able to find a reasonably helpful resource there. MR LINDSAY: If it had been collected and recorded in WebCOPS appropriately, through that narrative, yes, sir. 35 THE COMMISSIONER: Right. Okay. Thank you. MR KELLY: Just staying with the impacts of ATS use, if you would turn to paragraph 21 of your statement. You say there that police within the Richmond 40 district respond to a large number of mental health and related incidents. Is that right? MR LINDSAY: That’s correct. 45 MR KELLY: Are you able to give some more detail around the scale of those responses?


MR LINDSAY: I can’t quantify that response. Certainly take it on notice. MR KELLY: And you say there that the response is undertaken in accordance with the state-wide MOU between Health, ambulance services and New South Wales Police. And I believe you referred to that earlier, in your earlier evidence, about 5 ambulance officers and transport. If I could just get you to turn back to Mr Skinner’s statement, at paragraph 36. Mr Skinner says that recent updates of the MOU significantly improve issues around the view within each agency of other agencies not fulfilling their responsibilities under the MOU. And he says that those issues have significantly improved under the recent update. Do you agree with that 10 characterisation? MR LINDSAY: That the relationships and cooperation between the agencies have improved? 15 MR KELLY: Yes. MR LINDSAY: Yes, I do. And locally we have a local protocol committee, which is formed and chaired by the Department of Health - - - 20 MR KELLY: Yes. MR LINDSAY: - - - which – sole role is to – operation-wise that MOU locally between those key members. 25 MR KELLY: I see. And who else sits on that committee? MR LINDSAY: As I understand it, ambulance, Health, ourselves – and there may be another member. I – I’ve provided the draft terms of reference that Health have provided me - - - 30 MR KELLY: Yes. MR LINDSAY: - - - in relation to that. 35 MR KELLY: And Mr Skinner also says at paragraph 36:

Ultimately, there are insufficient resources in any agency to implement the ideal scenario under the MOU.

40 Do you have anything to say about that? MR LINDSAY: I can’t comment about other agencies’ resourcing. MR KELLY: And in police, would you say there are insufficient resources to 45 implement the ideal scenario under the MOU - - -


MR LINDSAY: I won’t say there’s - - - MR KELLY: - - - speaking to this district? MR LINDSAY: - - - insufficient. 5 MR KELLY: Yes. MR LINDSAY: I would say that it is a – a larger portion of our business, though. 10 MR KELLY: What is a larger portion? MR LINDSAY: In terms of response to mental health. MR KELLY: I see. And what are the effects of that response on police or how are 15 you responding to these mental health incidents? MR LINDSAY: So we take them on a case-by-case basis. MR KELLY: Yes. 20 MR LINDSAY: Clearly we want to ensure the safety of both the person who’s suffering that crisis at the time but also other members of the community and our police. So we want to get the right service as quickly as we can for that person. 25 MR KELLY: And earlier you said that a police station was not the ideal form of transport for a person suffering from a significant mental health impact. MR LINDSAY: A police vehicle? No. 30 MR KELLY: Yes. And is it the case that police are sometimes required to transport people suffering from an acute mental health condition? MR LINDSAY: Sometimes, yes. 35 MR KELLY: And where is it that they take them when that’s happening, in this district? MR LINDSAY: In the main, one of the main hospitals, which would be Lismore Base Hospital, Casino or Ballina. 40 MR KELLY: I see. And in terms of the time that that takes – can that be a significant amount of time? MR LINDSAY: It can be. 45 MR KELLY: Can you give me some idea of the travel times within - - -


MR LINDSAY: 40 minutes. MR KELLY: - - - the district? I see. And once police are at the hospital, are they then required to remain there? 5 MR LINDSAY: In cases, yes. MR KELLY: And so when you said it’s a – I think the words you used were a large part of your business or - - - 10 MR LINDSAY: For general duties police – it can form a large part of their business. MR KELLY: I see. And would you describe that as a significant drain on police resources? 15 MR LINDSAY: Not so much a drain. It’s just an element that needs to be considered on a shift-by-shift basis. MR KELLY: “Drain” is probably the wrong word. But has significant impacts on 20 police resources in the district. MR LINDSAY: It can do. MR KELLY: It can do. Regularly? 25 MR LINDSAY: Hard to say. I would have to look at the data more closely. MR KELLY: And I should make it clear that in your statement – you’re referring there to a large number of mental health related incidents. 30 MR LINDSAY: Correct. MR KELLY: And so these are not mental health-related incidents that are necessarily related to methylamphetamine use. 35 MR LINDSAY: That’s also correct. It’s not. MR KELLY: And are you able to say what proportion of those mental health incidents that we’ve been discussing are related to methylamphetamine use? 40 MR LINDSAY: I’m unable to say that. I don’t have the data. MR KELLY: I should say, Mr Skinner also says that police officers – and this is at paragraphs 38 and 40. Police officers often report having to wait extended periods of 45 time for Health vehicles to arrive, during which they are required to restrain the


person in circumstances that are not safe for the person or police. Do you have anything to say about that, in this region? MR LINDSAY: There can be delays in – in attendance of other resources from other agencies, yes. 5 MR KELLY: And do you agree that that can require restraint in circumstances that are unsafe? MR LINDSAY: I can’t say that. 10 MR KELLY: And in terms of your experience in this district, are you able to say whether police have reported to you long delays in staff and beds becoming available at mental health facilities? 15 MR LINDSAY: That has been reported. MR KELLY: And does that mean that police in your district have to wait at health facilities for long periods of time supervising an individual until they can be assessed by health staff and placed in appropriate - - - 20 MR LINDSAY: In cases. But the local protocol network that I’ve mentioned and liaison between our senior managers and supervisors and other agencies, including Health, attempts to reduce those impacts. 25 MR KELLY: In terms of – just sticking with impacts at this stage. You’ve referred at paragraphs 25 and 26 to the workplace impacts of crystal methylamphetamine and ATS use being of considerable concern to the police district and the New South Wales Police Force in general. Would you just speak to that in a bit more detail, please. 30 MR LINDSAY: Yes. Certainly. So as mentioned before, incidents where people are seriously affected by ice have resulted in injuries to police and civilians or – or good Samaritans. I’ve provided an example in my statement, which is a recent example, sir, in Woodburn, which is a local township in our district, where police 35 were called by members of the community in relation to a male potentially trespassing. Police located that male with the assistance of the community, spoke to the male. A violent confrontation occurred very quickly therein. The full range of verbal/weaponless control and other tactics were deployed ineffectively, unfortunately to the point where two civilians had to assist. As a result of that, two 40 of our police, one community member and the person who was spoken to originally were injured and resulted in treatment being required. This to me is a case study of this type of interaction and the risk posed by our police and members of the community in these circumstances. 45 MR KELLY: And what sort of injuries are you seeing in – well, in that particular case,


what injuries were sustained? MR LINDSAY: Soft-tissue. A significant bite to a thumb. Bruising. MR KELLY: And in terms of other injuries that you’ve seen to police in the context 5 - - - MR LINDSAY: Very similar. MR KELLY: Very similar. And those are some of the physical impacts of 10 attending these incidents. Can you speak at all to the mental health impacts on police of attending - - - MR LINDSAY: Certainly. So attending such violent incidents over the course of a career has been proven to provide trauma, unfortunately, to our police. 15 MR KELLY: And you mentioned this case study, which you’ve outlined in some short form in your statement at paragraph 26. And in response to a summons that was issued on Friday by the inquiry for further detail in relation to WebCOPS event number E7O7O1O76, this morning the narrative from that WebCOPS event was 20 produced. Is that right? MR LINDSAY: That’s correct, sir. MR KELLY: And I will show you a document. Is that a copy of that WebCOPS 25 event? MR LINDSAY: It is, sir. MR KELLY: Yes, I tender that, Commissioner. 30 THE COMMISSIONER: Thank you. MR KELLY: I tender it – if it could be added to the tender bundle and not given its own exhibit number behind the Superintendent’s statement at tab 9. 35 THE COMMISSIONER: All right. Have other parties seen the document? Is that - - - MR KELLY: The police have seen the document. 40 THE COMMISSIONER: Right. MR KELLY: But I also should say I would seek a non-publication order over portions of that document pursuant to section 8 of the Act, and that being the names 45 and identifying features of the accused attending police and any civilians named in the document.


THE COMMISSIONER: So you just want the non-publication in relation to the names of individuals? MR KELLY: Yes. Names and any other identifying features. Haven’t had a chance closely to review that, but I will do so ensure that those identifying features 5 are not redacted prior to publication. THE COMMISSIONER: All right. Thank you. Well, I will admit that tender and it will be a part of Exhibit F, to be added being Superintendent Lindsay’s statement as an addition to that statement. And given that it’s sensitive information, I think it’s 10 appropriate that I do make a non-publication order in relation to any naming of individual names referred to in that document or any other material that would identify any particular individual referred to in that statement. 15 EXHIBIT #LF SUPERINTENDENT MENZIE’S STATEMENT ADDED THE COMMISSIONER: And, Mr Kelly, if you think there’s any need to amend or add to that order after you’ve had a look at the document just raise it with me at a 20 later stage. MR KELLY: Thank you, Commissioner. THE COMMISSIONER: Thank you. 25 MR KELLY: Superintendent, at paragraph 26 you refer to this incident as not isolated, and you say that it is indicative of the potential for extreme violence during such interventions, risk upon an impact to police, the community, and ice and methamphetamine users; is that right? 30 MR LINDSAY: That is. MR KELLY: And earlier I think you used the word case study to describe it. 35 MR LINDSAY: I would use that as a recent example of the risks involved. MR KELLY: And can you speak at all to the frequency of incidents of the kind that you’ve just described that you see in this district? 40 MR LINDSAY: It’s not frequent. MR KELLY: Is it monthly? MR LINDSAY: Potentially, yes. 45 MR KELLY: That seems relatively frequent.


MR LINDSAY: Too frequent, to my mind. MR KELLY: Too frequent? Yes. MR LINDSAY: I think one of these incidents for – for all parties involved is too 5 many. MR KELLY: But monthly, is that a fairly accurate description, you would say, of what the district is experiencing? 10 MR LINDSAY: I would support that. THE COMMISSIONER: So it would be a dozen times a year, perhaps, roughly, you would have an incident of that scale. 15 MR LINDSAY: So I can talk for the seven months that I’ve been here, sir, and I would say that probably wouldn’t be over-representing the incidents. THE COMMISSIONER: yes. Right. Would not be over-representing them. All right. Thank you. 20 MR LINDSAY: Would not be. It would be – I would support it. MR KELLY: In terms of the workplace effects on police of dealing with people affected by ATS and crystal methamphetamine in particular, Mr Skinner again, at 25 paragraph 30 of his statement, refers to facilities and design of custody areas as a considerable factor in the risk of injury to officers present. Do you have anything – could you comment on that statement in – by reference to your experience in this district? 30 MR LINDSAY: In terms of this district, I’m satisfied I’m responsible for the custody – safe custody of people in our area, and I’m satisfied with the facilities we have. MR KELLY: Thank you. Now, I would like to talk a little bit about – or ask you 35 some questions about police responses to ATS in the region. If I could start by asking you to turn to paragraph 14 of your statement. Could you speak to the matters that are outlined there in terms of police responses? MR LINDSAY: 14, was it? 40 MR KELLY: Yes. So you say you’re aware of current and suspected historically convicted methamphetamine dealers within the area is that right? MR LINDSAY: In the main that’s correct. 45


MR KELLY: And then you say that those individuals, all groups, have been subject to numerous overt and covert police operations and disruption initiatives. MR LINDSAY: That’s also correct, and they’re ongoing. 5 MR KELLY: And what – we’re conscious of the concerns around not disposing any sensitive operational information. Could you give the commissioners some more information about the sorts of – at least overt and operations and disruption initiatives that are undertaken? 10 MR LINDSAY: I would probably point to paragraph 15 and just discuss the disruption. MR KELLY: Yes. 15 MR LINDSAY: So we had three pillars as part of our statement of strategic intent: the prevention, disruption, response, and our internal capability. The question, as I understand it, is our disruption activities. MR KELLY: Yes. 20 MR LINDSAY: So, locally, disruption at street mid-level illicit drug supply – we utilise overt and covert means. Often we are assisted by recovered asset pool funding, which is supplemental finding, to enhance our operational reach and effectiveness. 25 MR KELLY: And how is that funding used? MR LINDSAY: It’s upon application, and there are clear controls and policies around that. 30 MR KELLY: And what sorts of activities did it fund? MR LINDSAY: In the main, covert activities. 35 MR KELLY: Yes. Thank you. Go on, I interrupted you. MR LINDSAY: Certainly so, in addition to those disruption-level activities, we utilise Crime Stoppers. That has been utilised in this district, as I’m aware, twice in terms of Dob in a Dealer campaigns – very effective in terms of information sharing. 40 The community is able to share with us anonymously. Information and drug supply manufacture and, to a lesser extent, possession. But in the main it’s around that manufacture and supply. We’ve recently concluded the most recent Dob in a Dealer campaign, and the statistics I had provided to me was around 300,000 information reports solely from Crime Stoppers around drug use, manufacture and supply. So a 45 significant amount of information the community has provided to us locally, as the Richmond Police District, is a result of that tool.


MR KELLY: You also mention there are high-visibility policing operations and taskings on a daily basis. What are some examples of that? MR LINDSAY: Correct. So uniformed police, which is the main in our response police, when discretionary time is available are deployed to intelligence-based 5 locations for high visibility uniform presence. It’s a deterrent as well as a community engagement opportunity. MR KELLY: I see. Would a music festival be an example of - - - 10 MR LINDSAY: that’s a combination of prevention, disruption and response activities in the main. But yes, high visibility is certainly one strategy. MR KELLY: So that’s your disruption response that you’ve just outlined. Could you speak a little to response? 15 MR LINDSAY: Yes. Certainly. So we have, obviously, response operations, investigations. In the main, a lot of our activities self-initiated those overt and covert investigations, but if we do come across a supply or such – locally a cannabis crop, per se, that may be a response requirement. It would have been something that we 20 knew about before. MR KELLY: I see. And in terms of, still, of – sorry, I withdraw that. Just turning back briefly to disruption, have you had the opportunity to review the statement of Mr – Dr Edward Wims before today? 25 MR LINDSAY: No. MR KELLY: No. Could the witness be shown the tender bundle please? 30 THE COMMISSIONER: Sure. I will hand him that without that last addition. MR KELLY: And tab 14. MR LINDSAY: Thank you. 35 MR KELLY: This is a statement of Dr Edward Wims, Superintendent. If you just turn to paragraph 8. MR LINDSAY: I’m there now. 40 MR KELLY: Dr Wims says, at the end of that paragraph:

I’m also aware that a recent success from law enforcement in seizing a large amount of amphetamine from one of the largest distributers has correlated with 45 the reduction of admissions to ED and acute admissions to the unit.


Could you just shed any light on the recent success from law enforcement in seizing a large amount of amphetamines there? MR LINDSAY: I’m not sure which one he’s referring to, but certainly a recent strike force deverill was resolved earlier this year, which saw seven kilograms of 5 MDA amongst other drugs, weapons and cash. So it’s just a result of one of those disruption operations that I talked about. MR KELLY: And how do you spell that strike force? 10 MR LINDSAY: Deverill. D-e-v-e-r-i-l-l. MR KELLY: And how long had that been running for? MR LINDSAY: Mid too late 2018. 15 MR KELLY: And you said that you weren’t sure precisely which one Dr Wims was referring to. Does that mean there have been some other significant successes, is the word that Dr Wims uses. 20 MR LINDSAY: They have over the last few years. MR KELLY: I see. And can you just describe some of those? MR LINDSAY: At 43, strike forces that I’ve reviewed since 2014. I think I 25 mentioned earlier we had a spike in those strike force operations and investigations in 2016. There were some 14 conducted in that year alone. MR KELLY: And turning back to your paragraph 15, which deals with your three pillars of response, we’ve covered disruption and response; could you speak a little 30 to the prevention strategies and initiatives that police have undertaken in this region? MR LINDSAY: Thank you. There’s – there’s three elements that I would like to raise, Commissioner, in relation to our prevention response. First and foremost locally: RISEUP program, which is the Commissioner’s initiative in terms of at-risk 35 youth. Locally we fully developed that program with Youth and Crime Prevention Command, as well as in collaboration with PCYC – the Lismore PCYC is a fantastic facility. It’s a hub for youth – it’s a safe hub for youth and also crime diversion. At August last year we implemented the foundational program through RISEUP, which is known as Fit For Life, which targets at-risk youth around the 10 years of age, but it 40 can be higher and can be lower. They engage with our youth case managers, local police, including myself, other senior management team members, our Aboriginal community and liaison officers, as well as members of the public. We’ve had some Bundjalung elders join us as 45 well. So it’s an opportunity where police identify these kids, divert them through to PCYC facilities – this program, specifically. We collect them in the mornings once a


week. We take them to PYCY, engage with them through fitness. We feed them breakfast, facilitate their attendance at school. Really positive outcomes. We get about 15 to 20 kids once a week at Lismore. We’ve also conducted outreach at Casino Public School at the request of Department of Ed which is a fantastic 5 outcome. It’s separate to the Fit For Life itself. That’s 70 kids attend that once a week. So this, from my perspective as a district commander, is one of our foundational prevention activities attempting to divert kids or at-risk youth from crime. There are other benefits in terms of domestic and family violence liaison, etcetera, but we want a positive interaction with kids to reduce the likelihood of them 10 ending up in the criminal justice system. THE COMMISSIONER: Great. MR KELLY: Do you have any measures in place to review the effectiveness of 15 those programs? MR LINDSAY: So out of the children that I’m aware of that attended, we’ve had one child involved in youth case conference as a result, out of all the kids that had been through that we’re aware of. 20 MR KELLY: And you’ve mentioned there, in your statement, Operations Banshee and Dragonslay. Could you explain a little bit about what they are? MR LINDSAY: Certainly. So Banshee is a multiyear ad hoc high profile crime 25 disruption operation. It also has benefits in terms of prevention because we’re engaging with the youth on the street. We’re diverting them to programs such as Rise Up and Fit For Life locally. In the main, though, it’s a disruption operation to prevent crime through our business periods, specifically summer, or in times when we identify that we’re having a peak in that particular crime type. Dragonslay was – 30 in essence, it was a precursor locally to the Rise Up program. The Rise Up program is now a consolidated suite of really good initiatives that police were involved in or police led over the years. I think Redfern boxing was portably one of the initial standout programs and a whole bunch of other activities that were 35 done in isolation. The Commissioner and Mr Kasserou Assistant Commissioner in charge of that command brought them together, and they’ve been deployed across the state consistently. I see it as one of the most positive prevention activities the New South Wales Police Force has involved in, the 25 years I’ve been in the job. 40 MR KELLY: You mentioned, in the course of giving that answer, the involvement of some Bundjalung elders in some of those diversionary programs. MR LINDSAY: Correct. 45 MR KELLY: And you also say in your statement at paragraph 20 that you were advised by local Aboriginal community members that they fear the prevalence in ice,


methamphetamine in the community. Are there any strategies or initiatives that are in place in the district that are specific to the Aboriginal community? MR LINDSAY: Yeah. Certainly. So as part of our New South Wales Police Force Aboriginal Strategic Direction, on the northern region sponsored for that direction, 5 we have a functional police and Aboriginal community consultative committee across three main elements basically centred around Ballina, Lismore and Casino. They’re great opportunities to – for full and frank conversations with our local Aboriginal communities around their needs and also policing initiatives. They support the Rise Up in the main. We’re developing that relationship with them 10 through Rise Up and Fit For Life. It’s also an opportunity to problem solve with those communities. MR KELLY: Thank you, Superintendent. Do you have any awareness around the schools’ drug and alcohol working group that was established as part of the crystal 15 methamphetamine project? MR LINDSAY: I don’t, sorry. MR KELLY: Yeah. Now, just in terms of – you’re aware that the inquiries required 20 to report on options to strengthen New South Wales’ response to methamphetamine. In the context of that, could I take you to paragraph 22 where you say – I think you made an amendment to that paragraph. You say:

Northern Rivers communities are not serviced by a Koori Court, but are 25 serviced by MERIT programs.

And you say:

Dependant on resourcing. 30 Do you have – could you speak at all to the police’s engagement with the MERIT program? MR LINDSAY: I don’t have data in relation to the amount of referrals, but, 35 certainly, from briefings I’ve received, when this program is run, it has been effective from a policing perspective, as has circle sentencing which has been in operation since about 2005, I understand. MR KELLY: And you say, “When they’re run,” does that mean, sometimes, they’re 40 not run? MR LINDSAY: I understand that they’re dependant on resourcing, but that’s the briefing I’ve received. 45 MR KELLY: And in your experience so far during your time in the district, do you know whether they have been available throughout that time or - - -


MR LINDSAY: I’m unable to say that. MR KELLY: At paragraph 23, you also state that you’re aware that a drug court is under consideration and you fully support that initiative, and you repeat that in paragraph 29. Could you just explain to the Commissioner a little why you support 5 that initiative. MR LINDSAY: Yep. Certainly. So we were canvassed in September last year, I understand, around the potential for this district being a drug court jurisdiction. The investigations that my senior management team prosecutors undertook with 10 commands where that drug court was in operation was very positive. The diversionary corrections and support pillars, as we understand the drug court that operates in Parramatta, been very effective. We’d very much like to support that initiative in this district. 15 THE COMMISSIONER: Good. MR KELLY: And, lastly, Superintendent, could I just get you to speak a little to the matters that you’ve outlined there at paragraphs 27 and 28 of your statement. 20 MR LINDSAY: Is that okay if I read it on the record? MR KELLY: Yes. MR LINDSAY: 25

I believe that Northern Rivers would benefit from the following responses to issues associated with methylamphetamine: further development of rehabilitation and education services to local communities; continued enforcement activities to reduce the supply of illicit drugs including 30 methylamphetamine and ATS; introduction of a dedicated drug court within the Northern Rivers providing a consolidated approach to diversion, corrections and support as it relates to methylamphetamine and ATS; and further coordination and efforts across government and non-government agencies including the police relating to diversionary programs and funding 35 for at-risk youth away from methylamphetamine and ATS.

MR KELLY: Could I also ask you to read paragraphs 27 and 28. MR LINDSAY: 40

New South Wales Police Force remains committed to the three pillars of supply, demand and harm reduction under the National Drug Strategy. The approach is both comprehensive and pragmatic. It requires the whole of government support and agency collaboration if it’s to be effectively 45 implemented. New South Wales Police recognises that supply reduction is its


core business. It is also aware of the important role the organisation plays in demand and harm reduction, and that I echo that for our local district.

MR KELLY: And paragraph 28. 5 MR LINDSAY:

New South Wales Police Force has and continues to advocate for sufficient and suitable treatment services to meet the needs of those struggling with substance misuse. It’s also the view that greater emphasis needs to be placed on effective 10 prevention programs and projects that can reduce both the rate of uptake and the age at which people first use drugs.

MR KELLY: Thank you, Superintendent. Those are my questions, Commissioner. 15 THE COMMISSIONER: Thank you, Mr Kelly. I just have a few other questions, Superintendent. You mentioned in paragraph 14, I think, toward the end of paragraph 14, in relation to supply of methamphetamine, you say, as I read it, is predominantly supplied from southeast Queensland; is that correct? 20 MR LINDSAY: That’s correct. That’s the information we have. THE COMMISSIONER: Right. So in terms of local clandestine laboratories, for example, do you – are you having – are you finding many of those in this district or not? 25 MR LINDSAY: One in my tenure, Commissioner. THE COMMISSIONER: Right. 30 MR LINDSAY: It was inactive. THE COMMISSIONER: Right. Okay. And do you liaise with Queensland Police? Is there a - - - 35 MR LINDSAY: Established working relationship, sir, with - - - THE COMMISSIONER: Right. MR LINDSAY: - - - Warwick patrol group in the main which – we have quite a 40 lengthy border with Queensland Police Service, but we’ve got effective relationships now underway. THE COMMISSIONER: Are you able to say whether the predominant supply that you say is coming from southeast Queensland, whether that is manufactured in that 45 state or whether it’s imported from overseas?


MR LINDSAY: I’m unable to say that. THE COMMISSIONER: Right. Okay. Do you carry out drug-driving roadside tests - - - 5 MR LINDSAY: We do, sir. THE COMMISSIONER: - - - in the district? All right. Is that a – something that’s – a policing activity that’s constantly carried out or on the – for various periods? 10 MR LINDSAY: No, constantly carried out. THE COMMISSIONER: Right. And do you have any – can you give me any sense of a volume of positive findings in relation to methamphetamine? 15 MR LINDSAY: So a recent operation in response to a large community event at Nimbin resulted in 2300-plus tests and around 65 of those came back as positive. There was – and I’ll have to refer and I can provide that information. There were a number that were amphetamine solely. There were also a combination as well. 20 THE COMMISSIONER: When you say amphetamine, is that – are you able to distinguish it as methamphetamine or just amphetamine substance? MR LINDSAY: Amphetamine. I’d have to give you out of session, on notice, that data. 25 THE COMMISSIONER: Right. All right. Thank you. You gave us this very helpful example of an incident where there was a person affected by the drug and by methamphetamine and some violence that occurred. As I understand it, often, when somebody is high on this drug, they can be paranoid and you can – they can 30 sometimes move over into a state of psychosis. I’m just wondering in terms of what becomes of an incident like that. Is it invariable police practice that the person would be charged or would that be a discretionary matter entirely, given the likelihood or possibility that that person may, you know, have this psychotic state of mind at the time. 35 MR LINDSAY: So in this particular instance, medical treatment was declined by the offender and he was charged with the matters and subsequently convicted. THE COMMISSIONER: Right. Okay. If there were an incident – in general terms 40 with incidents like that, is it left up to the police on the ground to decide whether it’s appropriate or not to actually charge the individual for the behaviour that they exhibit whilst affected by the drug? MR LINDSAY: In the main, yes, and certainly guidance will be provided by the 45 supervisors on deck.


THE COMMISSIONER: Right. All right. Thank you. So it wouldn’t be invariably the case that a person behaving badly because they’re on this drug would necessarily be charged. MR LINDSAY: No. There would be serious considerations in relation to the health 5 of that person. THE COMMISSIONER: Yes. All right. MR LINDSAY: That would be one of the primary concerns of police. 10 THE COMMISSIONER: That’s helpful. Thank you. And, look, the last thing I just wanted to ask you was with the Aboriginal communities here, is there any scope or room for appointments of special constables in that community, or is that - - - 15 MR LINDSAY: So we have the three ACLO positions that I mentioned which are our Aboriginal Community Liaison. We also have a number of sworn officers who perform uniform policing that identify as Aboriginal. THE COMMISSIONER: Right. 20 MR LINDSAY: Part of our Aboriginal strategic direction is also encouraging local recruitment. We have the IPROWD program which is a TAFE-run program, precursor towards police recruitment and other government agency recruitment. So we are always looking for representatives of the community to join our force. 25 THE COMMISSIONER: Right. Okay. Do you know how many constables who identify as Aboriginal you would have? MR LINDSAY: I don’t have that statistic locally. 30 THE COMMISSIONER: All right. Okay. MR LINDSAY: There’s a number of hundred in northern region though. 35 THE COMMISSIONER: Just again on that point just for my own understanding, to be a special constable as distinct from a permanent – what would you call it – a sworn officer, perhaps, what’s the difference? MR LINDSAY: Principally it relates to the powers and investigative powers 40 specifically. THE COMMISSIONER: Yes. MR LINDSAY: So locally the question would be will we see more value in a 45 greater community consultative approach and allow police to conduct those powers. I would say we would rather involve more community engagement, more

.SPECIAL COMMISSION INTO ICE 14.5.19R1P-612 E. LLOYD XN MR BEAUFILS

information and cooperation and allow us to discharge our duties as opposed to having a specific special constable for a specific area. THE COMMISSIONER: All right. Thank you. All right. Any other questions by any other counsel today? 5 MR KETTLE: No questions. Thank you. MR REGENER: Nothing, thank you. 10 THE COMMISSIONER: Mr Kelly, would you like the witness excused? MR KELLY: Yes. Thank you, Commissioner. THE COMMISSIONER: All right. Superintendent, thank you for your helpful 15 evidence. You’re excused. MR LINDSAY: Thank you very much for the opportunity, Commissioner. THE COMMISSIONER: Thank you. 20 <THE WITNESS WITHDREW [11.06 am] 25 MR KELLY: Commissioner, Mr Beaufils will be calling the next witness. MR BEAUFILS: Commissioner, I call Eddie Lloyd. THE COMMISSIONER: Thank you. 30 MR BEAUFILS: And it’s Beaufils for the transcript, B-e-a-u-f-i-l-s. THE COMMISSIONER: Thank you, Mr Beaufils. 35 <EDWINA LLOYD, AFFIRMED [11.07 am] <EXAMINATION BY MR BEAUFILS 40 THE COMMISSIONER: Thank you. Please sit down. MR BEAUFILS: Ms Lloyd, can you please state your full name for the transcript, 45 please?


MS LLOYD: Sure. Edwina Lloyd. MR BEAUFILS: Commissioner, the materials that I will be referring to with this witness are contained within tab 6 and tab 10. 5 THE COMMISSIONER: Thank you, Mr Beaufils. MR BEAUFILS: Ms Lloyd, can you please state your current position in the Aboriginal Legal Service and just provide us a brief description of your professional background. 10 MS LLOYD: Yes. I’m a trial advocate for the Northern Region of the Aboriginal Legal Service. I’ve been in practice for about eight years. I’m also the Councillor on Lismore City Council and the chair of the Social Justice and Crime Prevention Committee. 15 MR BEAUFILS: And how long have you been within the Lismore area? MS LLOYD: About five years. 20 MR BEAUFILS: And prior to that, were you close by or did you live - - - MS LLOYD: Practising in Sydney but I had spent – and lived up here beforehand. MR BEAUFILS: And as a practitioner with the ALS, which courts do you go to? 25 MS LLOYD: So our office services Lismore, Ballina, Kyogle, Casino, Tweed Heads, Byron Bay and I also attend courts in Kempsey – in my role as a trial advocate – Kempsey, Gloucester and Port Macquarie. 30 MR BEAUFILS: And can I show you a document. This is tab 10 of the tender bundle. Perhaps the witness can be provided with a copy – the exhibit. THE COMMISSIONER: Sure. 35 MR BEAUFILS: Just as a preliminary matter, are you familiar with a person by the name of William Bon? MS LLOYD: I am. He’s our Aboriginal field officer. 40 MR BEAUFILS: And have you spoken to him about his statement previously? MS LLOYD: Yes, I have and he apologises that he can’t be here today ..... MR BEAUFILS: If I could just take you to paragraph 4 of Mr Bon’s statement, Mr 45 Bon states that over the period of 10 years that he has been working as a field officer, he has witnessed his clientele base increase dramatically and the offending – increase


in prevalence and seriousness and he believes that the increase is directly related to the prevalence of crystal methylamphetamine in Aboriginal communities. Do you share that view? MS LLOYD: Yes, that’s certainly consistent with my experience as well. 5 MR BEAUFILS: What have you observed happening within the Aboriginal community, particularly in relation to amphetamine-type stimulants? MS LLOYD: Well, I agree with the evidence given by Inspector Lindsay in regards 10 to the prevalence of methylamphetamine use, particularly in the Aboriginal communities, has increased and is having a very significant impact. And what we are seeing is there are a lot of violent offences being committed and a lot of break and enter with violence and also a lot of domestic violence offences that are being committed with people who are using methylamphetamine. 15 MR BEAUFILS: And you understand that our inquiry is looking at amphetamine-type stimulants. Is there a particular type of those drugs that you see impacting Aboriginal communities in this area greater than others? 20 MS LLOYD: Crystal methylamphetamine. MR BEAUFILS: Has crystal methamphetamine changed the way that you have been delivering your services to your clients? 25 MS LLOYD: We have a lot of clients who are in great states of crisis with – presenting with a complex array of issues. Generally speaking, when we see a client in the cells, they can be aggressive, upset, sometimes in psychosis, and the fact sheets that go along with the offending generally reveals very unsophisticated and chaotic offending – impulsive, opportunistic and violent. 30 MR BEAUFILS: And is that having an impact as well on the workforce at the Aboriginal Legal Service? MS LLOYD: I guess we all can be a bit traumatised by some of the issues that our 35 clients present with and we find it very frustrating because we can’t get them the help that they need and we will see them in the cells and they’re often not fit to give us instructions at all and yet they are bail refused in many cases and there are no beds available in local rehabilitation centres for them to go to. 40 MR BEAUFILS: And Mr Bon further observes that:

Crystal methamphetamine is breaking relationships, families and communities.

Is that something that you have also observed? 45


MS LLOYD: Yes, it’s having a far-reaching effect within the Aboriginal communities, within their families. MR BEAUFILS: Perhaps if that part of the exhibit could be returned. Ms Lloyd, I now want to ask you some questions about your involvement in the Lismore City 5 Council Social Justice and Crime Prevention Committee and there’s a document, Commissioner, at tab 6 which may assist ..... THE COMMISSIONER: Yes, I have that. Thank you. 10 MR BEAUFILS: Ms Lloyd, do you have a copy of that document in front of you? MS LLOYD: I do. MR BEAUFILS: Can you just as an introductory remark just tell us a little bit about 15 what this Committee is and how it’s set up and what its purpose was? MS LLOYD: So given my work and my involvement with council and the wider community, it became apparent that we needed a body to explore the issues in our region and gather that information to provide to politicians. It’s really – the 20 Committee report is really our community’s cry for help. It’s made up of stakeholders from across the divide. We’ve got defence practitioners; we’ve got the Aboriginal Legal Service, Legal Aid; we’ve got Department of Community Corrections; we’ve got the local office of the Director of Public Prosecutions; we have a housing member. It really is a group of experts in our community that are all 25 very concerned about not just crystal methylamphetamine but wider illicit substance use disorder in our community and the impact it’s having on our families and we decided that we needed to do something about it, so we brought together these people to address the issues. 30 MR BEAUFILS: And all these people came together on a voluntary basis? MS LLOYD: That’s correct. So we had about I think five meetings over the year of 2018 and we’re hoping for the committee to continue and those meetings went late into the night and nobody really wanted to leave because there is just so much to be 35 said which is why we want to continue the committee until we start to see solutions to the issues. MR BEAUFILS: Yes. If I can take you to page 7 of that report, the committee came up with some recommendations or – can you just give us a summary of what 40 the committee found this community needs? MS LLOYD: So in line with the task that council had set us, we did agree that there was a need and demand in our region for a further residential rehabilitation centre, a youth and adult Koori Court, a Drug Court and to explore justice reinvestment 45 initiatives. In addition to that, the committee also found that we need very badly a culturally and gender-appropriate residential rehabilitation services for Aboriginal


women and children and women and children and residential rehabilitation services that address people who present with dual diagnosis issues which is a very common thing now with the methylamphetamine use; a lot of people are presenting with mental health conditions as well and those residential rehabilitation centres don’t have the relevant expertise to address those kinds of complex clients. 5 We also feel that we need a detox centre for youth and an expansion of the current MERIT program which they often close their books because they don’t have enough resources to service the demand in our region, and in addition to that, our committee felt that there needed to be an expansion of the MERIT program to service people 10 who present with alcohol-only related criminal issues because the service does not currently do that and we also felt there was a need for the return of the Life on Track program. MR BEAUFILS: Before I drill down into a little bit of the detail behind those 15 recommendations, page 9 – perhaps in the middle of the page – there’s a reference to stigma as being a barrier. MS LLOYD: Yes. 20 MR BEAUFILS: Could you just explain what you – what the committee meant by that? MS LLOYD: People who are experiencing substance use disorder often experience a lot of discrimination in the wider community. I think it begins – our committee 25 believes it begins with the criminalisation of illicit substances and it’s a barrier for people to accessing treatment as well and certainly the committee wish to emphasise to this Inquiry, to politicians and to the wider community that it would be helpful if people started to adopt the medical term for this health issue which is substance use disorder and avoid using inflammatory terms such as “ice addict”, “junkie”, “drug 30 addict” and terms like that which does nothing to help people access treatment. And it is unfair that these people are treated in this way because this health issue is listed in the Diagnostic and Statistical Manual for health conditions. It’s a disorder in there. And the committee really wanted to emphasise that politicians really need 35 to take leadership in this area and call it for what it is and accept that the war on drugs is over, put the guns down and come to some agreement – bipartisanship – on this issue and avoid stigmatising and demonising and criminalising and punishing people who have got this mental health condition. And we believe that it’s a human right to access health treatment for this and people with substance use disorder are 40 denied that. MR BEAUFILS: You have mentioned previously the MERIT program. As a practitioner with the Aboriginal Legal Service, how important is it to have a program like the MERIT program? 45


MS LLOYD: The MERIT program has been fantastic in helping people turn their lives around and to rehabilitate from substance use disorder and address some of the surrounding issues. MR BEAUFILS: And have you often felt that having something like that to help 5 your clients was incredibly valuable? MS LLOYD: Incredibly valuable. It’s a wonderful program when it is up and running. 10 MR BEAUFILS: And courts generally, do they like getting a report they can read through on sentence, in your experience? MS LLOYD: Yes. So the MERIT program is a 12-week diversionary program and there’s usually a check-in with the client at court every four weeks and a MERIT 15 report is given to – given to the court just to advise the court of the progress of that person, that they’re staying on the program, that they’re complying, that they’re doing what’s required, and then at the end of the 12 weeks, a final MERIT report is given to the court and that is very comprehensive and outlines, really, where the client has come from to where they are today and that’s taken into account on 20 sentence. MR BEAUFILS: At page 12 of the report, there’s a quote from yourself in about the middle of the page. It says: 25

The MERIT office in our region is often closing its books due to a lack of resources to service the demand in our region.

Is that the current position with the MERIT program as we sit here now? 30 MS LLOYD: At the moment I think MERIT are accepting referrals, yes, but there have been times that the books are closed; they won’t accept any referrals for two weeks or six weeks. MR BEAUFILS: How long do they become closed for – two to six weeks, or can it 35 be longer? MS LLOYD: Yes, yes, yes, two to six weeks. MR BEAUFILS: And what happens with the person when the MERIT is closed? 40 Do they have an opportunity to do something else like MERIT? MS LLOYD: No, there’s no other opportunity. There’s no other diversionary scheme besides the Extra Offender Management Service which isn’t available to everybody. 45


THE COMMISSIONER: How often does MERIT get suspended through lack of resources here? MS LLOYD: Two to three times a year we get notice that MERIT are not taking any referrals. 5 THE COMMISSIONER: And would that be for that sort of period – four to six weeks? MS LLOYD: Yes, yes. 10 THE COMMISSIONER: And can I – sorry, if I can just – and so when MERIT isn’t available, would it be the case that a person who otherwise would have qualified for the MERIT program is left with – the magistrate simply left with a more punitive approach, perhaps, rather than a diversionary approach? 15 MS LLOYD: That’s correct. And the opportunity is gone. There’s no opportunity for that person to rehabilitate, essentially, with the help that MERIT provide. THE COMMISSIONER: So in a sense it becomes a bit of a lottery from the 20 accused’s point of view as to the options available for them? MS LLOYD: That’s correct, and certainly people with alcohol-related substance use disorder – they are just never eligible for MERIT because we don’t have alcohol MERIT in our region. 25 THE COMMISSIONER: All right. Thank you. MR BEAUFILS: Towards the bottom of page 12, the committee mentions the Extra Offender Management Service. Could you just explain what that is? 30 MS LLOYD: The Extra Offender Management Service is a referral service by the staff of Extra Offender Management Services. They select clients from a database that are at medium risk of reoffending and they are told by the computer what criminogenic needs these people have that can be addressed and the workers from 35 EOMS work with that client to try to help them turn their life around and that’s a service that was something else that many members of our committee, especially the legal members, were quite vocal about – wishing the return of the original service before it got shrunk into EOMS. 40 MR BEAUFILS: What was the original service called? MS LLOYD: The original service was called Life on Track – it had a much less punitive name to it, and it was an incredible program. The people who run EOMS, Mission Australia, they also did Life on Track as well so we have some of the staff 45 left in EOMS but they had more staff with Life on Track. And Life on Track was a service that really understood the needs of our complex clients living in regional


areas – transport issues, mental health issues. The workers were incredible. They worked outside of the box. They would pick up our clients at night and take them to meetings. They would pick them up early and drive them to therapy sessions. They really worked outside of the box and they worked in a holistic way which I think is really missing now. They worked with that individual on not just on their criminal 5 needs but also all of the other social issues that have led to them becoming involved in substances and in committing criminal offences THE COMMISSIONER: Ms Lloyd, just in relation to Life on Track, I’m just casting my memory back, but that – that was an initiative of a – of a previous 10 Attorney General, I think. I’m just trying to call. Do you recall when that program came into effect? MS LLOYD: I think it has been around for a couple of years, two – two or three years. 15 THE COMMISSIONER: And who was – who was funding that? MS LLOYD: I think the state government were funding that. I’m not - - - 20 THE COMMISSIONER: Right. And - - - MS LLOYD: - - - sure which department. THE COMMISSIONER: - - - are you aware – is it a case that the funding dried up 25 or – or – do you know why it stopped? MS LLOYD: Well, we heard that there – there was a Life on Track in another regional area that wasn’t as successful, and that got shut down and ours got shut down at the same time, but what we understand from the – what the members of the 30 committee have told us is, Life on Track funding used to be with Rekindling the Spirit, and it was taken off them and given to Mission Australia, who then shrunk it down to EOMS. One of the most valuable things that came out of our committee was having all of the stakeholders in the one room, to hear each other and – and realise that there has been a lot of dividing and conquering in the sector, and a lot of 35 competition for funding, which has been really unhealthy. And a lot of these people, agencies, rehabs and services weren’t talking to each other and having this committee brought everyone into the room. So there’s a lot of harmony and unity and I think that has been a really powerful thing for this committee, to go forward with that united front to politicians, to say we all agree that we need help. 40 THE COMMISSIONER: So the funding – the funding, if I understand you correctly, used to be with Rekindling the Spirit? MS LLOYD: Yes. 45


THE COMMISSIONER: And then what – it was removed from them or for some reason it was transferred - - - MS LLOYD: Yep. 5 THE COMMISSIONER: - - - to Life on Track? MS LLOYD: Yes. THE COMMISSIONER: For a couple of years or so? 10 MS LLOYD: Yep. THE COMMISSIONER: And then it has come to EOMS - - - 15 MS LLOYD: Yes. THE COMMISSIONER: - - - which is a less well-resourced iteration by Mission Australia, when compared to Life on Track? 20 MS LLOYD: That’s correct, and EOMS only targets people who are at medium risk of reoffending, whereas Life on Track really stepped in early and assisted people who were at that – that early stage, to – to try to avoid them becoming entrenched into the system. 25 MR BEAUFILS: And you mentioned the benefit of having this committee together and a harmonious way, and coming up with this report, if there are other local councils out there listening in, would you recommend that they take this step, as well? 30 MS LLOYD: Absolutely. I think it’s really important for – especially councils in regional areas to gather this information that only their locals can – can know about and to provide that to politicians in Sydney and Canberra. MR BEAUFILS: And how important do you see that community-led initiative, in 35 terms of trying to tell government what the community needs being – is that an important thing for you? MS LLOYD: I think it’s vital. I think that often we see decisions being made in different places that don’t benefit our community and don’t address the unique issues 40 that our community is particularly facing. Community-led initiatives are very important, which is why our committee endorses exploring justice re-investment initiatives. MR BEAUFILS: So you would like something that – like what’s happening in 45 Bourke with Maranguka, to come to Lismore?


MS LLOYD: Yes, we would. MR BEAUFILS: And page 13, and you’ve heard some evidence from Superintendent Lindsay about drug court. You also support a drug court coming to Lismore, if there was one available? Why do you see that as a valuable step for your 5 community? MS LLOYD: Well, we know that they work in reducing recidivism and rehabilitating people. There have been a couple of evaluation studies done on the Parramatta Drug Court, so we know that they work and they also save a lot of money 10 and that benefits the community in a wider – in a wider way. The drug court sits in the District Court jurisdiction. Merit program sits in the Local Court jurisdiction. There is – there is a great need for people who are facing serious charges to be diverted into rehabilitation, especially with the increase in methamphetamine use and we’re seeing more violent and serious crimes being committed, that are dealt with in 15 the District Court. Those people should be availed the same opportunity as other people are, if they’re lucky enough to live in – in Sydney and win the lottery to be eligible for the drug court there. THE COMMISSIONER: Can I just ask you, Ms Lloyd, your service obviously 20 represents clients in the District Court. Do you have any sense of what percentage of the cases that you represent defendants for in the District Court involve methamphetamine? MS LLOYD: Working at the Aboriginal Legal Services, it’s very sad to say that 25 probably 90 to 99 per cent of people are committing crimes related to their substance use disorder, and most of that would be crystal methamphetamine. THE COMMISSIONER: That’s in the District Court - - - 30 MS LLOYD: Yep. THE COMMISSIONER: - - - matters in the District Court. MS LLOYD: Yep, very, very, very rarely you will come across a client that has not 35 been using whilst they committed the crime. THE COMMISSIONER: Thank you. MR BEAUFILS: If I can take you to page 25 of the report, there’s a quote from 40 yourself which I would just like to explore. And you say that, for example:

Casino Court operates on Wednesday and despite the Aboriginal population of Casino being about seven per cent, our clients make up 70 per cent of the court list on most Wednesdays. And that’s just the Casino court experience. 45


MS LLOYD: Yes. That’s my experience of running a list on a Wednesday. Quite often at Casino court that – we call it Koori Court day out there, because it is mainly Aboriginal people that are before the courts. MR BEAUFILS: And when you say Koori Court day, you don’t mean a Koori 5 Court, it’s more of a court filled with Kooris? MS LLOYD: Yeah, that’s right. We would like a Koori Court there. MR BEAUFILS: And tell me about that. What would a Koori Court look like? 10 MS LLOYD: Koori Court is a – a more culturally appropriate therapeutic way of delivering justice. It doesn’t need to be a whole new building. A Koori Court operates, and there’s one in Parramatta, a youth Koori Court, and I know Attorney General Mark Speakman provided some funding for Surry Hills to also have a youth 15 Koori Court, so again, we’re feeling like there’s a bit of postcode injustice here. In those Koori Courts, as I understand it, there’s an elder that sits within the court and other members from the Aboriginal community. It’s a – it’s a different approach to – to the normal justice because, of course, there are issues with our clients in the normal criminal justice system and the formality and the long-standing issues that 20 they have experienced as a result of being Aboriginal. So they’re just more – more – more a culturally-appropriate venues and forums. MR BEAUFILS: And do you get the sense that the local Aboriginal community would embrace the opportunity to have something like that? 25 MS LLOYD: Absolutely. And there are certainly a great need and we’ve got some very disturbing statistics in our region, which I’m sure you will ask me about at some point. 30 MR BEAUFILS: Your report, or the committee’s report, covers a number of different things that I haven’t taken you through today. Was there anything else in the report that you wish to put before this inquiry? MS LLOYD: I just wanted to highlight the disgraceful statistics of Aboriginal 35 incarceration in our region, if I could. These statistics have been provided by BOCSAR on request of JustReinvest, New South Wales. MR BEAUFILS: Is this page 29 of your report? 40 MS LLOYD: Page 20 – 28 and 29. What I’m aware of is that Aboriginal incarceration averages across New South Wales is about 24 to 28 per cent of the overall prison population. Yet we have, in Casino, 48 people incarcerated as of today, 32 of those are Aboriginal and 16 are non-Aboriginal. So not a quarter. Double. Also, in the Lismore LGA there are 79 adults incarcerated presently, 44 45 non-indigenous, 35 indigenous. So that’s three-quarters. In the Ballina Local Government Area, 18 non-indigenous, 17 indigenous. In the Kyogle LGA, which


covers quite a few areas and Tabulam and Muli Muli, 13 non-indigenous and 20 indigenous. So the – the statistics in our region are really upsetting and disgraceful. And we hope that this inquiry leads to urgent action to address those disproportionate numbers, especially given the Royal Commission into Aboriginal Deaths in Custody was about 30 years ago and we are still seeing frightening statistics like that, and 5 worse in our region. MR BEAUFILS: And despite these alarming statistics is it your experience in working with Aboriginal people that there is a great deal of hope that their children won’t have to go through the same sort of things that they are going through now? 10 MS LLOYD: There is hope but it’s very guarded and I think from speaking with members of the committee there were quite a few members from the Aboriginal community of the committee and my work at the ALS hope is dwindling. People have been members and given evidence at these committees for years and years and 15 years and yet nothing has happened. So we are hoping that this inquiry is going to lead to politicians putting their guns down and working together to address these very significant social issues that impact all of our community and cost us socially and economically. 20 MR BEAUFILS: Commissioner, I don’t have any further questions of this witness. THE COMMISSIONER: Thank you, Mr Beaufils. Can I just ask you, Ms Lloyd, I just want to clarify at page 32 of the – council’s report you refer to the recommendations of the Upper House inquiry on provision of drug rehabilitation 25 services in regional, rural and remote New South Wales and you indicate that your committee supports some but doesn’t support others of those recommendations. Could I just clarify on page 34 there’s a committee comment at the bottom of the page where it says the committee does not support the following recommendation 30 from the inquiry and, that is, investigate the efficacy of subsidising beds in regionally based private for-profit residential rehabilitation facilities. And I’m just wanting to clarify if the next recommendation that you refer to after that is on page 35, which is recommendation 3, and I’m just unclear as to whether the subsequent ones you refer to are supported or not supported by your committee. 35 MS LLOYD: Yes, they are. The subsequent ones are. THE COMMISSIONER: Right. 40 MS LLOYD: And the committee does not support, I think, recommendation number – I think it’s recommendation number 2. THE COMMISSIONER: Yes. 45 MS LLOYD: I don’t seem to have it in there.


THE COMMISSIONER: Yes, it’s the one about private - - - MS LLOYD: Yes, that’s correct. At its core we feel that this is a public issue, a public health issue and there should be public treatment services available. And the – I don’t have the relevant expertise to comment specifically on all of the reasons but 5 I note that Leone Crayden, the CEO of The Buttery, has provided a comment as to why that sector don’t support that recommendation; that obviously private rehabilitation is a good option for people who have a lot of money who can afford that. 10 And also they’re concerned about the lack of regulation over the operators who do not use private health funds and the lack of accreditation, processes and quality controls and, of course, subsidy for private clinics poses risks of unscrupulous operators entering the market and taking advantage of vulnerable people. 15 THE COMMISSIONER: Right. So in relation to a number of the other recommendations which you, I understand, support, you do nevertheless make comment perhaps adding some additional views about the recommendations. So, for example, if I can turn to recommendation 6 which is at the bottom of page 35, where the New South Wales – the recommendation was that the government – the state 20 government commit to providing funding grants to non-government drug and alcohol-related service providers that run for a minimum of three years with the option for a two-year extension. And in relation to that whilst you support that recommendation your committee feels that funding should be for 10 years. 25 MS LLOYD: Essentially beyond the electoral cycle. THE COMMISSIONER: Yes. MS LLOYD: So it goes back to asking our politicians to put the guns down and de-30 politicise this health issue and have a 10 year strategy in place and 10 years of secured funding for these treatment providers that need that to secure employment for their staff, that need that to ascertain whether the programs are working, to evaluate their programs – all of those reasons that they’re asking for a 10 year security and funding. But that can only happen, I think, if politicians agree to take 35 this out of the political sphere and put it back in the health sphere and commit to that. THE COMMISSIONER: So, for example, you discussed earlier the transition from Life on Track into this EOMS which seems to have been based in some change in funding - - - 40 MS LLOYD: Yes. THE COMMISSIONER: - - - even though Life on Track had only been in place for a relatively short period of time. So is that an example of - - - 45 MS LLOYD: That – that – yes, that is - - -


THE COMMISSIONER: - - - the problem that you’re - - - MS LLOYD: That is an example. THE COMMISSIONER: Yes. 5 MS LLOYD: And from what I understand that’s exactly what happened with Life on Track. It got shrunk – like, the funding got shrunk and the workers got halved. It was very disappointing because it was actually working and there is no getting away from the fact that people who are presenting with these chronic and problematic 10 substance use disorders need intensive case management across a whole range of their life and not just their criminal issues and that’s what Life on Track really addressed. THE COMMISSIONER: Right. And did that shrinking of funds result in loss of 15 personnel? MS LLOYD: Yes, it did. Yes, it did. THE COMMISSIONER: And I – is it the case that relationships formed between 20 personnel in terms of being able to facilitate the purpose of the work of the agency. MS LLOYD: Yes. THE COMMISSIONER: And when you lose people like that, those relationships 25 just dissipate. MS LLOYD: Yes. That’s true. And another point is that with the Life on Track service anyone could refer someone to Life on Track – the magistrate, lawyers, the person themself could self-refer. With the Extra Offender Management Service the 30 computer decides who is eligible for that service and no one else can refer. THE COMMISSIONER: How does that computer work? I don’t - - - MS LLOYD: You would have to ask the workers at EOMS. 35 THE COMMISSIONER: Is it just data is fed into the computer? MS LLOYD: It is. It is data that is – as I understand it from speaking with the worker there that it is they receive a printout of the people that they are allowed to 40 target at court so they will come to court on Monday on list day with a list of the people they are allowed to target and they will approach myself and Legal Aid lawyers and say, “We’ve got this person on our list. Can we have a chat to them?” As opposed to us approaching them or the person themselves approaching them - - - 45 THE COMMISSIONER: I see.


MS LLOYD: - - - and asking for help which many people do when they hit the criminal justice system. Can I just make one point just from some evidence Inspector Lindsay gave and I just wanted to note that there’s – what isn’t included in my report is anything about Circle Sentencing and that is because Circle Sentencing is not operating at the moment so it hasn’t been for a few months now. 5 MR BEAUFILS: Do you know when it might come back? MS LLOYD: There is no – no, we don’t know. 10 MR BEAUFILS: Why is that? MS LLOYD: We understand the woman that was facilitating it has gone on maternity leave and there is no one to replace her. 15 MR BEAUFILS: And is that another limitation to the options of your clients? MS LLOYD: It is, absolutely. I mean, Circle Sentencing is a very resource heavy diversionary scheme which takes the magistrate out of the Local Court for a whole morning as opposed to, we would say, Koori Court would be a more efficient way of 20 delivering justice to aboriginal people. But certainly when we had Circle Sentencing it was wonderful to refer people to that culturally appropriate system. THE COMMISSIONER: So Circle Sentencing has been available here but hasn’t been for a few months – the last few months – and that’s because an individual, 25 obviously for good reason, went on maternity leave. MS LLOYD: Yes. THE COMMISSIONER: And there’s no one to replace them. 30 MS LLOYD: That’s correct. THE COMMISSIONER: So the whole system came to a grinding halt. 35 MS LLOYD: That’s correct. THE COMMISSIONER: Were there cases that were – that you were aware of that were anticipating being dealt with? 40 MS LLOYD: Yes, there were. There were people that we had referred to Circle Sentencing that we had to pull out of that. They’re just not available for them. THE COMMISSIONER: And what alternative was there for them? 45 MS LLOYD: There’s no alternative.


THE COMMISSIONER: Just back to court. MS LLOYD: Back to court. THE COMMISSIONER: And these are Aboriginal persons who would have 5 benefited from the cultural - - - MS LLOYD: Yes. THE COMMISSIONER: - - - culturally appropriate way of doing things - - - 10 MS LLOYD: Yes. THE COMMISSIONER: - - - that is inherent in Circle Sentencing. 15 MS LLOYD: Yes. MR BEAUFILS: Commissioner, I note the time. THE COMMISSIONER: Yes. I have just one more question of the witness. 20 MR BEAUFILS: Yes. THE COMMISSIONER: And I might just then have the morning adjournment. Now, you refer in your report also to a number of cost benefit analyses that have 25 been done. Those have been by reputable accounting firms, as I understand it. Is that right? MS LLOYD: So KPMG have done an impact assessment on the Justice Reinvestment Project and there have been evaluation studies done for the Drug Court 30 and a MERIT program and I think the Koori Court has had its first evaluation as well. So we know that these options work. One of the recommendations from the state inquiry is that the government do a business case for regional areas like Lismore and our committee is really disappointed actually in the government’s response to that inquiry because we just seem to receive that they just in-principle 35 support everything. And now we’re a year down the track and the crisis – and I will call it that and I’m not using that to inflame the situation because it actually is a crisis – is getting worse and worse. We need urgent attention. There are business cases and evaluation 40 studies that are out there that we know – we know that these work. We have – our committee is providing the details and the statistics of our region and we really are asking for help now to deliver these services urgently to our community. THE COMMISSIONER: Have any of those recommendations that were made in 45 light of the Upper House Committee’s report actually yet led to any changes on the ground here?


MS LLOYD: No. THE COMMISSIONER: Right. So they’re still - - - MS LLOYD: Nothing. 5 THE COMMISSIONER: - - - being evaluated and are in the pipeline. MS LLOYD: Considered. 10 THE COMMISSIONER: Yes, considered. All right. Look, thank you very much, Ms Lloyd. That has been very helpful. Do any other counsel wish to ask any questions of Ms Lloyd? MR KETTLE: No. No, Commissioner, thank you. 15 THE COMMISSIONER: All right. Might she be excused, Mr Beaufils? MR BEAUFILS: Yes. 20 THE COMMISSIONER: All right. Thank you very much, Ms Lloyd. That is really helpful evidence to this inquiry and can I commend your Lismore City Council’s Social Justice and Crime Prevention Committee for its hard work and its earnest endeavour to improve things in this area. Thank you very much for your evidence. 25 MS LLOYD: Thank you very much for having me today. Thanks. THE COMMISSIONER: You’re excused. Thank you. 30 MS LLOYD: Thank you. <THE WITNESS WITHDREW [11.44 am] 35 MR BEAUFILS: Commissioner, perhaps if we could resume the hearing at 12 o’clock. THE COMMISSIONER: Yes. All right. Well, I will adjourn till 12 o’clock. 40 Thank you. ADJOURNED [11.44 am] 45 RESUMED [12.01 pm]

.SPECIAL COMMISSION INTO ICE 14.5.19R1P-629 R.J. DAVIES XN MR KELLY

THE COMMISSIONER: Thank you. Please sit down. MR KELLY: Commission, I call Dr Rob Davies. THE COMMISSIONER: What tab is - - - 5 MR KELLY: Dr Davies’ statement appears at tab 13. THE COMMISSIONER: Thank you. 10 <ROBERT JOHN DAVIES, SWORN [12.01 pm] <EXAMINATION BY MR KELLY 15 THE COMMISSIONER: Thank you, Doctor. Please sit down. MR KELLY: Doctor, could you please state your full name, occupation and current 20 professional address? DR DAVIES: I am Doctor Robert John Davies. I am the director for emergency medicine across the Tweed, Byron and Murwillumbah communities. I – my address where I practice mostly is at the Tweed Heads Hospital in Tweed. 25 MR KELLY: And could you – is it the case that you’ve worked at the tweed Hospital for 17 years? DR DAVIES: Correct. 30 MR KELLY: And you were working there as an ED consultant for 15 years prior to being appointed director in 2011; is that correct? DR DAVIES: Yes. Correct. Yes. 35 MR KELLY: And you’ve attached a – did you – have you made a statement in this matter dated 8 May 2019? DR DAVIES: I have, yes. 40 MR KELLY: And do you have a copy of that statement with you today? DR DAVIES: I do here, yes. 45 MR KELLY: Do you wish to make any changes to that statement?


DR DAVIES: No. MR KELLY: Have you been provided a copy with the Expert Witness Code of Conduct? 5 DR DAVIES: I have, yes. MR KELLY: And have you read that? DR DAVIES: I have. 10 MR KELLY: And do you agree to be bound by it in the evidence that you give? DR DAVIES: I do. 15 MR KELLY: You’ve provided the enquiry with a copy of your CV, which is attached to the back of your statement. You’ve referred to Tweed Hospital as being the primary place of your treatment practice. Is the Tweed Hospital a regional referral hospital? 20 DR DAVIES: It is, yes. MR KELLY: And what does that mean for your ED there? DR DAVIES: So we predominantly service from the communities down towards 25 Byron and out west towards Murwillumbah. So the EDs at – there are two emergency departments; one at Byron and one at Murwillumbah. They both see between 18 and 20,000 patients a year, and so if any of those patients need services that can’t be provided in those smaller hospitals then they are referred into the Tweed Hospital. The majority will come via – directly via the emergency department. So 30 that means that those hospitals tend to select the patients that need a high acuity of care to send to the Tweed Hospital; we can provide that – that care. MR KELLY: And is it the only regional referral hospital in the LHD? 35 DR DAVIES: No. So Lismore is south of us, and so from Byron south then tends to – to be referred to Lismore Base Hospital. MR KELLY: And are there – the status of those hospitals – does the status of those hospitals as regional referral hospitals mean anything about the available mental 40 health facilities in each hospital? DR DAVIES: They’re bigger hospitals, so they therefore tend to have more resources. It also the – mental health services have – you know, they’re probably the two – they are the two largest ..... department of mental health services based at 45 Lismore and Tweed Hospital. There are – you know, other services. So Byron has a community-based service based out of the Bryon Central Hospital. There are the


community services at a lot of the other smaller hospitals around as well, but by far the largest components of the mental health departments are based as Lismore and Tweed. MR KELLY: I see. And in terms of your current position as Network Medical 5 Director of Emergency Medicine, does that extend to – do you have any responsibility for the Emergency Department at Lismore? DR DAVIES: No. No, so I cover Tweed, Murwillumbah and Byron Central Hospital. 10 MR KELLY: And are you still – do you practice in the hospital as well as - - - DR DAVIES: Yes. So most of my clinical shifts – if I do any clinical shifts they’re predominantly at the Tweed. I have done clinical shifts at the other hospitals in my 15 director’s role and network director’s role. I do a lot of administrative work, quality assurance, that sort of stuff. So - - - MR KELLY: But primarily your clinical work is at the Tweed. 20 DR DAVIES: Yes. MR KELLY: Just in terms of your experience – I want to ask you some questions based on your clinical work around your experience with patients using drugs generally and amphetamine-type stimulants more specifically. And you’ve said in 25 paragraph 4 of your statement that in your experience you’ve encountered patients who’ve used speed, LSD, ecstasy, crystal methamphetamine and methamphetamine, and that it’s rare to see issues in relation to cocaine. And then you say:

Crystal methamphetamine and methamphetamine users are the ones who 30 typically present with acute behavioural disturbances.

What do you mean by behavioural disturbances in that context? DR DAVIES: So I suppose the – we see a lot patients in Emergency Departments 35 that have – you know, intoxication or varying degrees of consequences of drug use, be it – you know, from alcohol to, you know, marijuana to, you know, LSD, ecstasy. Those sorts of – alcohol aside, which is probably the biggest drug issue of the community that always seems to get missed, the next biggest users that we see tend to be those that have amphetamine use, and we are seeing those because of their 40 behavioural disturbance. The – yes. That’s – that’s particularly what I was talking about. So – and acute behavioural disturbance, you know, is a – it’s a spectrum, you know, and it may be from someone who is just mostly agitated and sort of restless, and where they may well be feeling a bit distressed by that all the way up to somebody who is completely psychotic and actually – you know, has – are very 45 disordered in their thought and their process and so.


MR KELLY: So you’ve mentioned a spectrum there. In your statement you use a couple of terms that relate to behavioural disturbances. I just want to understand what you mean by each of those terms. So you’ve used there acute behavioural disturbances in paragraph 4, which you’ve just described. 5 DR DAVIES: Yes. MR KELLY: In paragraph 6, in the second-last line you refer to, “really acutely severely behaviourally disturbed” patients. 10 DR DAVIES: Yes. MR KELLY: And then in paragraph 10 you refer to severe behavioural disturbance including aggression and violence. So can we start with “really acutely severely behaviourally disturbed”. In terms of the spectrum of acute behavioural disturbances 15 that you’ve described, whereabouts does that fit on the spectrum? DR DAVIES: That’s the top end. That’s the – the resource hungry – the patients that really are problematic for – for all services, you know, to look after from, you know, the police – these are usually the ones that, you know, the police are called to 20 or the ambulance are called to in the community because they’re so disordered, violent and aggressive. They often don’t even know where to direct their anger and violence, so it’s usually anything in front of them, and so – you know, these patients are a significant risk to themselves and to others. And so they’re frequently brought to us, and so they’re the top end of the spectrum – you know, the resource hungry. 25 And then it just, I suppose, scales back from there in terms of the amount of violence, aggression and disorder – disorder that the patients have. MR KELLY: And in paragraph 10, where you refer to severe behavioural disturbances including aggression and violence, where does that fit on that spectrum. 30 DR DAVIES: Well, we sometimes will get patients that are quite, you know, significantly agitated but they’re not – you know, they’re not showing overt aggression or violence at the time, but they’re very – can be quite easily triggered into that. So they’re sort of just a scale down from those that are already, you know, 35 very – very violent and very aggressive. So - - - MR KELLY: And in paragraph 13 you refer to a New South Wales health guideline for care of acute severely behaviourally disturbed patients. Does that guideline apply to everyone on that spectrum that you’ve just described? 40 DR DAVIES: It applies to those, again, usually at the top end of that spectrum, the ones that are so disordered that we basically have to make sure that we take care of them, and the guideline really is around ways of trying to deescalate, but often use and having to use chemical restraint in some ways, and medication to try and help 45 reduce the patient’s level of agitation and violence and aggression because of the risk to themselves and to others.


MR KELLY: I see. And in paragraph 31 you mention that guideline again, briefly, and you’ve just used the word de-escalation. And you say in that paragraph:

We do now have guidelines for escalation. 5

What does that mean? DR DAVIES: What I was talking about there is – so we have a guideline for the care of actually – you know, the patient whilst in the Emergency Department. What I was talking about in terms of escalation outside of the Emergency Department, we 10 don’t really have guidelines or anywhere to go because there really isn’t anywhere to go. So it’s not phone a friend or – you know. MR KELLY: Right. 15 DR DAVIES: Call Captain Marvel to come and help. There is no one else. So there’s no real escalation we have. Not specifically for – you know, for ATS users or drug-affected patients – severely drug-affected patients. We just manage that within that guideline for the acute severe behavioural disturbance and ..... guidelines, you know, that were applied to the ED. 20 MR KELLY: Okay. Thank you. I want to ask you some questions, first of all, generally around the types of people that you’re seeing presenting with presentations related to ATS use, and then also some questions around the harms that you’re seeing in those patients. But if we could start at paragraph 7 of your statement. Would you 25 just tell the Commissioner who it is that you’re seeing in your ED presenting with ATS-related issues. DR DAVIES: I suppose it’s – it’s – it’s interesting. I – I – I put in my statement that, you know, I’ve – I’ve been dealing with – been working in emergency 30 departments in Australia for 25 years now, and – and there has been a significant change in the types of patients presenting. Initially when I worked at the Gold Coast, it would be the typical sort of 20 to 30-year-old male that usually would in come if they had been using – IV speed in those days was commonly the thing we saw. And – and they would typically present, you know, with – often with violence and 35 aggression. But it still wasn’t of the level that we see now. And – and certainly, you know, we didn’t see young kids using. We didn’t see teenagers using. We didn’t see people in their forties and fifties. We never saw – very, very, very rare to ever see a female user of such medications. And - - - 40 MR KELLY: And when was this? DR DAVIES: And – this is back 20, 25 years ago. And certainly - - - MR KELLY: Right. 45


DR DAVIES: - - - the experience from the Gold Coast, just geographically – you’re probably familiar, Commissioner, that – you know, the – the Tweed is the southern end of the Gold Coast. And so we’re really sort of just talking the – the north and south end of a population. And – and certainly the – the hard-core drugs were the northern end of the coast. And – and in those days it was either speed or – or heroin 5 that – that people injected or – or used, in terms of hard-core drug use. And it was very – we used to see female heroin users. But we very, very, very rarely ever saw any – you know, speed or amphetamine users amongst the females. Now that seems to have completely changed, in that we’re seeing teenagers; we’re 10 seeing – you know, people even in their sixties that are using ice; we’re seeing, as I said, females as well – you know, not quite the same volume, and certainly not – we don’t see the violence and aggression as much with the females. Again, the preponderance is still male in that category. But we still see a lot of agitated, disordered, angry sort of females, as well, present that are – are – have become 15 addicted to ice. And it’s a – it’s a – yes. It has been a – a – a – a lot different change in terms of pattern of – of usage that we’ve seen presenting to the ED over that time. It seems to have been – become more ubiquitous, you know, across the community. MR KELLY: Are you able to say, based on your experience, whether you’ve 20 observed any particular demographic features that are more common than not in - - - DR DAVIES: We certainly see the – the more – in the – the more impoverished side of community. We often see, you know, patients that have criminal past as well. But it can be – you know, we’ve – we’ve looked after patients that may hold regular 25 jobs in mines and things like that. And they fly in, fly out. And their – their week off, they’re injecting. And – and, you know, they actually hold good jobs and – and function at other times, you know, successfully in the community. So it has – it has been a – a – you know, a fairly broad mix. But certainly there’s predominance in the lower socioeconomic groups. 30 MR KELLY: Now, in terms of the types of presentations that you’re seeing – you have given some evidence already about the behavioural disturbances that you see. In paragraph 9, you articulated some other presentations that you see. Would you tell the Commissioner about those? 35 DR DAVIES: In – so in terms of the – what - - - MR KELLY: Well, if we could - - - 40 DR DAVIES: What we have started seeing, you know, in terms of chronic use now or more prolonged use in – and especially in – in older people. As I said, we – we’re now seeing, you know, 40, 50-year-old men come in with damaged hearts. So there’s a – a – what we call a cardiomyopathy, where the heart can dilate and just then can’t effectively pump, which is a – a complication often from long-term 45 amphetamine usage, or there’s – also we’ve had patients with frontal lobe damage,


again from long-term amphetamine use, or that’s what it was – the diagnosis that was made. So there’s – there’s – there’s some quite significant sort of medical complications now that we’re seeing down the track, after patients have – have used and – or 5 misused these – or these drugs for – for many, many years that – that we hadn’t really seen before, not from the amphetamine group. You know, as I said before, the – the – the – the – in the past, you know, it would be, you know, the males that would use speed for several – for a few years and then would stop use and – and – you know. But with ice we seem to be seeing more of these chronic – and now more 10 sort of medical conditions as a result of – of the usage. MR KELLY: So these chronic conditions are related specifically to crystal methylamphetamine use? Is that your experience? 15 DR DAVIES: Hard to say. In – in – some of the patients have a – a mixed use. They’ve often used lots of substances throughout a period of time; they just – you know, for the last few years have been using ice. So - - - MR KELLY: And then you also say that some presentations are from intoxication, 20 some from mental effects. DR DAVIES: So we see the – the mix of – of, you know, patient presenting with – you know, they may have agitation, anxiety, suicide ideation – that sort of thing, you know, because of their – their chronic use or their – their – their addiction to ice. 25 And we will also see patients, you know, that are – obviously are – are not functioning or intoxicated from the medication. They may be ramped up. And they’re obviously then starting to get into the spectrum of behaviourally disturbed. And so as I said, there’s a – there’s a whole sort of spectrum and gamut of things that patients may present with. 30 MR KELLY: So in paragraph 10, you say:

Most commonly we see presentations relating to intoxication, worsening mental health symptoms and severe behavioural disturbance. 35

DR DAVIES: Yes. MR KELLY: Are you saying there that those – that worsening mental health symptoms and severe behavioural disturbance are symptoms related to intoxication? 40 Or are they separate things that you’re - - - DR DAVIES: They’re – they’re separate things. So you – we - - - MR KELLY: And so what - - - 45


DR DAVIES: Again, they’re part of the spectrum. So – but that’s the – we – we tend to see patients with the anxiety, the paranoia and the severe behavioural disturbance which psychosis, you know, can go with more commonly than we see other presentations of – of ice, such as the – the heart failure, the – the – those sorts of conditions. So - - - 5 MR KELLY: And when you say that you most commonly see presentations relating to intoxication, what are those presentations? DR DAVIES: That’s again sort of talking about the spectrum – you know, 10 anywhere, from, you know, someone that’s – that’s fairly agitated and – and anxious, paranoid, up to, you know, acute severely – severely behaviourally disturbed. THE COMMISSIONER: Can I just ask you, Doctor, how often do you see a person who has developed not just a transient psychosis but an ongoing psychotic condition 15 as a result of use of this drug? DR DAVIES: So that’s – that’s probably a – a – a question for my psychiatric colleagues - - - 20 THE COMMISSIONER: Right. DR DAVIES: - - - because we – we do look after the – the patients for a fairly short period of time. And so in the emergency department, a lot of patients who – who may come in quite behaviourally disturbed and – and even paranoid or even 25 psychotic – you know, they often will settle rapidly if - - - THE COMMISSIONER: Yes. DR DAVIES: - - - they’ve just been – sort of increased their dose or they’ve had 30 extra or access to the – the – the methamphetamines over the last – you know, few days, weeks, that sort of thing. So lot of those patients, when we treat them with our – the – the medications that we use, often clear quite rapidly, over 12, 24 hours. And so their psychosis isn’t ongoing. There are some – and those are commonly the ones that we have to admit – whose psychosis is ongoing. But how long after that is 35 difficult for me to know. THE COMMISSIONER: Right. DR DAVIES: We’ve – they’ve usually been admitted to the mental health units 40 then. THE COMMISSIONER: Right. DR DAVIES: So it’s probably a – a – a question that’s better answered by - - - 45 THE COMMISSIONER: All right.


DR DAVIES: - - - my psychiatric colleagues. THE COMMISSIONER: Good. Thank you. MR KELLY: In terms of the patients who are presenting as acutely severely 5 behaviourally disturbed which I understand to be those at the worst end of this spectrum that you’ve discussed, what proportion are they of the presentations that you’re seeing related to methamphetamines overall? DR DAVIES: I don’t have an exact, you know, figure or percentage to – you know, 10 to give you. It would be – by number, it would be a small proportion, whether that’s 10, 20 per cent of the overall presenting – as I said, it’s unfortunately a medication that seems to become more ubiquitous and we often find patients that you wouldn’t expect. You know, 50-year-old that’s coming with a chest infection, pneumonia is actually an ice user, you know. So there’s – and that may now be why he’s 15 presenting, but may have been a part of his presentation. He’s obviously not functioning well, not looking after himself, malnourished, and that’s why he’s got his pneumonia and it comes out through questioning. So, yeah, the proportion – I can’t give an exact figure, but I would suspect probably around the 20 per cent, sort of, for the - - - 20 MR KELLY: And - - - DR DAVIES: - - - real severe and – yeah. 25 MR KELLY: And in terms of presentations, generally, what sort of numbers are you seeing that relate to ATS? DR DAVIES: Again, I think I mentioned in my statement, it’s actually really difficult to know because of the way that the electronic medical records system 30 operates, that it’s hard to extract – well, it is hard for us to extract the data out of it. So the way a patient may present ..... present anxious and agitated, depressed, suicidal. That may be put in as your presenting problem. The fact that it then subsequently comes up that you’ve been using, you know, crystal meth for the last, you know, six months, year or whatever in – and you’ve developed these problems, 35 it’s not, then, very easily extractable from the record – from the medical record. So it’s actually very – it’s quite hard to get accurate data. MR KELLY: I understand, and that’s not confined to the health space in the inquiry’s experience so far. But based on your experience, clinically, are you seeing 40 a presentation daily, more than once daily, once a week? DR DAVIES: We’d see several patients every day. MR KELLY: Yes. 45


DR DAVIES: We’d see about 150 a day. We probably see, you know, probably five – five to 10 patients that actually have – you know, are using and have some component of their health presentation has to do with their chronic drug use. May not all be crystal meth. Certainly, again, coming back to alcohol – for liquor and alcohol would be a far higher percentage of those presentations that were – had some 5 sort of alcohol component. MR KELLY: In terms of the times at which you’re seeing presentations, are you able to say whether there’s any correlation between particular events in the LHD and the number of presentations you’re seeing related to ATS? 10 DR DAVIES: I – there’s a couple events – I mean, we’d be certainly – I mean, the festivals that are held around Byron and stuff are well known. Then we sometimes see some more presentation. Often, more from – they’re not necessarily the ones where we see lots of – a big spike in crystal meth or acute severe behaviourally 15 disturbed patients. We often see some that have taken too many ecstasy or worse and they’ve taken some tablets, whatever is in them, whether they thought they were ecstasy or fantasy or something else that has resulted in them having some – a bad trip or a bad day. So we certainly get an increase in those numbers around some of the festivals. 20 What we see with the crystal meth is usually more to do with what we think is access in the community that there’s been, you know, increased access to the community and will often see batches of patients, then, over a week or two weeks where we’re getting a lot of the acute severe behaviourally disturbed patients present, and we 25 think that that’s, you know, presumably a new shipment arrived and being distributed, and so access has gone up and so we then see a spike in the crystal meth. But, you know, it’s not something that we see that we would link, you know, we’ve got a festival in Byron. We’re going to see a lot of, you know, severely affected ice patients, you know. We know we may well see some more of the others in volume, 30 but it’s not that is – this is going to be a bad week for the methamphetamine users presenting. It can be anytime and they, as I said, do tend to come in batches which we tend to relate to, you know, the – just the access. THE COMMISSIONER: If I could just time the festival issue with MDMA, I mean, 35 I gather, from what you’re saying that when those festivals are on, I suppose – I think there’s one called Splendour in the Grass, I think, at Byron which the – you’re not planning for there to be a particular spike in methamphetamine use for those festivals; is that right? 40 DR DAVIES: Yes, essentially, I sort of said before, it’s – the ecstasy sort of side of it, we don’t tend to see with the partygoers using the ecstasy that the – acutely severely behaviourally disturbed range of behaviours. It’s – we tend to see that more with the crystal meth, with the ice. So even though, you know, Splendour, in particular, yes, there’s lots of ecstasy around. Those are the bad trips. The patients 45 not feeling well after taking a pill type of presentations, that increase that I’m talking


about, as opposed to when we do see shipments or what we feel are shipments of meth that have hit the area - - - THE COMMISSIONER: Right. 5 DR DAVIES: - - - where we certainly see spikes in the numbers of patients suddenly presenting with the acute severely behaviourally disturbed - - - THE COMMISSIONER: Right. 10 DR DAVIES: - - - problems. THE COMMISSIONER: So can I just ask, while we’re talking about festivals, how big an impact does that particular festival, for example, have on your work for that week? 15 DR DAVIES: Look, the – if this was 10 years ago or more, I’d say it could have a significant – especially on the peripheral hospitals at Byron and Murwillumbah – Byron and the old Mullumbimby which has now been shut – shut and combined into Byron Central, the festivals now are exceptionally well run. They have onsite 20 medical facilities that provide a full range of care from general practice all the way up to and actually have onsite resuscitation facility. So they have dramatically reduced the flow of patients from the site – you know, if you’re just having a bad trip, you’ll have a quiet room, you’ll be sat in the corner, you might be given some Valium, lots of fluid to drink, rehydrated and have several beds that they can fluid 25 rehydrate you if you’ve – you know, have got too much, throwing up, cold and shaking. And too much – you know, dehydrated from, you know, dancing and pill popping and stuff. So they have – that has been very, very successful in - - - THE COMMISSIONER: Right. 30 DR DAVIES: - - - managing the issue onsite and, obviously, that includes, you know, a lot of the issues with alcohol as well, and so the flow on from – they will refer it to – either to Byron or up to Tweed, the patients that they feel need higher levels of care. 35 THE COMMISSIONER: Right. DR DAVIES: So it’s a very comprehensive service. It’s managed. There’s, you know, general practitioners. There’s emergency physicians, intensive anaesthetists, 40 you know, that all do shifts in there. So it’s a very comprehensive service. So in terms of now, the last few years, it’s been – we don’t see massive spikes. We see a little bit. Byron’s is a little bit – certainly, a little bit more increase in activity from the festival ground itself. The issue for Byron is, is that the population on those weekends – because it falls – in particular, Splendour, sorry, is over New Year’s. I 45 think I got it right. I keep looking to Bronwyn because she’s one of the locals – Dr


Hudson there. Where the – just the volume of people, you know, in the vicinity of the hospital is dramatically increased from the - - - THE COMMISSIONER: Yes. 5 DR DAVIES: - - - tourism perspective, you know. THE COMMISSIONER: Yes. DR DAVIES: So those people obviously have conditions and some of them might 10 be related to partying too hard for too long and drinking too much alcohol. Some of it is completely nothing to do with that, you know. THE COMMISSIONER: Right. 15 DR DAVIES: It’s just people that are visiting the area that end up with a health condition, so we do get increases through those periods. Some of it festival related. Some of it just population related, and – you know, but the onsite, you know, management has been significantly improved in the last few years and the impact is not – it could – certainly, in the old days, could be overwhelming for the smaller 20 hospitals. Absolutely overwhelming, the volume of patients that they will get from the sites. It’s not the same. THE COMMISSIONER: Good. Thank you. 25 MR KELLY: You’ve been speaking there about some specific event-related presentations and patterns of presentation. You say that, in your statement, that you’ve observed an increase in crystal methamphetamine-related presentations over the past six years. That heroin overdose presentations have virtually disappeared in that time and that crystal methamphetamine presentations peaked in 2016 and seem 30 to have reduced a plateaued since that time. What was – when you refer there to crystal methamphetamine-related presentations, do you mean all crystal methamphetamine - - - DR DAVIES: I’m talking in – of the – the – you know, fairly – the acute severely 35 behaviourally-disturbed or, you know, those just – just lower down in the spectrum, so - - - MR KELLY: Yep. 40 DR DAVIES: - - - we were – we were just swamped, you know, at probably through that 2015/16 sort of period where we would – we were really, really struggling. We had – we would have just one sort of safe room, which is a – a room that was – was, you know, sort of purpose-built for behaviour-disturbed people and we – we just couldn’t – we – you know, we would have three or four patients 45 presenting like this in the space of a couple of hours and just, you know, we would be overwhelmed trying to manage, so that was not an unusual day back then and - - -


MR KELLY: So it was daily? The frequency was daily? DR DAVIES: In – in those days, it would be more unusual to have a day ice-free than – than to have a day, you know, with ice. So, no, you know, the – they weren’t all the acute, severely behaviour, but they were fairly – a lot of agitated, you know, 5 aggressive, distressed, anxious patients through that period and - - - THE COMMISSIONER: What period are you talking about? DR DAVIES: From about 2015/2016 probably into 2017. There was a period there 10 where it really sort of increased dramatically in volume of patients that we were seeing and struggling to manage in the emergency department, just because of the numbers and, again, in my statement, I’ve sort of highlighted the duration that we need to care for these patients that are – that are – that are disturbed or agitated, you know, they – they do - - - 15 THE COMMISSIONER: And you’re talking about amphetamine use? DR DAVIES: Amphetamine use, yeah. Yep. And so that – we certainly have come, you know, back quite a way from there and so we – we’re seeing, you know – 20 we have to – to administer sort of IM sedation, you know, with a full team to – to make a patient safe, you know, once a week, once a fortnight now, you know, as opposed to, you know, every day, two or three a day, at the peak, so - - - MR KELLY: So you do say in your statement, at paragraph 6, that it’s once a 25 fortnight and then, at paragraph 30, you seem to say that it’s once a week. So is it - - - DR DAVIES: Yeah, and that’s – it – it’s sort of between that. It’s – it’s hard to – to give exact figures because, as you’ve seen before, they sort of come in in little 30 batches, you know, or we will have a – a bad week where we see multiple, and then it sort of tails off and there might be a build up to that and, obviously, that’s why we think there is obviously batches in the community because we see – we see these little peaks and troughs, so – yeah. 35 MR KELLY: In terms of still on the impacts that you see in relation to ATS use, what sort of comorbidities are you seeing in presentations relation to ATS? DR DAVIES: Well, the – I suppose the – the first up are the – the – you know, the trauma sort of stuff, which is, you know, patients may have injured themselves, hurt 40 themselves, cut themselves, you know, so we will have people, you know, put fists through glass windows, punch walls, break knuckles, so there’s – there’s that first line sort of trauma stuff. That they will often – well, smash their heads against walls and – and so there – there is those sorts of level of injuries that need immediate care. 45 Then there’s the – the – as we said, you know, the – the secondary agitation, you know, and the psychosis, mental illness, and then there’s the more longer-term


issues, in terms of if they’re chronic IVD – injecting IV, that – so bacterial infections, local infections, you know, of skin, cellulitis injecting areas, bacterial infections that affect heart, lungs, brain with bacterial endocarditis, which is where the bacteria spread around the body, from the injecting site, and lodge on the heart and then continue to spread around the body, disruption of the heart valves, heart 5 failure, as we’ve said, as – as complications of that, so – so there’s a – a fairly wide spectrum, and then, you know, obviously, there’s the – there’s some mental health issues that can also result, you know, with anxiety and, you know, agitation, depression and in particular, psychosis - - - 10 MR KELLY: You say – you describe - - - DR DAVIES: - - - paranoia - - - MR KELLY: - - - those patients presenting with mental health issues, social issues, 15 and, acute, severe behavioural disturbances, being those that you see the comorbidities that you see most commonly - - - DR DAVIES: Yeah, we see – we see a lot of patients, you know, that unfortunately, you know, cease to function very well. You know, and I gave the example of the – 20 the miner, you know, the fly in/fly out, you know. Unfortunately, if they – they continue their use and they get more and more addicted to the medication, they end up losing their job. The mines, as you probably know, test for a lot of these sorts of drugs now and – and lose their – lose their job, can lose – end up losing their family, and – and, you know, can end up homeless or without much social support, you 25 know, so as they sort of slip down, you know, out of a productive member of society into, you know, a – a very poor, impoverished life. So - - - THE COMMISSIONER: How often do you see fly in/fly out presentations? 30 DR DAVIES: If I said four, five – or three, four, five years ago, you know, there was – there was quite a few patients that – and I used to – I started sort of asking if they told me they worked in the mines, actively asking them if they used such medications, whereas five years prior to that, I would never have thought of, you know, of asking them. So how often were we seeing it, was your - - - 35 THE COMMISSIONER: Yes. DR DAVIES: - - - question, Commissioner? It’s – it’s hard to say. It’s very hard to quantify because it relies upon you actually, you know questioning the patient 40 around, you know, what their – their job is and – and what their, you know, frequency of, you know, where they do it and – and, you know, where – their frequency of drug use and that sort of stuff, so it wasn’t frequent. It’s only a handful of patients - - - 45 THE COMMISSIONER: Yes.


DR DAVIES: - - - over many, many years but it was – it was something that I suppose was a little bit concerning as a doctor, in terms of – of (1) that they would get addicted to a – such a medication, (b) the complications and the – the results of that on their families and, you know, and their ability to function, so - - - 5 MR KELLY: You describe patients presenting with mental health issues as one of the comorbidities that you see most commonly. How often – or what – what – how often are patients being admitted to the mental health wards from your ED? DR DAVIES: Again, it’s difficult to quantify. The – and it’s probably better left to 10 – to some of my mental health colleagues that – to actually give the exact figure. There’s – there has always been a – a crossover or a mix of – of drug use with patients with mental illness and chronic mental illness, so it’s – it’s hard to quantify, at times, you know, what – what is the chicken and what is the egg and therefore, what is the cause of – of the mental illness and – or what is the cause of the – the 15 current mental – mental illness or – or mental health crisis. So certainly a lot of – of patients probably exacerbate a lot of their conditions by use of these sorts of medications. MR KELLY: You say - - - 20 DR DAVIES: But I can’t give you an exact figure as to how many are – it’s – it’s – as I said, the – the mixed or dual diagnosis is very, very common with mental illness. MR KELLY: Would you say patients are usually admitted if there is – to a mental 25 health unit if there is ongoing psychosis or mental – mental health issues following initial treatment? DR DAVIES: Yeah, and that was that chicken and egg and dual - - - 30 MR KELLY: Yes. DR DAVIES: - - - diagnosis I was talking to you about. So sometimes, you know – but quite often, the patients will settle quite quickly with the medications we use. Other times, they – they continue to be confused, agitated, psychotic, and then the 35 question is, is, you know, is it a psychosis or has a true mental illness actually been triggered by the – by the – the medication, as opposed to just intoxication. Does that make sense? MR KELLY: Yes, it does. And in paragraph 23, you say that ED and mental health 40 work together at the Tweed Hospital, but that your big issue is a lack of mental health inpatient beds and your inpatient unit runs at 97 per cent occupancy. So admissions often wait days in ED. Is that right? DR DAVIES: Yes, yes. 45 MR KELLY: And when you say often, as in, admissions often wait days in ED?


DR DAVIES: So – and it has been really good, the last few months actually but certainly in terms of the percentage of patients it is far more common for a mental health patient to have to wait in the emergency department for a bed in the hospital than it is if you, say, come in with a medical condition or surgical condition or an orthopaedic condition. Now, the figures if you look at – so health – the Ministry 5 record the number of admissions that wait more than 24 hours it’s one of the benchmarks in an Emergency Department before they get their bed. And if you look at those patients in – on the data what you will find is that the predominant number of those are medical and surgical patients and that sort of overshadows what is actually happening mental health wise. 10 So because not infrequently over winter we will have lots of patients that will wait for a prolonged period of time to get up into the medical and surgical wards, by number they’re a large number of patients. Though as a percentage or a proportion of those – of medical and surgical patients that have to wait in the ED for long 15 periods to get up to a ward, it’s a very small proportion. Whereas if you’re a mental – a patient with a mental illness or a mental disorder that needs to be admitted to a mental health unit it’s far more likely that you will actually have to wait a prolonged period of time. Does that make - - - 20 MR KELLY: And that extends to people whose mental health condition is either caused by or exacerbated by ATS use? DR DAVIES: Yes. Yes. 25 MR KELLY: And what impact does that have on your ED’s resources? DR DAVIES: Well, to explain it, an Emergency Department isn’t a ward. So if you’re a patient that gets admitted – if you’re a bed in a ward, a patient gets admitted there and you stay there two or three days. That’s what that does. I have about 15 30 beds that 150 patients a day go through so those beds have to be available for the next patient presenting, the next ambulance that needs offloading. So if our beds are occupied by patients that need to stay days you can see that if I’ve only got 15 beds very rapidly if two or three or four of them are occupied by patients waiting for prolonged periods of time – be it 8, 10, 12, 14, 16, 18, 24 hours – that reduces the 35 capacity of the Emergency Department to put patients through the rest of the department. So the – so it’s a flow or capacity issue for an Emergency Department as well as, you know, these patients are often quite resource intensive, as we’ve mentioned. They 40 often need specialling and they may need security around if they’re agitated and aggressive. And, you know, the Emergency Department environment is very stimulating. As I’ve said, you can imagine it’s a bit like an airport with this movement of traffic, you know, with 150 patients going through that area and so there is lots of noise, lots of light, lots of stimulation and so for such patients that 45 you’re actually trying to quieten, to de-escalate, to help them actually get over their –


through their intoxication and come out the other side it’s not the best environment for a patient that needs a more prolonged stay. THE COMMISSIONER: Can I just ask you – I just – I want to get a sense of the sort of where the demarcation is between ED and then mental health intervention. 5 DR DAVIES: I think that’s – you know, the – and I’ve just, as ..... outside, I’ve been touring all around the country because we’re building a new hospital at Tweed and visiting various places and everybody does it differently. Some units do it better than others. Victoria are now building behavioural assessment units, you might have 10 heard, and I’ve just been to see two of the operational ones in the Alfred and the Royal Melbourne and they have behavioural assessment unit models of care to try and address some of this problem. And it becomes a real issue because quite often, as you’ve said, from an ED 15 perspective as I’ve seen, you know, anything that’s staying more than a few hours in a bed is an issue in terms of occupying our space to see the next patients and offload the next ambulance. For patients often presenting with behavioural disturbance, psychosis, we know or we suspect a lot of that is triggered by the medication and the intoxication and when they have metabolised and got rid of that medication they will 20 actually get better. From a psychiatrist’s point of view – and again it’s best from a psychiatrist, colleagues to actually give you their side of the story – but from their point of view, talking to them, knowing those patients will clear, to admit them, you know, under 25 the Mental Health Act, to put them in a unit with other mentally ill patients is not always the best place from their perspective to put such patients. So the patient gets stuck in between as to where is best – and this is part of my statement is actually where is best to look after these patients and this is what those behavioural units or the PANDA unit in Sydney in St Vincent’s has tried to address in that mental health 30 units aren’t necessarily the best place to put these patients but they tend to be historically the patients that we look after – mentally disordered, psychotic, those sorts of patients. But these patients are often very violent and a cut above – you know, it’s very 35 unusual, you know, for – I can’t ever remember being threatened by a patient with schizophrenia that’s psychotic or a bipolar patient that’s psychotic or hypermanic – you know, the levels of violence are just different. So from the mental health unit’s perspective to have those sorts of violent patients in with, you know, other patients that may be quite disordered – vulnerable, unable to protect themselves – it’s very, 40 very difficult to put the two together. From an ED perspective, as I’ve said, you know, we have a very stimulating environment. We need high throughput through our beds to actually be able to provide the care for the community that we’re expected to provide. And so there is a mixture. So I’m not answering your question directly now because - - - 45 THE COMMISSIONER: No, you are. You’re getting there.


DR DAVIES: Because it’s not easy to – you know, it’s not theirs, it’s not ours, it’s not – you know, it’s actually a separate problem for – it’s – well, it is almost a separate problem distinct from, you know, as I said, the pure – patients with pure mental illness like schizophrenia, bipolar depression and anxiety depression that typically have been the ones that we admit to mental health units. 5 THE COMMISSIONER: So either ED or the mental health unit isn’t the best place for these people. DR DAVIES: Well, yes. Look, I would say as they are now. 10 THE COMMISSIONER: Yes. DR DAVIES: As they are now. So – and a lot of that is to do with the levels of violence and aggression and agitation that we see. And the volume of nursing and, 15 you know, mental health assistance or, you know, and security-wise, that sort of stuff that these patients need to keep them safe and keep staff safe in that phase, in that – especially that first 24, 48 hours. And so, as I said, that’s why Victoria tried to address some of this with their behavioural units. Just, you know, touring them, they haven’t fixed it. 20 And the behavioural units again are happy to look after those that might be a little bit drunk and a little bit agitated or, you know, someone that’s threatening suicide and cut – cut their wrists or something like that that’s quite a mild case but they don’t even want to admit to their own behavioural units those ones that are agitated and 25 violent and aggressive because again you’re trying to put them in with other patients that are more vulnerable and less violent. And so it’s actually a problem and it’s not just simply a problem as ownership. I think, you know, the areas that we have got built and the resources that we have for 30 this particular group of patients is problematic and that’s why often there’s – there can be a bit of a ..... , for want of a better ..... , but there may be reluctance on the service’s behalf to prolong care for these patients over a more prolonged period. And, on the whole, you know, we tend to try and get them to a point in the emergency department where they’re no longer as violent and as aggressive before – 35 if they have ongoing problems before they get admitted to mental health units, you know. The problems inside the mental health units, as I said, are probably best for my psychiatric colleagues to discuss but I think, you know, there certainly is – there’s an 40 environmental resource aspect, you know. Often it’s seen that it’s easier to leave them in the Emergency Department because we have more staff. We’re staffed, you know, more vigorously sort of 24 hours whereas a lot of other units sort of scale down quite a bit at night and we do also scale down in the ED; people seem to forget that as well. But, you know, the problem – I don’t think anybody has really, you 45 know, fixed the problem of where best naturally, you know – and – yeah, for patients, from my perspective, and emergency physician, you know, if a patient –


there’s no patient that should be, you know, after 46 hours. It’s usually quite evident in an emergency department where a patient needs to go, and it’s limited what more sort of stuff we do, other than the short stay model of care in the ED. So there are subsets of patients that we know will get better within 24 hours and we’ll – we can look after you for that period, and some of those patients will fit, but not the ones 5 with the severe levels of aggression. So - - - THE COMMISSIONER: So just – let’s say you get – somebody comes in and they’re quite severe in their levels of disruption and aggression who would say they qualified as mentally disordered persons under the mental health legislation; would 10 you hold those until the effect of the drug wore off in ED normally, or would you just sedate them to a point where they could then be handed over to mental health? DR DAVIES: So we – so we will tend to get – so a lot of the patients are actually brought in on a section by police and ambulance, and under the memorandum of 15 understanding often, you know, the police may be called because of the disruption and the aggression, the ambulance will come, sedate, bring them in the ambulance, and they may be, you know, still agitated or maybe partially sedated. We may add to that, or – at that point, because they’re under the mental health schedule, then they need to be seen by the mental health service. So – now, the mental health service 20 may at that point feel that within, you know, six, eight, 10, 12 hours this patient may have improved and cleared enough to be discharged with community follow-up. We don’t at that point it’s often difficult to know exactly what’s going to happen. The process usually within the emergency department is to get that drug and alcohol 25 mental health sort of input if we can, and then, you know, work out what the path of the patient is going to be. Now, certainly some of those patients state in emergency departments as I’ve said. Unfortunately, what makes the issue difficult at Tweed is that we’re – our mental health unit is very, very full. So even if the psychiatrists are happy to look after this patient, then they often stay in the ED for prolonged periods. 30 THE COMMISSIONER: Right. DR DAVIES: You know, we’ve had patients at 100 hours waiting for beds. You know. And that’s not unusual all around the state for our mental health statements, 35 unfortunately. You know, whether they’re ice or not ice, you know. So it makes it difficult is – it’s very hard to work out what the best path is – the best pathway for the patient. THE COMMISSIONER: Yes. So just to finish this sort of line of inquiry - - - 40 DR DAVIES: Sorry I’m not giving you a specific answer. THE COMMISSIONER: No, you’re – it has been very helpful. I’ve got a sense now of the problem. These safe rooms that I guess were instigated after the Garling 45 inquiry. But you say in paragraph 22 that you’re now trying to undo – what do you mean by that?


DR DAVIES: Unfortunately, the experience – you know, I’m old enough to – to have worked with these types of patients pre-safe rooms and post-safe rooms, and certainly now there seems to be – with the safe room there seems to be a – a belief by – and it’s not just mental health, it’s everyone in the hospital – that we have a safe room; therefore anybody agitated, be it a demented patient, be it – you know, 5 anybody that’s – you know, intoxicated, whatever, we have a safe room, so they can stay there until they’re more settled, and they we will come and look at them as the rest of the hospital. Which I think was not really Garling’s intention, and I think has been detrimental to the care of patients, because before that these patients would actually go to specialist units, be it – you know, the – you know, elderly patients 10 ward – you know, the geriatric ward or, you know, dementia unit or – or, you know, other things. So it has created – and, you know, even fight patients that try to – if someone gets a little bit agitated on a ward they want to bring them back to the Emergency 15 Department safe room to lock them in because we can sort of lock the door and fold our arms and observe from the – a distance. And, you know, that has ended up in – in patients being secluded – assuming you understand the – you know, the rules around the seclusion. And, you know, we didn’t used to do that before, you know. Okay, we didn’t have a room to receive an agitated patient, but we used to manage 20 them. They would still get medication if they needed. They would be managed in a normal, acute way. They would get the services, and then they would be moved to whichever service was deemed best, and often in a more reasonable timeframe, so those patients didn’t say – seem to wait, you know, 24, 48, 72 hours in an ED waiting for – you know, for mental health to accept there or for other services to accept them, 25 because we didn’t have a safe room. So I think it has clouded the picture a little bit. It’s also hard – you know, Tweed experience, as I said, because it was – our mental health beds have become more and more difficult – more and more filled – is also – that’s also, you know – well, the 30 place where we can leave them is the safe room for – until we’ve got a bed around here, even if we’re happy to admit them. And I think that’s – that’s – actually we’ve gone backwards a little bit in terms of our – our care, if that makes sense. THE COMMISSIONER: Right. Yes, thank you. 35 DR DAVIES: So – you know, and it’s – it’s – we’re just having a second safe room built and that’s purely on the basis – I – I didn’t actually want it built, a second one, but it’s purely on the basis ..... actually an extra space for us to provide consults in. So it won’t be used as a safe room much, hopefully. 40 MR KELLY: Is a safe room the same as a PECC, P-E-C-C? DR DAVIES: No. So a PECC is a psychiatric emergency care centre, which is a unit that – or units that were built attached to emergency departments. You can co-45 locate them in Emergency Departments. And the hope of PECCs were that it – they would take, you know, the patients with mixed sort of diagnoses and things.


Unfortunately, the – it didn’t result in that and, you know, there’s actually – you know, much has been written and the ministry have – Ministry of Health have – have written on, you know, what they see as the – I suppose the variable performances of PECCs in addressing these issues, and certainly, yes, the failure in terms of model of care for – for fixing what we currently have. Hence, you know, the hospitals looking 5 at these other models like these behavioural assessment units to try and address the problem that’s still being left over. MR KELLY: I’m conscious of the time. I have just a couple more questions that relate specifically to this area and then I will ask that we break for lunch. But I just 10 want to understand quite clearly where the issues around this crossover between mental health and the ED occurred, and as I understand the evidence you’ve given, it’s primarily around that initial acute period of 24 to 48 hours where it’s not necessarily clear where a patient’s – whether a patient’s symptoms are due to intoxication and will resolve or are likely to persist beyond that time; is that right? 15 DR DAVIES: I think so. So I think it’s good to hear from the mental health side of things. But, you know, it’s – it’s that clarity of, you know, does this – is this patient actually mentally ill or is it just drug or intoxication? And if it’s drug intoxication then – then it’s not really a matter of illness, so as a physiatrist – you know, that’s not 20 my domain, so therefore we shouldn’t be admitting such there. MR KELLY: And Dr Wims, in his statement, says that:

Mental health and the emergency department have been developing closer ties 25 over the last number of years, particularly around proactively managing the ATS-affected patient, trying to reduce harm to the patient to staff and to ensure the best patient outcomes. At times, this can be strained if there is a difference of clinical opinion, but the professional relationships are such that collaboration will usually overcome any difficulties. 30

Would you agree with that characterisation? DR DAVIES: I would agree with that. You know – and again, as I said, going back to – you know, it’s this – where the disagreement usually comes is in – you know, 35 while this patient is obviously – you know, they’re psychotic, they’re – they’re going to be sick for days so they can’t stay in an emergency department, you know. And it’s usually around that sort of process – well, psychotic patients, psychiatry has – has typically looked after them, so we see that as – as a domain that they’re experienced in, but as you said before, you know, the levels of aggression and 40 difficulty managing these patients on a psychiatric unit make it very hard, and that’s why psychiatrists often – you know, don’t feel it is the best place for them – those patients to be managed. So that’s where the – the conflict can come. MR KELLY: And so - - - 45


DR DAVIES: But we were – I absolutely agree that, you know, we – we – you know, worked together to try and, you know, work out where is going to be the best and the safest to look after the patient in that particular instance, given the levels of aggression and violence, and - - - 5 MR KELLY: And from your perspective, the difference in clinical opinion is generally related again to that specific period that we’re talking about where it’s unclear whether these symptoms are intoxication-related or likely to persist? DR DAVIES: Yes. Or even if they’re – even if they’re – they are thought to be 10 intoxication related in the – you know, we think the patient may just take a longer period to clear, but from an emergency department perspective – you know, well, that’s not going to be in the next 12, 20 hours. You know, it really – you know, as I said – you know, we’re - - - 15 MR KELLY: I see. DR DAVIES: We’re not an admission unit, we’re not a ward. MR KELLY: Thank you, Doctor. You will need to come back after lunch at 2 20 o’clock if you have time. DR DAVIES: If I have time. THE COMMISSIONER: You still have a few questions - - - 25 MR KELLY: Yes. I have a number of questions still, commissioner. THE COMMISSIONER: All right. Well, Doctor, we know you’re busy. We will get through your evidence as efficiently as we can. So you can come back at 2 30 o’clock. Thank you, you’re excused until then. DR DAVIES: Yes. No worries. Okay. Thank you. THE COMMISSIONER: All right. Well, I will take the luncheon adjournment. 35 Back at 2 o’clock. Thank you. ADJOURNED [1.02 pm] 40 RESUMED [2.01 pm] MR KELLY: Yes. If Dr Davies can come back into the witness box, please, 45 Commissioner.


THE COMMISSIONER: Yes. Thank you, Doctor, just resume the stand there and you’re on your former oath, thank you. DR DAVIES: Okay. Thank you. 5 MR KELLY: Doctor, I just have a few more questions arising out of the matters covered in your statement. To start with, I want to ask you some questions around screening. You explain in paragraphs 14 and 26 that – why it is that routine screening is not necessarily most appropriately done in the Emergency Department, and I understand the reasons that you’ve set out there for why you say that is. Could 10 you explain the extent to which screening is necessary for clinical reasons? DR DAVIES: So that’s I – I think, you know, what the – doesn’t clarify in the – the statement exactly what screening is and - - - 15 MR KELLY: Yes. DR DAVIES: - - - and, obviously, screening can be done on all patients for lots of things, you know. What is relevant to what needs to be done for – for patients is a relevant history or component of history that – that can be used in terms of screening 20 for – for patients that may be affected, you know, in a – for example, a patient may come in with a sprained ankle, doesn’t need screening for – or my belief is an Emergency Department can’t screen all of those patients, as I said, for – ED sees 150 a day. I don’t have the resource to screen every single one of those patients to see if they’re using, you know, ATS or other substances. 25 It would also potentially create barriers for patients if they think, “Every time I go to the emergency department with a sore ear, I’m going to be asked about my drug use.” So there’s – there’s – you know, there’s real reasons why screening isn’t appropriate in the emergency department, but appropriate screening of patients that 30 are at risk or that are part of their presentation, if the patient’s fallen down the stairs because they’re intoxicated and that’s how they sprained their ankle, then an alcohol screen is completely relevant and appropriate. Does that - - - MR KELLY: Yeah, I understand. 35 DR DAVIES: - - - clarify it? So - - - MR KELLY: What I don’t understand is how you’ve – when the – where the decision is made about the extent to which that question be – is appropriate. 40 DR DAVIES: So the LHD has various, you know, guidelines and stuff on – on – so, for example, when a patient is admitted to the ward, they’re supposed to have the – a – the nurses are supposed to do a – a screen of their alcohol and drug use just to make sure patients don’t withdraw, don’t have complications from treatment because 45 of background use of – of drugs. So that’s a – you know, a process, you know. There are other sort of areas where the government may mandate or the LHD may


mandate. So, for example, we do domestic violence screening in the emergency department, and the target for that is for all patients – all females over 16 get screened with domestic violence. Now, the target won’t ever be achieved because of the resource implications of that. 5 That you just can’t devote the time to it because you actually have to provide care as well for – for the patient. So – so there are mandated things that we’re supposed to screen for. There are – in terms – such as admission, and so some of them, we can fit in, some of them, we can do ad hoc, but to expect an emergency department to be able to screen all patients for various things is – is unattainable and also, as I said, 10 counter-productive and also it – you know, it can compromise the care of other patients in the emergency department. So - - - MR KELLY: You mentioned a guideline that relates to screening when a patient is admitted to the ward is – did you have the opportunity to review, before giving 15 evidence, the LHD clinical procedure - - - DR DAVIES: Yeah. MR KELLY: - - - titled Alcohol and Other Drug Assessment – yes, and on page 2 20 of that document, at paragraph 3.1.3 – and, Commissioner, for your reference, it appears as an attachment to Mr Dobbie’s statement behind tab 17. THE COMMISSIONER: Thank you. 25 MR KELLY: It says:

Patients presenting to the emergency department should be assessed using substance use assessment forms alcohol, smoking and other substances.

30 DR DAVIES: Yep. MR KELLY: So I understand it’s done by the nurses. DR DAVIES: So – that’s right. So – and, again, it didn’t clarify or I didn’t clarify, 35 you know, medical screening, nursing screening and – you know. So this is a – is something that the nurses do. It used to be in paper form when we got the – onto the EMR2 last year. We’ve been converting over so that the nurses do – do this or attempt to do this in the EMR now. 40 MR KELLY: I want to ask you some questions around stigma. DR DAVIES: Yep. MR KELLY: So we’ve dealt with that in paragraph 18 of your statement, and you 45 say that you:


…do not feel there is stigma around ATS use resulting in a barrier to treatment as the patients I see presenting to ED receive treatment.

What treatment are you referring to there? 5 DR DAVIES: Yeah. Again, I – do I believe patients get – have – have their issues with stigma? Absolutely. Undeniably so. What I’m naturally treating – meaning there is when a patient is in front of us in the emergency department, we treat them. It doesn’t matter whether you were there because of alcohol, because of – of ice or because of anything else. You get treatment. So I don’t believe it’s a barrier to your 10 treatment. I think there’s lots of barriers to patients accessing treatment to actually get into – presenting to healthcare, presenting to, you know, various community services and – and because of – of stigma. Can – can the perception, sometimes, affect some patients’ care? I’d like to think not. I think, sometimes, that it – it does. 15 MR KELLY: In the Emergency Department? DR DAVIES: Yeah. MR KELLY: Yes. 20 DR DAVIES: In an Emergency Department, but the actual treatment component, you know, if a patient comes in and they’re severely agitated with ice, they get treated. The fact that it’s – it’s from ice, it’s got nothing to do with it. Or if it’s alcohol, they get treated. It’s got – does that make sense? 25 MR KELLY: Yes, it does. DR DAVIES: That’s - - - 30 MR KELLY: As I understand that what you’re saying is - - - DR DAVIES: But the access is – is often an issue. MR KELLY: Yes. So I understand your evidence to be that access – stigma may be 35 a barrier of a person seeking treatment, but it’s your expectation that once they arrive at the emergency department, stigma would not - - - DR DAVIES: Yep. 40 MR KELLY: - - - effect the treatment they receive in any way. DR DAVIES: Yep. MR KELLY: But you accept that there may have been – there may be some cases 45 in which stigma does - - -


DR DAVIES: Yeah. Look, you’re – you’re - - - MR KELLY: - - - affect treatment? DR DAVIES: - - - with – with human beings, you know, and – and you can’t 5 universally speak for everybody, but the – the principle would be once someone is in the Emergency Department, it doesn’t matter what they’re there with or what has caused them that they get – so – and I think, by and large, that’s actually the case. I think the bigger issue is probably around access. People – their belief if they, you know, actually divulge that they’re using substances or, you know, they – they need 10 help, but they know it’s because of the substance is one they need help, so they don’t seek that help. I think that’s a bigger barrier than – than the ED side is what I was trying to say in the statement. THE COMMISSIONER: Doctor, do you ever get anybody just coming into ED 15 saying, “Look, I think I’ve got a problem with meth. Can you help me?”? DR DAVIES: They – they do. Yes, often, they’re – they’re actually presenting, then, for – often, they’re – they’re asking for mental health services is what they typically present in that sort of setting. They say, “Look, I’m – I’m distressed. I’m 20 agitated. I’m using ice. I need” – you know, and see a mental health team. And, sometimes, they just say, “I want help.” So it does happen. It’s not the usual, though. It’s usually on subsequent questioning, or in the acute severe behaviourally disturbed, there’s often history from somebody else because they’re so disordered, you know. It’s – it’s the wife or the mother or the friend, you know - - - 25 THE COMMISSIONER: Right. DR DAVIES: - - - that have, you know, said, well, they’re an ice user or the police have found or the ambulance have found the – the needles and the - - - 30 THE COMMISSIONER: Yes. DR DAVIES: - - - the packet. So - - - 35 MR KELLY: In paragraph 15, you – of your statement, you – talks about data collection, and you refer there to FirstNet, I understand that’s your electronic medical record program, and then you say that in relation to – data specific to ATS use presentation, that electronic medical record system captures useful data, but the information can be difficult to access. Can you just tell me what data it is that it 40 captures that you consider useful and what it is that’s difficult about access? DR DAVIES: Okay. So the – the data that’s entered into FirstNet is very – can be non-specific. So, for example, if you presented with your broken ankle, as I was saying, because you kicked the wall from ice, the presenting problem will be 45 recorded as just broken ankle, not ice use. Does that make - - -


MR KELLY: Yes. DR DAVIES: You know, if you present with anxiety or agitation, the presenting problem will be put into FirstNet as a – as agitation, not drug use. So – and – and the diagnosis at the end may also be that, you know, broken ankle, not ice use. It may be 5 mental disorder, anxiety, not drug use. So the way that the – the system and, in particular, those two – the presenting problems, diagnosis are the easiest bits of information for us to pull out of FirstNet in terms of the – the data dredging, sort of, systems, the software that’s built into it. In the body of the notes that everybody’s written in there about your care and between you coming in and going home, there’ll 10 be lots of information in there. That’s very, very difficult to get out of FirstNet. So if it’s not in these specific data fields of, say, your presenting problem or your diagnosis that we put in, if the information is not there, it becomes really difficult to extract out of the current system. 15 MR KELLY: And the utility of the information that’s in there, but not easy to extract from a clinical perspective is - - - DR DAVIES: So then it – it often gives us trends, you know, so if we noticed that there is a – a spike in, you know, agitated patients, you know that – that may have 20 behavioural disturbance, then we can assume that may well be the overlap month, whatever we’ve had – you know, an increased use of – of amphetamines in the community or – or ice in the community, but it’s very, very difficult to be exact in that information and that’s – the real difficulty is that’s, you know, being very specific. And the numbers is – is also – I think I – I mentioned later on as well that 25 you can then for – often see trends. MR KELLY: Yes. DR DAVIES: But it’s trends in very non-specific data and you make assumptions, 30 but the actual numbers are often very difficult to pull out as to who has what. MR KELLY: And - - - DR DAVIES: I hope I’m making sense. It’s – it’s - - - 35 MR KELLY: No, no, you’re making perfect sense. From a clinical perspective, does the inability to easily retrieve the data that you’ve spoken about in the notes affect the care that’s provided to individual patients in any way? 40 DR DAVIES: I don’t know that – it certainly affects our ability as a system to – to prepare, to – to improve, because it’s very difficult to know. If you don’t know your volumes of stuff, you don’t know where to put your resources. When you’re – obviously when you’re trying to identify all your resources and – and lobby for resources, data is – data is key. Data is your friend. And so certainly it becomes 45 difficult as well from a quality perspective to actually know is your – is your service actually matching the volume of patients and where are deficiencies in care, because


it’s very, very difficult to find the records. It basically means you’ve got to – you’ve got to search a huge volume of records, and you’ve got to go from head to toe through every record, which is just – we don’t have time, in the health system, to do that sort of thing. So - - - 5 THE COMMISSIONER: Doctor, for a patient that comes in who you’ve seen before, ED has seen before, I presume you can pull up a patient’s - - - DR DAVIES: Yes. Like that. Yes. 10 THE COMMISSIONER: - - - file, and the nursing staff or the clinician can quickly see what the history is and - - - DR DAVIES: Yes. 15 THE COMMISSIONER: - - - what they presented previously - - - DR DAVIES: Yes. THE COMMISSIONER: - - - for. And that would enable someone to pick up 20 previous ice use, if that had been recorded in - - - DR DAVIES: Yes. THE COMMISSIONER: - - - the notes. And how often do you think you’re seeing 25 repeat users? DR DAVIES: I – it – it often depends on where they are in their journey. We – we see some patients recurrently for – for many months or – or, you know, recurrently, you know, for weeks over - - - 30 THE COMMISSIONER: Sure. DR DAVIES: - - - several months. 35 THE COMMISSIONER: Right. DR DAVIES: And then, you know, they may finally – you know, either move away or they may hook in to rehab or – you know, and – and their pattern changes considerably. So – so we do see a lot of repeat patients, especially those that have 40 been difficult to engage with drug and alcohol and that sort of thing, you know. If we can get them and, you know, there’s – I’m sure you will hear more from – from the alcohol and alcohol service. But if we can get them engaged – and we have had a stimulant program clinical liaison nurse in the emergency departed for over – well, probably 18 months or more now. 45


And they – you can see, you know, the effect they have on return users. You certainly get the feeling that they get to engage them; they actually – whilst they’re actually in the Emergency Department, and they actually get contact and make that connection with those patients. There’s a lot higher uptake of those patients actually following up with the drug and alcohol service. If they’re not there and we just give 5 them a piece of paper and a phone number, even if we refer them to the clinic, you know, the – the uptake is a lot less – because the clinic follows them up, so I’m told. So - - - THE COMMISSIONER: All right. 10 DR DAVIES: And so, you know, it is a – it is – yes, we do see frequent flyers, as we call them. And that’s where the drug and alcohol service, in particular, is key to – to trying to help reduce that and engaging the – the – the patient in a – in a – hopefully, a – a better path and better course. 15 THE COMMISSIONER: And just on FirstNet – whilst it’s useful for showing trends, if you were using it to estimate or guestimate the number of people presenting with ice as part of their presenting problem, it would be underrepresenting if you just used the raw data. 20 DR DAVIES: Yes. THE COMMISSIONER: Yes. 25 DR DAVIES: Absolutely. THE COMMISSIONER: Yes. DR DAVIES: Yes. 30 THE COMMISSIONER: Okay. DR DAVIES: Yes. So, I mean, the Ministry and some of the other LHDs have invested more in these tools to – to dredge data. And they may be able to – to get a 35 better idea with more powerful tools. But certainly from a – a local clinician, you know, network sort of – you know, the – with the tools that are just built – simply built into it – it’s a very superficial look. Yes. THE COMMISSIONER: Okay. Thank you. 40 MR KELLY: You mentioned clinical liaison, drug and alcohol clinical liaison in the answer that you just gave to the Commissioner. Is the drug and alcohol – when you use the phrase “clinical liaison”, is that the same as “consultation liaison”? 45 DR DAVIES: Consultation - - -


MR KELLY: Yes. DR DAVIES: - - - liaison as well, yes. MR KELLY: And is the – are the consultation – I withdraw that. Are the clinical 5 liaison services that are available to you for drug and alcohol services sufficient to meet the needs of the ED? DR DAVIES: Yes. I will rephrase your question. Is it sufficient to need the meets – need the meets – meet the needs of the patients? 10 MR KELLY: Yes. DR DAVIES: My response would be no. There are probably a few ED staff that need some help. But yes. No. The – the large proportion of patients – we’re a 24-15 hour service, 365 days of the year. So there’s a large proportion of patients who will present out of hours. And, as I said, that first contact in particular and tying in with the services is very important. And, you know, in a – in a smaller LHD, you know, a regional service, you know, we have, I think, four days a week, three or four days a week, liaison. So absolutely would I like more, yes. Do I think it would help engage 20 some patients and reduce re-presentations? Absolutely I believe that. Would it improve just, you know, the – a lot of the patients’ journeys? Absolutely. So - - - MR KELLY: As I understand it, what it involves is practitioners from other specialties being available to you for consultation. So the patient remains under your 25 care, and you have the primary responsibility for clinical decision-making, but you have the benefit of the input of other specialties in making your clinical decisions. Is that right? DR DAVIES: Yes, that’s right. So the – the benefit is – is – is not just that we have 30 their input into the care then; what often happens or more – or is more often the – the end result is – is that the patients are then referred to that service or have follow-up with that service as a result of that consult or as a result of that input. So you’re tying the patient in to ongoing care at that point. So it’s not just a bit of advice on you can, you know, perhaps treat this one with this or treat that one with that. It’s the 35 fact that you tie the patient in to – or hope to engage the patient in the ongoing care that is what makes the difference. MR KELLY: And I understand that the drug and alcohol consultation liaison is not generally available out of hours. And what proportion of the acutely severely 40 behaviourally disturbed patients affected by ATS that you see are presenting out of hours? DR DAVIES: It’s hard to say, because they actually present all times, you know. And certainly up to, you know, the – you know, later hours of the – the night, you 45 know, 10, 11, 12 o’clock at night, we’re still seeing people present, you know; less through the – the small hours and the early hours of the – the night, early hours of the


morning. And so, you know, it is fair to say that a lot of those patients, especially in their highly agitated state, you know, can’t undergo consultation liaison and often have to have treatment and have settled before consult liaison. So, you know, it does lend itself to be able to, you know, still capture a lot of 5 patients, with a – a daytime service. But if we’re only weekdays, then we’re missing a large volume on weekends. And – and some patients don’t stay around. In particular, the alcohol patients, you know, that – that – frequently they’re not as behaviourally disturbed. They often sober up quicker than the ice patients. And they’re – they’re gone. And they’re very frequent re-presenters, you know. And so 10 again, you know, it’s not just with the – the ice but, you know, the – the in-reach from drug and alcohol into the ED for the alcohol problems as well, you know, has shown major benefit with some patients, you know, breaking that cycle. So - - - MR KELLY: And that - - - 15 THE COMMISSIONER: Must – I’m sorry, Mr Kelly. It must happen, I’m assuming – and correct me if I’m wrong – that a number of the people who come in with ice who are agitated – as soon as it wears off, they’re out of the place. 20 DR DAVIES: It depends. If they’re held under the Mental Health Act because they’ve been disordered - - - THE COMMISSIONER: Yes. 25 DR DAVIES: - - - then there’s a process that they have - - - THE COMMISSIONER: Sure. DR DAVIES: - - - to go through - - - 30 THE COMMISSIONER: Yes. DR DAVIES: - - - and that’s to be cleared, from the Mental Health Act. So – so that may enable other services to see them in – in between. Often, you know, the 35 patients do want help when they’re out of that state, especially if they’ve been through a crisis; like, they’ve just been through – they may not remember a lot of it. But they remember bits at the start, and they remember bits at the end. And – and it’s not a nice journey for people to go through. Very terrifying, very scary. So it’s quite interesting that a lot of the patients don’t want to be straight out the door. 40 Some do. THE COMMISSIONER: Okay. DR DAVIES: But there are some that actually understand that they’re – they’re in 45 need of help. So – and if you’re not there at the time to offer that service, then,


unfortunately, yes, you know, they can be back out into the community and re-using within days. And - - - THE COMMISSIONER: Right. 5 MR KELLY: All right. In terms of the crossover between ED and mental health, which we were talking about earlier, would the availability of more alcohol and drug consultation liaison services assist with that tension between the two departments, if I can put it like that? 10 DR DAVIES: I often term the patients as a mixed bag presentation. You know, there’s varying components of drug and alcohol, mental illness or mental disorder, and physical issues as well a patient present with in terms of intoxication and complications of that. So attack and – and there’s often social issues as well that’s – we often get social work input as well for homelessness or – you know, crisis and 15 accommodation and things. So they actually need a multi-faceted approach to – input from all sides actually will improve the chances of successful treatment of the patient. So – yes, as – you know, as much input as possible is usually key to success. MR KELLY: But just very specifically around those issues about determining 20 where a particular acutely behaviourally disturbed patient should go - - - DR DAVIES: It’s – it – you - - - MR KELLY: Would the input of drug and alcohol consultation liaison assist in that 25 process? DR DAVIES: From my perspective, if the patient is still, you know, potentially psychotic, agitated, still suicidal and they need mental health admission, then the psychiatrist may feel that if there’s a significant drug and alcohol component that 30 may help. Again, I think that’s best heard from the psychiatrists. Yes. You’re probably noticing that I’ve sent – you know, there’s – these patients are a mixed bag; they have multiple problems and it’s not just one domain’s responsibility to fix. MR KELLY: Ms – in her statement, Ms Deirdre Robinson says that: 35

A fulltime addiction medicine specialist would provide a significant advantage to support improved client care across a range of services.

Would you agree with that? 40 DR DAVIES: I would. You know, and again, coming to – that’s the whole spectrum from input into the consultation liaison to community care, to inpatient care, to everything. 45 MR KELLY: And just – lastly I want to ask you some questions around the effect on staff and some workplace issues around treating these patients. Could you give


some example of the effect on staff that you’ve seen in the course of treating people with ATS-related presentations? DR DAVIES: So I suppose – probably similar to the police experience, there’s a whole spectrum from physical injuries, you know, staff punched, bitten, spat at, you 5 know – verbally abused in significant amounts, which is probably the commonest type of abuse – all the way through to, you know, the psychological impacts of, you know, continuously looking after very angry patients. For health care workers, you know, we go into the profession to help people and to have a subset of patients, you know, that want to do you harm in the course of you trying to care for them is very 10 confronting. And so some staff get very distressed and dismayed and very much want not to be part of the care of those patients. Whilst that’s understandable, that’s also part of emergency medicine, so it would be impossible – or I think it would be hypocritical for me to say, well, I don’t want to 15 treat ice patients, why is that my problem? Well, it’s my problem because I trained in emergency medicine. If I didn’t want to do that, then 25 years ago when I started this path and started caring for these patients – because as we’ve said, they were in the EDs then – then I should have chose another path. Does that make sense? You know - - - 20 MR KELLY: Yes. DR DAVIES: They were always there, they were part of emergency medicine. That was always going to be part of my job to care for them. So I don’t think it’s 25 right to say, well, it’s not part of emergency care to care for them. So we therefore have to – if it is part of our job and part of our role, then people need to be given the sills and the support to be able to do that, especially long term. What we don’t want to have in emergency departments is losing staff that would otherwise do emergency medicine because of an aggressive subset of patients who – you know, they don’t 30 want to be there trying to kill people, they just unfortunately – their drug use have got to that state. And I don’t say that lightly. You know, some of these patients want to do harm and they tell you so in no uncertain terms. So – and it can be scary for a young nurse when they’re telling you 35 that they’re going to come and find you in a few days time and find where you live and murder your family. So these are the levels of violence that staff are exposed to, and that is – can be very, very distressing for staff. MR KELLY: You’ve said there that you’ve always had these acute behaviourally 40 severely disturbed – acute severely behaviourally disturbed patients. DR DAVIES: I know, it’s a pain. Just say ASBD. MR KELLY: But you also say that the level and frequency of violence had not been 45 dealt with before and EDs were ill-equipped?


DR DAVIES: Yes. MR KELLY: Could you just explain what you mean by that? DR DAVIES: So that’s the numbers thing I was talking to – you know, as I said, 5 when I started training we had then, and then we had patients that – patients that we’ve - - - MR KELLY: Yes. I don’t want to interrupt you, but I meant more about the ill-equipped nature of the Emergency Departments. 10 DR DAVIES: Yes. It was the volume in particular that we see, and the level of aggression is of scale with the ice. Amphetamines patients would always get agitated and aggressive, but not the same level, and so the numbers equate – it just means because they’re so resource-intensive, if you have several of these patients 15 under your care at any one time you don’t have adequate places to put them. We also try and pick a more secluded that of the emergency department, but one that’s still visual, still has plenty of staff – you know, we can still watch and see and hear. There’s only so many of those places in an Emergency Department. When you have 20 more and more of those patients it becomes harder and harder to care for them. Specific rooms – as I said, SARs rooms were built to try and help in the receiving and the initial assessment and care of these patients. Unfortunately, they ended up as places for extended care of these patients, which then meant the next patient coming in couldn’t be received into that area. And so that’s what I mean by EDs being ill-25 equipped for the volume and the level of aggression. MR KELLY: I see. Is there anything that would assist EDs to be more well-equipped to deal with these patients? 30 DR DAVIES: Less patients. It’s – it’s a difficult one. There are – there’s lots of different models. As I said, I’ve been touring, you know, the country, and there’s lots of different models in how to deal with these patients. Some hospitals don’t use safe rooms; Victoria, they have safe rooms – they call them behavioural rooms – but they don’t actually sue locks on them. They’re not lockable doors. Some hospitals 35 would use their resus rooms, which is what we now do at Tweed, to actually receive the very violent patients and the patients are taken there to be sedated in the first instance. So there’s actually very different models that patients are cared for – I don’t know if I’m answering you question – that that then tells you that no one has actually got the model or the solution. 40 MR KELLY: I see. DR DAVIES: So I can’t give you the solution because there’s lots and lots of more cleverer people than me that haven’t fixed it. 45


MR KELLY: I see. Dr Wims, in his statement, makes the point that the biggest difficulty for managing these individuals is being able to safely administrate sedating or settling medication, which puts treating clinicians at direst risk of assault and serious injury; would you agree with that? 5 DR DAVIES: Yes. So that’s that – often that first point of contact – physical contact when we need to sedate people, and it can be very – that’s often where injuries occur. MR KELLY: And lastly you say that you believe training on ATS would be good as 10 well as in relation to current trends in reduction of seclusion. Could you explain what you mean by that? DR DAVIES: So the – well, I should have put in seclusion and care. So – I think Dr Wims also mentioned, you know, using, you know, trauma-informed and least-15 restrictive practices, which is sort of the aim of the game with mental health services and care in general – you know, maintaining patient autonomy is very, very difficult when the patient is threatening such – you know, violence. So, with the best will in the world, you know, you still actually have to be able to, you know, care for the patient and care for the staff, keep the staff safe. So that’s going to require most of 20 the time these patients in sedation in areas to do that. Sorry, your question again? MR KELLY: And it’s about training. The question is specifically about the training. 25 DR DAVIES: So – you know, the training, therefore, is trying to keep up with those, I suppose, that change in the little bit, but also the best practice, and that, I suppose, comes back to my previous point in what is best practice at the moment, essentially, in a state of flux and invariably by lots of different places. So - - - 30 MR KELLY: Thank you, Doctor. Those are my questions, Commissioner. THE COMMISSIONER: Thank you. Doctor, can I just ask you – you say in your last paragraph, 36: 35

Mental health’s nursing experience in ED is also an issue. In my experience, few ED nurses have a mental health background or training.

Do you have any ED nurses at the moment who have a mental health training? Just one. All right. 40 DR DAVIES: And that’s out of 100 head of nurses – out of 100 nurses. THE COMMISSIONER: Out of – one in 100 nurses has mental health training? 45 DR DAVIES: In my ED.


THE COMMISSIONER: Right. You clearly, I assume, would like more than that. DR DAVIES: Yes. So this is the point I was making around, you know, current models and learning to – not just deescalate, you know – we do try and access violent prevention, management sort of systems that the LHD provides training on. It’s 5 difficult, as you can imagine – 100 nurses that are constantly in flux plus 40-odd doctors that are constantly in flux to keep up with that level of training to – you know, and to then keep them up to date with the latest trends and methods is – and that’s what I was really getting at in the prior question. So the – and a lot of the care for these sorts of patients – you know, patients that are coming down off of drugs – 10 lends itself a lot more to mental health nursing than it does to emergency nursing. Emergency nurses will receive a patient; they will help, you know, do all the obs and help stabilise the patient and typically that patient will then get admitted to a unit, you know. These patients that often need – they may not need a huge amount 15 of medical care, but what they need is constant observation. They need someone talking to them, someone, you know, defusing situations, that know how to work with patients that are disturbed and disordered and that is, you know, typically the domain of mental health nurses. So that sort of understanding how to deal with and that sort of skill set and knowledge would be very, very good to have in amongst 20 emergency nurses but it’s largely devoid because the work that we do is frequently different. But obviously there’s a need in the ED to actually be able to care for people in this way. THE COMMISSIONER: If you have just one mental health nurse out of your 25 hundred, presumably they have shifts and they’re – so you would have long periods of time when you wouldn’t have one there at all. DR DAVIES: Yes. 30 THE COMMISSIONER: And how many do you think you should have if you – if you were up to speed in terms of what your requirements are? DR DAVIES: Well, what we’re trying to instigate – or I’m trying to build at Tweed – is one of these new type of behavioural sort of units and the idea will be that – I 35 mean, it will be mainly just for assessment and, as I said, some of these assessments are more prolonged, but the idea is to have two nurses in that area. There’s a couple of beds and the safe rooms and that so they may care for four or five patients at one point in time, and to have two nurses there day and night. So it will be, you know, two in the morning; two nurses in the evening; two at night. 40 So to answer your question, in that sort of model, I would like at least one of those nurses to have – or one of the nurses ideally would have mental health background and the other nurse would have an ED background so that they are able to look after the physical and the mental health needs of the patient and they would also then 45 cross-pollinate in terms of skills and knowledge. Does that make sense? That’s - - -


THE COMMISSIONER: Yes. So in - - - DR DAVIES: But that’s an isolated unit, so that would be – you know, you would need probably, I don’t know, 12 nurses out of the 100 to run that sort of - - - 5 THE COMMISSIONER: 12 with mental health training or - - - DR DAVIES: Yes. THE COMMISSIONER: Yes. 10 DR DAVIES: But ideally, you know, you will have ED nurses with more mental health training. The problem for an ED always is the – it’s a very general field. So, you know, we need training into ..... children, into trauma, into how to look after people with heart attacks, with strokes, with diabetes, you know. 15 THE COMMISSIONER: Sure. DR DAVIES: Mental health is one of those components and ice and drug use is a component of that. So it’s hard to get all the training that all the staff need for all the 20 staff. It’s an enormous, enormous task. THE COMMISSIONER: Sure, sure. But from what you’re saying, you’re significantly short on mental health-qualified nurses. You’re nodding “yes”; is that correct? 25 DR DAVIES: Yes, well, with – well, with nurses with mental health experience, you know, that have worked in mental health units and understand those principles of care. 30 THE COMMISSIONER: Yes, yes, yes. All right. Thank you. Those are all the questions I have. Thank you, Mr Kelly. Any other questions of the doctor? MR KETTLE: No, Mr Commissioner. Thank you. 35 THE COMMISSIONER: All right. Thank you. All right, Doctor. Well, thank you very much for taking time off your no doubt very busy schedule and we’re grateful for your evidence. You’re excused. Thank you. 40 <THE WITNESS WITHDREW [2.38 pm] MR KELLY: Commissioner, the next witness is Dr Edward Wims and followed by Dr Wims are Drs Helliwell and Hudson to give evidence together. We are running a 45 little bit behind schedule, so I will do my best to make up time, but it may be at this stage that we may run a little bit past 4 pm.

.SPECIAL COMMISSION INTO ICE 14.5.19R1P-666 E. WIMS XN MR KELLY

THE COMMISSIONER: All right. Well, we will see how we go. It shouldn’t be a problem. MR KELLY: I call Dr Wims. 5 <EDWARD WIMS, SWORN [2.39 pm] <EXAMINATION BY MR KELLY 10 THE COMMISSIONER: Thank you. Please sit down, Dr Wims. MR KELLY: Commissioner, Dr Wims’ statement appears behind tab 14. 15 THE COMMISSIONER: I have that. Thank you. MR KELLY: Doctor, could you please state your full name, current occupation and professional address. 20 DR WIMS: My name is Edward Gerard Wims. I’m the clinical circumstance of the Richmond/Clarence Mental Health Services. That’s based at 60 Hunter Street here in Lismore. 25 MR KELLY: And you’ve been a psychiatrist for 14 years. DR WIMS: That’s correct. MR KELLY: And you commenced your present position in October 2016? 30 DR WIMS: That’s correct. MR KELLY: And in your current role, you’re responsible for the clinical direction and quality of clinical service within this network? 35 DR WIMS: Yes. MR KELLY: And you’ve attached a copy of – have you made a statement in this matter dated 9 May 2019? 40 DR WIMS: That’s correct. MR KELLY: Do you have a copy of that statement with you? 45 DR WIMS: I don’t, I’m afraid.


MR KELLY: Could the witness be provided with the tender bundle and tab 14? THE COMMISSIONER: Certainly. MR KELLY: You’ve annexed a copy of your CV to that? 5 DR WIMS: That’s correct, yes. MR KELLY: And are there any changes that you wish to make to that statement at this stage? 10 DR WIMS: There’s one slight change which is – it was around the prevalence. I’m just trying to find the exact paragraph. MR KELLY: You deal with that in seven and following. 15 DR WIMS: The prevalence rate – yes. So in paragraph 8, I said about 20 per cent of people in the community; that should be two point zero. MR KELLY: And have you been provided with a copy of the expert witness code 20 of conduct? DR WIMS: Yes, I have. MR KELLY: Have you had the opportunity to review that? 25 DR WIMS: I have, yes. MR KELLY: And do you agree to be bound by it? 30 DR WIMS: Yes, I do. MR KELLY: I would like to start with, first of all, just as a discrete topic, at paragraph 6, you say: 35

Within this LHD, dexamphetamine and methylphenidate – which I understand is under the brand name Ritalin, amongst other things - - - DR WIMS: Yes. 40 MR KELLY:

- - - are commonly diverted by ATS users and is of such prevalence that in my clinical practice I would not prescribe that medication unless I was extremely 45 confident that the patient will not clinically divert. The risk of diversion is


something that you consider whenever a patient is requesting a prescription for this type of medication.

Could you just expand on the prevalence that you mean when you say that it’s of such prevalence that you wouldn’t prescribe that? 5 DR WIMS: In my experience from talking to patients who have been prescribed these stimulants, whether by – it’s rarely by myself; it’s usually by other practitioners – they’re – these medications are commonly diverted. I come across patients who tell me that they are able to access these medications on the street and 10 they have quite a high street value. We have had an incident of where a prescription pad was stolen from our community mental health clinic and a very sensible pharmacist identified that the prescription was invalid and the prescription was specifically for dexamphetamine. So where people have difficulty in accessing other types of illicit amphetamines on the street, they will then try to source prescribed 15 amphetamines or other stimulants. MR KELLY: And that understanding is based on your own conversations with patients? 20 DR WIMS: So that’s my own conversations with patients. It’s also observations from other jurisdictions within which I have worked. MR KELLY: And with this region specifically? 25 DR WIMS: Yes, within this region specifically, it – it remains a problem. MR KELLY: And the basis is, I think you said earlier, it was some discussions that you had had with other clinicians, as well? Are they clinicians - - - 30 DR WIMS: Other – other - - - MR KELLY: - - - within this - - - DR WIMS: - - - clinicians who would have observed this and other patients who 35 have told me that they are able to procure street dexamphetamine. MR KELLY: I see. In terms of user profiles of the sorts of patients that you’re seeing used ATS, you describe that in paragraph 7 and you say that: 40

Use of ATS crosses many socioeconomic classes, including professionals to the disenfranchised, poor and Aboriginal community.

You say that you’re aware that within the gay community, ATS are commonly used. And that, surprisingly, the age range of ATS users varies widely. Can you just 45 unpack those observations by reference to specific ATS, if you’re able to?


DR WIMS: So the – the ATS that I would see most commonly would be methamphetamine or ice, and that’s across this diverse range of – of communities. Within the LGBTI community, it may also include MDMA in addition to methamphetamine but it – it would be either predominantly methamphetamine with some MDMA use. 5 MR KELLY: And in terms of the diverted stimulated medication, do you have any observations around the demographics of those users? DR WIMS: Again, those users would tend to be younger. They tend to be more in, 10 kind of, the 18 to 25 year old group, with a very small discrete number who are parents of children who have been prescribed amphetamines for their – for their child’s ADHD. MR KELLY: You also say, in paragraph 7, that ATS use is used for a variety of 15 reasons, either for a general lift in energy, or to combat other side effects to medication or to reduce inhibitions. Are you able to say – speak to that in – and the basis for those observations? DR WIMS: Sure. I – I think I could use a summary statement in that all substance 20 users, regardless of the substance that they are using, have their own good reasons for choosing that substance. No different from the – those of us who like a coffee in the morning, we have a strong belief as to what that coffee is going to do for us on our way into work or in the middle of the day as we, you know, might experience an afternoon slump. So for our ATS users, they’ve got very strong beliefs about what 25 that particular substance is going to do for them. For some people, it gives them a strong sense of pleasure. For a lot of my client group, who we prescribe sedating medication that might lower their motivation, might cause apathy or where, say, for example, they have a 30 diagnosis of schizophrenia and have what we describe as negative symptoms, which is associated with apathy, amotivation, slowing of thinking. Amphetamines are very rewarding for them because they – it – it gives them that lift. It gives them – some people describe it as feeling like they’ve got a life again. They feel normal again. So they – they have the energy to get out of the house. They have the energy to go 35 shopping. They have the energy to – to clean up, to look after their children. However, of course, the – the – the negative effect, then, is that this can exacerbate their psychotic symptoms and we then end up in this negative cycle of the psychiatrist increasing their medication because they have more psychotic 40 symptoms. This person then feels worse physically because of the side effects and then they go on to use more ATS to counteract those side effects. MR KELLY: Could you just excuse me for one moment. Commissioner, I’ve been advised that the live stream is currently unavailable and that it will require about five 45 minutes to – apparently it’s back.


THE COMMISSIONER: We’ve got it back? MR KELLY: Yeah. THE COMMISSIONER: All right. Good. 5 MR KELLY: Well, then, I withdraw that. THE COMMISSIONER: That’s all right. Thank you. 10 MR KELLY: Doctor, the – those people that you were just giving evidence about, they’re specific to schizophrenic patients who are using particular medications? Is that my understanding? DR WIMS: Not – not just people who have schizophrenia but other people who 15 have been prescribed either anti-psychotic medication or medication where the side effect is sedation. And the side effect can induce apathy. MR KELLY: I see. Now, you’ve – in terms of prevalence, you deal with that in paragraph 8 of your statement and you’ve adjusted that to say that the ATS using 20 cohort is stable at about two per cent of people in the community. DR WIMS: Yes. MR KELLY: And what is that observation based on? 25 DR WIMS: So that would be based on – on my general observation. However, I’ve recently read the waste water treatment – I can’t remember exactly the name of the – the – the title, but it’s where waste water has been examined and contrary to what a lot of people have been saying regarding drug use decreasing in regional – regional 30 New South Wales since 2016, there is now good evidence to say, from the waste water treatment program, that that – the level increased in 2017 and increased again in 2018. MR KELLY: So your evidence there is that two per cent of all people in the 35 community or two per cent of people who you treat in the community? DR WIMS: So the AIHW data would say that approximately two per cent of the entire population - - - 40 MR KELLY: I see. DR WIMS: - - - are methamphetamine users. However, the waste water treatment program would suggest that that use is increasing rather than plateauing, as I previously believed. 45


MR KELLY: And in terms of your experience, with numbers of ATS users that you come into contact with, are you able to put a number on those people? DR WIMS: So I – I would estimate that within my client group, approximately 40 to 50 per cent would be ATS users. 5 MR KELLY: I see. DR WIMS: And - - - 10 MR KELLY: And say – sorry, I cut you off. DR WIMS: I – I was just going to say, I’ve got a very concrete example of that at the moment, which you may have been going to ask about later on, in the context of criminal justice. We’ve had a period in our unit that has been very quiet. We’ve had 15 – at one stage, our high dependency unit, which is where we put our most acute patients, was empty. And for the first time in the two and a-half years I’ve been working here, it has been empty. In the last week, we now have six patients in – in that ward, five of whom are ATS affected. So I – I think that’s, you know, quite a – a dramatic change and I do think it’s associated with availability. 20 MR KELLY: And when you say ATS affected, any – is there a common ATS that has been used? DR WIMS: Ice. 25 MR KELLY: Ice. THE COMMISSIONER: Just pausing there, Doctor, you referred to an acronym which I think you’re referring to the – the household survey, the two per cent figure. 30 DR WIMS: Yes, that’s correct. THE COMMISSIONER: Right. 35 DR WIMS: So it’s – it’s - - - THE COMMISSIONER: That’s the self-report - - - DR WIMS: So it’s the Australian Institute of Health and Welfare - - - 40 THE COMMISSIONER: Yes. DR WIMS: - - - that conduct that – the survey. 45 THE COMMISSIONER: Yes. All right. And my understanding, from evidence we’ve heard, I think elsewhere, Mr Kelly, is it that was last updated in 2016.


DR WIMS: Correct. THE COMMISSIONER: And so the waste water survey that you refer to is subsequent to that year, 2017/2018, you’re referring to? 5 DR WIMS: That – so the last waste water survey was in 2018. THE COMMISSIONER: Right. Okay. Thank you. MR KELLY: You’ve given evidence that in your present position, in this LHD, 10 which has – you’ve been in placing since October 2016, you say that you – your experience is that the number of ATS people that you see – ATS users who use it clinically, seems to have plateaued. DR WIMS: Yes. 15 MR KELLY: Is that since 2016 or – so - - - DR WIMS: So, I suppose, in – in the – the two and a-half years that I’ve been working in the LHD, I’ve not seen an increase. 20 MR KELLY: I see. DR WIMS: So I think it would be based on other evidence that has been given today and also on the reports from my colleagues, where they saw an increase in 25 ATS presentations prior to my starting in 2016. Now, I think that that has stabilised over the last two and a-half years. I’ve not seen further increases. MR KELLY: And you – are you able to say, in your experience, which ATS is the most prevalent? 30 DR WIMS: Again, methamphetamine. MR KELLY: And you say, in paragraph 9, that patterns and occasions of use tend to be associated with access to funds and you gave some evidence earlier that you 35 believe patterns in ATS use are associated with availability?---Correct. MR KELLY: Could you just explain what you mean by those two - - - DR WIMS: So by access to funds, certainly within my client group, most are on 40 either disability support pension or on Newstart and on the day that they get their allowances paid, that is when they will procure their – their drug of choice. And if they are ATS users, that’s when they will procure ATS. MR KELLY: In terms of the presentations that you see and the harms associated 45 with ATS use, you say, in paragraph 11, that:


The sorts of presentations seen most commonly in this LHD are acute behavioural disturbance, drug-induced psychosis, exacerbation of pre-existing mental health disorders and social issues such as homelessness, poverty, where funds are directed to amphetamine use, and poor nutrition. 5

Are those – when you say the sorts of presentations seen commonly, is that in the context of ATS use? DR WIMS: Yes. In the context of ATS use, with the – the mental health population that I work for. 10 MR KELLY: And a – is it consistent with that that, of those presentations, mostly they are associated with crystal methamphetamine? DR WIMS: Methamphetamine, yes. 15 MR KELLY: You also say, in paragraph 10, that your impression of ATS users in this LHD is that there tends to be more acutely disturbed patients presenting with significant disinhibition, increased paranoia, aggression and behavioural disturbance. And – and you say that that evidence is given by reference to your overall experience 20 in other LHDs. DR WIMS: Correct. MR KELLY: Which other LHDs are you using – which – where were you – where 25 was the experience obtained that you’re using to make that observation? DR WIMS: So I’ve – I’ve been living in Australia for 12 years, starting on the Gold Coast. And I’ve pretty much circumnavigated the country twice now and have worked in 16 different mental health services since I qualified. So I have experience 30 from both sort of regional areas like Lismore, metropolitan areas like St – I worked in St Vincent’s in Sydney. I also worked in a very rural regional area called Geraldton in Western Australia. And my experience is that our – certainly I – I believe that our patients seem more acutely disturbed here, in northern New South Wales, than I’ve experienced in – anywhere else in the country. 35 MR KELLY: And when you say more acutely disturbed, do you mean that the number of acutely disturbed patients is higher - - - DR WIMS: So - - - 40 MR KELLY: - - - or the level of acute disturbance is more severe? DR WIMS: Both. 45 MR KELLY: Both. And you mention also in that paragraph in your statement your high-dependence unit, which you’ve given some evidence about already, and that it’s


almost always full, and a significant portion of those patients are acutely behaviourally disturbed from ATS use. So this recent period where the high-dependency unit was emptied is unusual, is it? DR WIMS: Incredibly unusual for our service. 5 MR KELLY: And what other – you said that that unit is where you care for the patients who require the highest level of care. DR WIMS: Correct. 10 MR KELLY: What other sorts of patients, other than these severely behaviourally disturbed ATS users, are in that high-dependency unit? DR WIMS: We would also have patients who are at very high risk of self-harm, 15 patients who are very high risk of falls, which may be – due to their level of aggression, they’ve required large amounts of sedative medication, and despite the sedative medication, they still are – the term we would use is that they’re trying to push through it. So they’re – they may be walking around the unit staggering, have the, you know, very disturbed gait, so are at high risk of falls. So they require very 20 high-intensity nursing supervision to protect them from injury. MR KELLY: And does the need to care for the acutely behaviourally disturbed ATS users in this high-dependency unit impact in any way on your ability to care for the other patients who are in that unit? 25 DR WIMS: Yes, in the sense that they – they – they require quite a lot of intervention. They – they require pretty much constant supervision, constant support. Managing the behavioural incidents takes the nurses away from doing other forms of therapeutic work with – with other patients. So it takes the nurses away 30 from having time to sit and actually just have a conversation regarding what led up to the person coming in to hospital, what are their hopes and ambitions and – and how we’re going to get you out of hospital. However, we do transition people from that high-dependency unit to a lower-dependency unit as quickly as possible, so that, you know, that – that level of care can – will certainly be taken over in the lower-35 dependency unit. MR KELLY: Is – withdraw that. In paragraph 13, you give some evidence about admissions to the mental health unit. And you say that on some occasions, you’ve seen patients where admission to the mental health unit has not been appropriate 40 because the patient was suffering from amphetamine intoxication:

…which tends to be self-limiting as the intoxication tends to run its course. Once the patient is no longer intoxicated, admission to the mental health unit is not appropriate. 45

And then you say:


However, the dilemma of whether or not to admit a patient to the mental health unit can sometimes be determining –

if the individual is intoxicated, rather, and not mentally ill. Were you here earlier – and then you say, I should say: 5

We tend to err on the side of caution and assume a patient is mentally ill and admit them unless it is obvious that they are just intoxicated.

How do you make that determination about whether they are just intoxicated or 10 they’re mentally ill? DR WIMS: It – it’s – it’s a very hard decision to make. And that’s why I say that we would err on the side of caution. And often we are going on their past history. Is it somebody that’s known to us? Is it somebody who has had a previous mental 15 illness? Or is this somebody who has been previously highly functioning in the community; we know that they ingested a point of ice either the day before or earlier on that day and then 12 hours later they’re presenting to our department with – with paranoid ideation, with agitation, with anxiety. 20 So in – in those situations, there is sometimes – and it’s part of our clinical judgment and skill to kind of look at the chronology and go this seems to fit with an intoxication picture rather than just a – rather than a psychotic or a mental illness picture. But as – as Dr Davies was pointing out, the emergency department is often not the best place for – to – to – to look after these individuals. And in mental health 25 we have the skills – our nursing staff are – are highly skilled in – in managing behavioural disturbance. The psychiatrists are very familiar with the pharmacotherapy of managing behavioural disturbance. So often our – our intervention is necessary, and sometimes admission to our unit is 30 the – the best course of action, rather than leaving somebody in an ED, where – as – as Dr Davies was pointing out, it’s a very stimulating environment. There are – are lots of – there’s lots of through-put. And it’s – it’s easy for these patients to – to kind of get missed or where they require being placed in a – a safe assessment room with the door locked and essentially being secluded, which can then cause even further 35 agitation and can be very distressing and traumatising for the patient as well when they eventually recover from the episode. MR KELLY: And are these patients who present you with this dilemma patients who are always coming to your attention through the ED? 40 DR WIMS: Nearly always through the ED. Very rarely would they self-present to community mental health. Exceptionally rarely would they come via a section 33 from the – the – from the courthouse, because again, usually if – if they were that intoxicated in the courthouse, they would probably be brought to the emergency 45 department in the first instance.


MR KELLY: And are these – were you in the court when Dr Davies was giving his evidence? DR WIMS: Yes. 5 MR KELLY: And are these the patients who you – would fall at the more severe end of the spectrum that Dr Davies was describing of behavioural disturbance? DR WIMS: Again, it varies from individual to individual. You know, no more than the rest of us – people who use ATS will have different effects depending on their 10 physiology, depending on their brain make-up, depending on their psychology. So some people who use ATS – they just get very busy and get very active, and are hyperactive – others who may have more anti-social traits, those anti-social traits might manifest more pronounced, and they might be more prone towards aggression. If they’ve been habitual users of ATS and have front lobe problems, or if through 15 earlier childhood trauma or foetal alcohol syndrome, for example, or some other neurodevelopmental problem, the ATS might cause even more disinhibition, and these are the group who are most risk of violence and aggression and being extremely threatening. 20 MR KELLY: And so this – the dilemma that we’re talking about, about whether to admit a patient to the mental health unit or not – that falls within that area of – falls within that group of patients that Dr Davies and I were speaking about where – when I took him to your statement, where you would mention a difference of clinical opinion in the ED; is that right? 25 DR WIMS: And usually we will collaborate. But, to be honest, often by the time we get to having that discussion the emergency department have had to intervene very quickly to contain and manage this person’s behaviour, and often this requires very large doses of sedative medication. And then, therein comes the other dilemma, 30 that the mental health unit is not the best place to manage people who are extremely heavily sedated, where their airway might be compromised. And I have been in the situation in the emergency department where we’ve had to give somebody a lot of tranquilisation, then it’s difficult to do – and it’s impossible to do an assessment because the patient is asleep. 35 And then we are trying to get to this fine point about where they are sedated enough to give us a story, but they don’t then become so aroused that they become a risk again, and we end up having to go back and having to tranquilise them all over again. So it’s a real – I suppose a combination of art and science and collaboration and 40 communication with the emergency department and the mental health physicians to try to find a way of how do we look after this person as best possible? THE COMMISSIONER: Doctor, when you sedate someone in ED, just wondering – the legal basis for doing that. If they come in and they’re not well enough to sign a 45 consent to be treated, do you treat them as mentally disordered people? Is that how it works? I’m just wondering how you - - -


DR WIMS: Sometimes we don’t even have time to do the paperwork. THE COMMISSIONER: Right. DR WIMS: We might actually have to use duty of care. 5 THE COMMISSIONER: Yes. Okay. DR WIMS: Often they will come in under section 22 from the police. Rarely – less commonly a section 20. If they’re that agitated – if they come in under a section 20 10 and they’re that agitated, often the ambulance officers will have administered some sedative medication prior to them arriving. THE COMMISSIONER: Right. On a duty of care basis. 15 DR WIMS: Yes. Or under their section 20 - - - THE COMMISSIONER: Yes. Okay. DR WIMS: And then when they present to us, we will continue the section 20 or we 20 might put them on a schedule, and then a form 1, and then use that as the basis – the legal basis for the administration of the sedation. THE COMMISSIONER: Right. I imagine it would be quite rare that one of these people would consent to be sedated. 25 DR WIMS: It does happen. It does happen. Again, often people will err on the side of caution in terms of does this person have genuine capacity to make that decision. THE COMMISSIONER: Yes. Sure. 30 MR KELLY: And do they then require the protection that the Mental Health Act offers? THE COMMISSIONER: Right. 35 DR WIMS: So more often than not we will go down the road of implementing the Mental Health Act to ensure that there are those checks and balances, and very clear rights and responsibilities. 40 THE COMMISSIONER: Right. Thank you. MR KELLY: Dr Davis gave some evidence that presently he would estimate that these heavily resource-dependent patients – he would see about once a week, once a fortnight; is that consistent with your experience? 45


DR WIMS: I think that’s an underestimate, to be honest. I think we see people like that more often. MR KELLY: And what frequency would you put on it? 5 DR WIMS: I would say probably two or three times a week. MR KELLY: And these are patients who are coming in through the ED with significant behavioural disturbances that require this discussion with mental health to determine where they should best be based? 10 DR WIMS: Yes, that’s correct. MR KELLY: In paragraph 14 you give some evidence about comorbidities. You say that the most common comorbidity seen in patients is Hepatitis C and there’s an 15 active treatment program available through the Lismore Base Hospital Liver Clinic; is that most common comorbidities seem amongst patients that are presenting with ATS-related illnesses? DR WIMS: Who – or have comorbid mental health problems. Yes. 20 MR KELLY: I see. So they’re patients who already have ATS use and a comorbid mental health problem, and amongst that cohort of patients Hep C is what you’re seeing most commonly as an additional comorbidity. 25 DR WIMS: Correct. MR KELLY: In terms of the patients that are you are seeing who have a – both a mental health diagnosis and are ATS users, what proportion of those would meet the criteria for a substance use disorder? 30 DR WIMS: Well, technically, under the ICD 11 or the DSM 5, they would all meet the criteria for a substance use disorder. It’s just how you categorise it. So whether it’s dependent, harmful use, currently in remission or intermittent use – you know. So in that sense, from a technical point of view, they would all meet that criteria. 35 MR KELLY: All meet that definition. Now, I want to ask you some questions briefly around screening. And you refer to screening in paragraph 23 in response to a question asked by the special commission. And you reference there what appears to be a current screening practice for tobacco dependents. Do you screen for things 40 other than tobacco dependents, currently? DR WIMS: Yes. So we have a checklist, which is a screening tool for substance use, which would include amphetamines. But, unfortunately, it’s not particularly comprehensive in terms of – it’s more of a checklist. And the reason that I compared 45 the SBIRT program to the screening for tobacco dependents, the work that we’ve done around tobacco dependents in reducing the nicotine on hospital campuses has


been much more comprehensive than just a checklist. So it finds out more about the frequency of use, when you first use it during the day, what are the situations that you use it in, how can we support you as a service in remaining abstinent whilst you’re on the ward and coping with the fact that this is a smoke-free environment? So I think in that context, SBIRT would be – could be really useful and could mimic 5 that kind of intervention. MR KELLY: And for the benefit of the transcript, you’ve referred there, a couple of times, SBIRT, which is S-B-I-R-T. 10 DR WIMS: Correct. MR KELLY: Screening, Brief Intervention, Referral for Treatment. And so that – as I understand what you’ve described is, essentially, what’s done with tobacco which is screening and then a brief intervention and then referral. 15 DR WIMS: Correct. MR KELLY: Yep. In paragraph 25, you refer briefly to identification of individuals affected by ATS through urine drug screening. When does that occur in 20 your service? DR WIMS: It’s – it’s – it’s intermittent. One of the challenges in identifying methamphetamine is that it’s got a short half-life and, often, getting a – a – a patient to comply with providing a urine specimen during the very acutely – just 25 behaviourally disturbed phase is – is challenging. We do sometimes use saliva swabs as well, but, again, that – that’s similarly challenging during that – that acute phase. So we sometimes elect not to screen using urine drug screens because we feel, well, the moment has passed or the individual has already admitted to having used amphetamines, and in order to just manage scarce resources, we might not, kind 30 of, use the – the urine drug screen. Where we might use the urine drug screen more often would be in community managed clients who have got conditions under the community treatment order or where they’re also involved with community corrections, and – and we can use it as part of our – our risk assessment and risk profiling of that individual. 35 MR KELLY: You also say in that paragraph that, at times, ATS use can be overlooked. Is that a problem for you in the treatment that you provide? DR WIMS: It – it – well, it is, in that, as I alluded to just now, it can be an 40 indication of risk for that person in the community. It can also be a missed opportunity for recognising what can precipitate somebody’s psychosis, but somebody’s – sometimes, somebody’s psychosis is just so severe that – that that’s where all the attention goes, and we are more concerned about symptom management and optimisation of the individual and then it – we may forget to ask 45 about the role of amphetamines, or if it’s not particularly obvious in the beginning, it may get overlooked.


MR KELLY: Do you have any sense that stigma plays any role in the extent to which it may be missed – ATS use may be missed? DR WIMS: I – I don’t think so. That’s not my feeling. 5 MR KELLY: You give some evidence in your statement about your experience with patients who have been in custody or are currently in custody, and at paragraph 28, you say that:

We are currently working to keep track of our patients who are in custody. 10 How do you do that? DR WIMS: By phoning around and, really, it’s by – by trying to make contact with the various people that we know within, kind of, Justice Health, criminal justice, 15 community corrections, “Do you know where X, Y and Z is?” And I had a recent example of wanting to make sure that there was continuity of care for one of our patients. He was moved to Grafton. By the time I had organised the psychiatrist review in Grafton, he had then gotten moved onto Cessnock. Luckily, he did get seen by a psychiatrist in Cessnock, but before the treatment plan could be 20 implemented, he was moved to Windsor. The mental health nurse at Windsor didn’t know anything about this individual or – or – or what – you know, what the nature of his problems were, and then he got moved from there and I lost track until, eventually, we – we found him in another 25 part of the corrections system. But that – that took quite a bit of work and effort in – in having to make lots of phone calls and – and – and tracking, and despite, you know, trying to provide continuity of care and despite trying to advise colleagues that this person needs treatment, needs intervention, because of being moved so often, he just fell through the gaps. 30 MR KELLY: And in the context, specifically, of patients who you see have comorbid mental health and ATS use issues, what effect does your inability to keep track of those patients have on the care that you can provide to them? 35 DR WIMS: Well, it means that patients will often go without medication. It often means that they will end up psychotic within the prison system. From speaking with some prisoners, they will kind of keep that amongst themselves within the prison population, and it’s only if the prison officers are particularly vigilant or the – the person with the mental illness is particularly obvious or problematic that they come 40 to the attention of the mental health nurse within the – the prison environment and may then get back on treatment. However, the other obstacle then within the prison system is the – the legal framework within which they are allowed to act and only certain units where you are allowed to administer medication against the patient’s will. So in the majority of prisons, if a prisoner is refusing his long-acting injectable 45 medication which would prevent his psychosis, that there’s very little that the mental health nurse or psychiatrist that’s visiting can do about that.


MR KELLY: And my understanding of the challenges for you is that you may be able to know in advance that a particular patient requires medication and they will rely on a self-report, which those in custody who don’t have the benefit of continuity of care would need to rely on. 5 DR WIMS: And it’s also when they are then exiting the – the system, that’s when I might not know that they are coming out, and we not – might not be prepared to – to receive them and, sometimes, there are plans and – and interventions that we need to – to put in place before one of our patients is exiting criminal justice system, and – and that can be difficult. 10 MR KELLY: And for, again, that particular cohort of patients that you see that are ATS and mental health comorbid, what effect does that have on the treatment that they might - - - 15 DR WIMS: It – it – it’s a missed opportunity because if we – if we can’t intervene really quickly, if we can’t provide that – that cushion for them to come out of prison and to say, “We’ve got you. We’re here. We’re containing you. We realise that you have been through this experience. We don’t want you to go back to prison. You don’t want to go back to prison. Let’s work together and find a way of stopping that. 20 Part of that may be stopping your ATS use, and part of that may be getting on medication. Let’s work together.” So it’s – it’s – it’s a – it’s – we’ve got a very short window where the individual is motivated to – to start maybe making some changes in their lives before their dealer finds them and says, “Welcome home. Here’s a free little bag just to get you back on track,” because if we can intervene 25 before that happens, then we’ve got a chance, but the dealers are often quicker than we are and they often know that somebody is out of prison before we do. So that’s a problem. MR KELLY: And in your experience, does Justice Health know when these 30 prisoners are – when and where these prisoners are released? DR WIMS: Not always. Not always. Sometimes, you know, you – you get a – a distressed phone call from a Justice Health college saying, “I saw this person only on Friday. I had no idea they were leaving, and they got released on the Sunday, and 35 they’re now back in your area, but I don’t know where they’ve been released too.” They may have been released to a boarding house. They may have been released to Link2home which is a – a very temporary homeless service. So whereby people get put up in a motel for maybe two – two nights. So we are then left, as a service, trying to track down these – these people and – and to link them back into more, kind 40 of, pro-social services than allowing them to get back into the criminal justice system. MR KELLY: So based on your evidence, it sounds as though the methods available to you for keeping track of a patient once they are in custody and the methods 45 available to you of finding out where a patient and when a patient has been released from custody are really interpersonal connections and telephone calls.


DR WIMS: And – and – and a willingness as well, and it – it’s – it – it’s highly dependent on the individuals. MR KELLY: Which individuals? 5 DR WIMS: So the – so I would say, in my case as, kind of, the leader of the service, you know, trying to, I suppose, instil the belief in – in – in my teams that these are a really important client group that we need to keep hold of, and it’s not that out of sight, out of mind. It’s we need to continue to keep them in mind so that we’re ready for when they come back home to start picking up the pieces and – and – and setting 10 them on a better trajectory. But we don’t have systems set in place to make that easy for everybody across the organisation because all – all of New South Wales Health is stretched, and mental health services across the – the – the state are incredibly stretched. So this takes a lot of resources to – to – to put an effort into what, normally, is one individual that we might not even get paid for in today’s ABF 15 funding because whilst they’re still in prison, they don’t have a Medicare number. They’re not officially on our books. So that’s – that’s – that – that’s a dilemma from a – a – a resource management point of view. THE COMMISSIONER: Sorry, could you just explain that again, that Medicare 20 number? DR WIMS: So once a prisoner enters into the – into a correctional centre - - - THE COMMISSIONER: They lose their Medicare rights. 25 DR WIMS: - - - they lose their access to Medicare, exactly. THE COMMISSIONER: Yes. 30 DR WIMS: So, therefore, to link them in with services from the outside we can’t provide Medicare-related services. And in today’s activity-based funding model, that also means that we then don’t get any compensation – financial compensation for that intervention. 35 THE COMMISSIONER: Right. So are you doing interventions without compensation for these people, do you find? DR WIMS: Absolutely. 40 THE COMMISSIONER: Right. Now, just with the Medicare being – is it cancelled or suspended when they go into prison? DR WIMS: My understanding is that it’s cancelled and they then have to reapply upon exit from prisoner, and that can be challenging because a lot of our consumers 45 coming out of prison have literacy difficulties. They – their main priority is having access to home, somewhere safe to stay. Meeting their friends and family after


having been separated from them for quite some time. So it can take a while for them to get their Medicare care reactivated. THE COMMISSIONER: So then they’re sort of in this dead space of not being able to get treatment that is given other than in a voluntary way. 5 DR WIMS: Yes. THE COMMISSIONER: Can you think of any good reason why, as a matter of policy, it would be Medicare’s practice or the Federal Government’s practice – the 10 Federal Health Department’s practice to cancel or – cancel a Medicare card? If someone is in custody they wouldn’t be able to use it, one would have thought, there. DR WIMS: It’s – I don’t know. I really can’t explain it. 15 THE COMMISSIONER: Right. I just wondered if there might be a rationale. I can’t – I’m having trouble thinking of one, but – all right. Thank you. MR KELLY: You give some evidence about workplace issues about dealing with patients who are ATS-affected. Would you just speak briefly to those workplace 20 issues? DR WIMS: I think Dr Davies described the workplace issues quite strongly, and similarly our police officer who presented first thing this morning. The anxiety that having a severely behaviourally disturbed ATS-affected person coming into an 25 emergency department, in particular, causes is phenomenal. As a team of professionals who have been trained in violence prevention management, who have the skills to, you know, rapidly tranquilise somebody, you’re left confronted with this individual who is basically saying bring it on, I’m ready for you. You know, the police officer mentioned that it can often take a lot of intervention on their part, 30 using, you know, quite strong physical interventions to subdue the individual. We’re not trained for that. We’re – that’s – that’s not how we were ever built. We have been designed or created through our professional training to be compassionate and caring. So to then have to restrain and forcible medicate somebody – and sometimes have to physically restrain somebody for a prolonged period of time while sedation 35 works is extremely traumatising. That’s from a psychological point of view and a mental health point of view. There’s also the perceived threat that I’m going to get assaulted, and all of my colleagues who – you know, they’ve got loved ones, they’ve got children – I’ve had 40 nurses, you know, in tears having to – telling me about explaining to their child why mummy had a bruise on their face. You know, why their clothing has been ripped, and then – you know, I know husbands who worry about their wives going into work in this environment and asking why would you put yourself through this? 45 And so it’s – you’ve got your frontline workers who are extremely traumatised by it, who are worried about it in the back of their mind everyday; we’ve got security staff


who we ask to be front and centre in management of their behaviour; we’ve got families who are affected who worry about their loved ones going into work everyday. Then there’s the trauma that occurs to the person who is ATS-affected, because – you know, they get forcibly restrained, they get forcibly medicated. In some situations – I mentioned this in my statement – they end up in the intensive 5 care unit. I’ve had one client who required large doses of a particular anaesthetic that caused her to dissociate, which is where people lose contact with reality. Now, we weren’t aware that that’s what her experience was; we just thought that she was continuing 10 to kick out and lash out, so she ended up getting more sedative medication. But she was extremely traumatised by that experience and, you know, it caused a lot of distrust. So this whole cycle is just traumatising everybody, and it’s a dilemma about how do to it better. 15 MR KELLY: And the frequency with which you’re seeing these events which you would describe as traumatic, they equate to the two to three times a week that you were – you gave evidence about earlier. DR WIMS: Yes. 20 MR KELLY: I – and I’m rushing through it a little bit here because we’re running up against – out of the time that we have available, but I want to ask you some questions about the consultation liaison or clinical liaison services that are available which you refer to at paragraph 19 of your statement. You heard the questions that I 25 asked Dr Davies about this. Are they services that are presently available to you for drug and alcohol consultation liaison sufficient in – for the needs of your patients? DR WIMS: Look, the woman that we have working in our consultation liaison service is remarkable. She’s absolutely amazing, I don’t know how she manages to 30 be in so many places at the one time. Having a second person would certainly result in much between provision of services. Much more education. I don’t – I think, as Dr Davies alluded to, the emergency department isn’t always necessarily the best place to do that, because you need the acute crisis to settle down a little bit. 35 But then, intervening early – and for somebody who has got the knowledge and the skill to be able to sit alongside that person saying, mate, you’ve come back in again in this terrible state. You’ve – you know, essentially been assaulted. You’ve assaulted other people. How can we break this cycle? And by continuing – we know from just the – kind of the smoking literature, by continuing to offer an opportunity 40 and seeing every single time that we meet somebody as an opportunity to help them change, they will eventually get there. So without a doubt, having more drug and alcohol consultation liaison would be a great help, and that would help not just within mental health services, but across the rest of the general hospital, where our ATS users are on the medical wards, they’re on the surgical wards, the orthopaedic 45 wards, in maternity services. So it would allow much better coverage and a much more comprehensive way of dealing with these people.


MR KELLY: And do you agree with Ms Robinson’s statement that the – having available a fulltime addiction medicine specialist would be particularly helpful in providing care? DR WIMS: We need more than one, you know. I mean, hats off to Dr Helliwell, 5 who’s sitting down the back, and Dr Hudson, who made – and their colleagues who make really Trojan efforts – but we’ve got clinicians working out in the community without access to medical practitioners to support their practice. We’ve got a really lean drug and alcohol service who are really up against it but are providing the very best that they can do. But I think with adequate resourcing – you know, with the 10 passion that they’re already showing they could do so much more. MR KELLY: And Dr Davies gave some evidence around the importance of having available consultation liaison services out of hours because of the nature of an emergency department. Does your department have the same – or do mental health 15 services have the same needs for out of hours support? DR WIMS: No, no. Not so much. I mean, it – it would be useful, I think, in the – in the evenings because often it’s a quieter time on the wards, the – the patients are less occupied. I think during those quieter moments, it’s a really good time to do 20 therapeutic interventions. So from that point of view, yes, but in general, within business hours works as well. MR KELLY: Thank you, Doctor. Commissioner, I note the time. It’s 25 to 4. We have two doctors to get through together. 25 THE COMMISSIONER: Yes. MR KELLY: Those are my questions. 30 THE COMMISSIONER: All right. Thank you, Mr Kelly. I do have a few questions but I – I will be as efficient with them as I can. So Doctor, your – you have one person only by way of a drug and alcohol liaison person. Is that right? DR WIMS: Yes. So we have one clinical nurse consultant who works - - - 35 THE COMMISSIONER: Clinical nurse consultant. DR WIMS: - - - part time as a consultation liaison nurse - - - 40 THE COMMISSIONER: right. DR WIMS: - - - for drug and alcohol. THE COMMISSIONER: Right. And at least one more would be a considerable 45 help to your service?


DR WIMS: Absolutely. THE COMMISSIONER: Yes. Now, with the percentage of your clients who you say have – are ATS users, I think you said 40 to 50 per cent, has that changed significantly the way you’ve had to develop your practices? 5 DR WIMS: Not really. Other than we’re probably seeing more, you know, higher acuity, which is more demanding on medical staff and nursing staff and allied health professionals. But then, when we just come back to basics, our treatments continue to be pretty much the same. 10 THE COMMISSIONER: Yes. DR WIMS: But needing to piggy back along with advising people about how to – to remain abstinent from substances. But certainly throughout my career, substance 15 abuse problems have – have been – when I worked in London, it was crack cocaine. And it was also skunk cannabis, so very highly concentrated cannabis. So I – I’m kind of used to this dual diagnosis comorbidity. So it’s – I just see it as part and parcel of my practice these days. 20 THE COMMISSIONER: Right. Can you tell me how many high needs beds you have? DR WIMS: We have eight in total. 25 THE COMMISSIONER: And what about just normal beds? DR WIMS: We have 18 – no, sorry, 16. THE COMMISSIONER: Sixteen? 30 DR WIMS: Yes. THE COMMISSIONER: Right. So 24 beds all up? 35 DR WIMS: Correct. THE COMMISSIONER: And we’ve heard evidence that, I guess, you’re often close to capacity. I think Dr Davies said that. 40 DR WIMS: That’s correct. THE COMMISSIONER: Do you need more beds? DR WIMS: That’s a challenging question to ask because the – it fluctuates. What 45 we have found recently is that our community teams, by putting extra resources into our community teams, we can manage better and by having – being able to intervene


earlier, and see people more often, can actually prevent admissions and – allows us to manage our beds appropriately. But, again, as I alluded to with this activity-based funding model, it’s a rather vexed situation. We get paid more to keep people in hospital than to keep people out. So we’re incentivised to keep hospital services open, rather than intervening early, preventing disability and keeping people out. 5 THE COMMISSIONER: And do your community mental health centres that you supervise, or that are within your – your area, are they adequately staffed? DR WIMS: In a word, no. We need many more clinicians within, I think, at last 10 count, we estimated we would probably need an extra 20 clinicians across the – the board. THE COMMISSIONER: Twenty clinicians? 15 DR WIMS: For – for community services. THE COMMISSIONER: Right. DR WIMS: To – to provide the – kind of the robust clinically responsive service 20 that we would like to provide. THE COMMISSIONER: Right. That’s a – that’s a – quite a shortfall, then, that you’re working with at the moment. 25 DR WIMS: Yep. THE COMMISSIONER: And by clinicians, you would include psychologists, social workers, case managers, nurses - - - 30 DR WIMS: Absolutely. THE COMMISSIONER: Yes. DR WIMS: So - - - 35 THE COMMISSIONER: Now, I – I just want to ask you if – if somebody has already schizophrenia or a bipolar disorder, and they start using ice, is the compounding effect more severe than if they hadn’t started using ice? 40 DR WIMS: Again, it’s a – it’s a difficult question to ask. Instinctively, I would say – and – and there’s some evidence to say yes, because of the – the – the direct impact of the amphetamine-like substances on the neurons. So we know from neuro-imaging studies that severe mental illness, such as schizophrenia, bipolar disorder, already disrupts neurons. So if you then add in this toxic mix of high purity 45 stimulants, like methamphetamine, then I think it makes sense that you’re going to do even more damage.


THE COMMISSIONER: In terms of the local general practitioners in this area, how supported are they in terms of mental health outreach and drug and alcohol outreach? DR WIMS: I think if you put any of them up here, they would say they struggle. They – they struggle to access services timely. They feel they are carrying a – a – 5 quite a heavy load of clients with mental health problems, plus substance abuse problems that they feel unsupported with. THE COMMISSIONER: All right. Now, you talk quite a lot about – and gave some very interesting and important evidence, I think, about the problems with 10 people transitioning in and out of jail and the loss of continuity of care that arises from that. I’m just wondering, is – are there privacy problems in terms of accessing like an eHealth record, for example, of someone, so that you can pick up very quickly where they’ve been and where they’re going to? 15 DR WIMS: One of the vexed issues we have in New South Wales Health is that certain jurisdictions use one form of electronic medical record, other jurisdictions use another. THE COMMISSIONER: Yes. 20 DR WIMS: I know that – say, community forensic – well, forensic mental health services and Hunter New England use a specific electronic medical record, iCommunicate. I’m not even sure what electronic medical record is used within the – with Justice Health. 25 THE COMMISSIONER: Right. DR WIMS: But ours doesn’t communicate with theirs. 30 THE COMMISSIONER: They don’t speak with one another. DR WIMS: No. THE COMMISSIONER: I see. So do you think there would be benefit in there 35 being a database that – so that all these health areas could speak to one another and pick up clients, so they don’t get lost to care? DR WIMS: I – I think that would be very useful. I do think privacy issues may be a part of it, as well, in that prisoners entering into a correctional facility may say, I – I 40 don’t give you consent to contact my GP or my mental health provider. And this may be a way of evading treatment. So – so that is a – a dilemma to be overcome. And I think finding ways forward for better multi-agency working is – is going to be really important. 45


THE COMMISSIONER: Right. Now, I just want to ask you again on that correctional theme, do you find that – I know that Justice Health can arrange for a community treatment order within the jail population. So somebody - - - DR WIMS: Correct. 5 THE COMMISSIONER: - - - in jail can be put on a CTO. Are you finding that that’s being used sufficiently, as far as your observations are concerned? DR WIMS: The – the difficulty, as I understand it is that there are only certain 10 gazetted facilities within the corrections systems that can apply for a forensic community treatment order. So when – when we have clients in those facilities, then, yes, it is used and used appropriately and is very helpful but when somebody is in, say, somewhere like Grafton, where it can’t used, then we can run into difficulties. 15 THE COMMISSIONER: So as far as you know, they’re not being used in – in Grafton? DR WIMS: No. 20 THE COMMISSIONER: Right. Have you had any issues with people smuggling crystal methamphetamine into your mental health unit? DR WIMS: Occasionally we would get a small amount in but cannabis is probably 25 – cannabis and tobacco are probably the more likely ones. However, in my experience, patients will often find places outside of the unit to secrete those, rather than bringing them on. THE COMMISSIONER: Right. 30 DR WIMS: And thankfully, methamphetamine is something that I’ve – I think I’ve only come across it once in our unit. THE COMMISSIONER: Right. All right. Just a couple more questions then I – I 35 will be through. You mentioned, at paragraph 21, that you note that the LHD here does not provide safe injecting facilities for ATS users, nor are there any other established harm-minimisation program or substituted prescribing available. Putting aside substituted prescribing, do you think a safe injecting facility would be a worthwhile investment for the community here, if – if the government saw fit to 40 allow that? DR WIMS: I think everything that we can do towards harm minimisation for this client group is an opportunity to intervene and to provide better health for this – this client group. 45 THE COMMISSIONER: Yes.


DR WIMS: And the – the ramifications across the community into their families, into their functioning, into their ability to be kind of pro-social and partake in society is increased with every single harm-minimisation program we put in place. THE COMMISSIONER: All right. Last question. In your view, are there adequate 5 detox and rehabilitation services available in this area? DR WIMS: I think we could do with more detox facilities. We have Riverlands here in Lismore, which provides a fantastic service. We don’t have such a facility in Tweed, and that would be very useful there. And similarly down the – the – the 10 southern end of the LHD, in Grafton: that would also be useful. Access to rehabilitation is a huge problem. The time delay in accessing the rehabilitation is far too long. And I think with increased resourcing within our drug and alcohol services, we could provide, perhaps, ambulatory rehabilitation, so similar to a – a community mental health model of care, providing rehabilitation in the individual’s 15 home rather than them having to go away from their – their – their supports and their families across the border into Queensland, for example, to do a rehab program. If can keep people as close to home as possible, keep them linked in with their supports, keep that social connectedness or build on that social connectedness, we’ve got a much better chance of positive outcomes. 20 THE COMMISSIONER: Final question. Do you think – you mentioned that CTOs, community treatment orders, are sometimes used with a condition of urine screening, for example, for people who have, I guess, a mental health and a substance use issue. Do you see any – would there be any benefit in having something equivalent to a 25 CTO for simply substance use, without the necessity for a mental health diagnosis? DR WIMS: I think the evidence base would say it’s unhelpful. And I think if we look at the IDAT program, so the involuntary detention for alcohol and drug treatment – it’s successful for the length of time that the individual is there, but the 30 evidence doesn’t say that that’s – that is sustained upon – upon leaving. THE COMMISSIONER: Right. So compulsion isn’t the way - - - DR WIMS: Doesn’t seem to be the way. 35 THE COMMISSIONER: - - - with addiction. DR WIMS: No. 40 THE COMMISSIONER: No. DR WIMS: It seems to be – the – the – the best way forward seems to be that motivational interviewing, that coming alongside the individual, helping them to – to – to make connections, find ways of – how can I – you know. “I have my good 45 reasons for using substances; are there alternative ways of meeting those needs?” And that requires a different therapeutic frame to compulsion.

.SPECIAL COMMISSION INTO ICE 14.5.19R1P-691 E. WIMS XN MR KETTLE

THE COMMISSIONER: Right. All right. Look, thank you for answering those questions, Dr Wims. Any other questions of Dr Wims? No. MR KETTLE: Sorry, Mr Commissioner. I just have a couple of clarifying – I will be very quick. 5 THE COMMISSIONER: All right. <EXAMINATION BY MR KETTLE [3.49 pm] 10 MR KETTLE: Doctor, two matters. The first one is you referred to there being 24 beds in the mental health unit. 15 DR WIMS: Correct. MR KETTLE: Does that just cover Lismore alone? Or does that cover broader? DR WIMS: So that – that just covers Lismore. There are 25 beds in Tweed. And 20 five of those are high- – high-dependency beds. MR KETTLE: Right. The other matter is you assessed the number of acutely behaviourally disturbed presentations at about two to three per week. 25 DR WIMS: Yes. MR KETTLE: Does that apply only to Lismore? Or does that apply on a broader - - - 30 DR WIMS: It certainly seems to be the same in – in – in Tweed. Would be much less so in – in – in Grafton. That may be a – a – I’m not quite sure what type of error that would be. But it’s I – I think because Grafton doesn’t have its own mental health service – they would have to come to – to – to Lismore for – for treatment – that people might go on miss – go – go missed, may get managed within the wrong 35 community rather than presenting to the emergency department. MR KETTLE: Right. And in terms of those – you’re speaking – you say that the presentation would be similar in Lismore. 40 DR WIMS: Yes. MR KETTLE: And in Tweed, would Dr Davies – would you defer to his assessment? 45 DR WIMS: I – I think Dr Davies is being a little bit conservative.


MR KETTLE: Right. Now, you were asked some questions by the Commissioner about various information systems, electronic information, between services. Now, where you are, there would also be this issue of cross-border connection electronically. Would that be right? 5 DR WIMS: That’s correct. MR KETTLE: And do you have any difficulty accessing electronic medical information in Queensland? 10 DR WIMS: Again, it will come down to a matter of consent. But the Queensland electronic medical records, particularly for mental health services, is incredibly robust, very detailed, so that when we do get those records, they’re incredibly helpful. 15 MR KETTLE: Right. But what about the issue of access, though? Are they compatible with the New South Wales system? DR WIMS: No. Completely different. 20 MR KETTLE: Okay. Thank you. No further questions. Thank you. THE COMMISSIONER: Thank you, Mr Kettle. MR KELLY: I have two questions arising from your questions, Commissioner. 25 THE COMMISSIONER: Thank you, Mr Kelly. Yes. <EXAMINATION BY MR KELLY [3.51 pm] 30 MR KELLY: Just briefly - - - THE COMMISSIONER: Yes. 35 MR KELLY: You were asked some questions by the Commissioner about the need for more beds. And you gave an answer which referred to the resourcing need being more around clinicians. I think you said you needed 20 clinicians, particularly for the community work. Do you remember that? Assume that you had the funds 40 available to pay for those additional 20 clinicians. Would you be able to find people to fill those positions? DR WIMS: That’s a very good question. And unfortunately, in regional and particularly rural areas, despite the beauty of where we live, it is challenging finding 45 clinicians to move into the area.


MR KELLY: And secondly, you were asked some questions around electronic medical records and the extent to which access to Justice Health medical records may assist in tracking prisoners. Do you – yes? Is it the case that it’s Corrective Services New South Wales who holds the information around when a prisoner will be released - - - 5 DR WIMS: That’s correct. MR KELLY: - - - so that even if you have access to the Justice Health medical records, that may not solve the problem? 10 DR WIMS: That’s correct. Yes. MR KELLY: Thank you. Those are my questions. 15 THE COMMISSIONER: Thank you, Mr Kelly. Well, Dr Wims, your evidence has been really helpful for the Commission. Thank you very much. And if I might just say that it’s clear that you and your staff, your fellow clinicians are bringing a real passion to the work that you do here. And for what it’s worth, I commend you for that. 20 DR WIMS: Thank you. THE COMMISSIONER: And keep up the good work. It’s clear that resources aren’t everything that they might be. But that kind of passion you obviously bring to 25 your work is priceless. Anyway, might the witness be excused? MR KELLY: Yes, please. THE COMMISSIONER: Thank you, Doctor. 30 DR WIMS: Thank you for your time. THE COMMISSIONER: Good. You’re excused. 35 <THE WITNESS WITHDREW [3.53 pm] MR KELLY: Commissioner, it’s – I’m instructed that we have to finish at 4.30. 40 THE COMMISSIONER: Right. MR KELLY: I haven’t – perhaps I could make inquiries of – through you, Commissioner, to Mr Kettle whether or not he knows, at this stage, whether either or 45 both of Doctors Helliwell and Hudson would be available tomorrow. We could start


early again tomorrow, at 9.30, to try and make up the time that we would otherwise lose. THE COMMISSIONER: Yes. All right. Do you - - - 5 MR KELLY: But I anticipate that I will need more than half an hour. THE COMMISSIONER: Right. Mr Kettle. MR KETTLE: Just making those inquiries now. 10 THE COMMISSIONER: Yes. Thank you. MR KETTLE: Thank you, Mr - - - 15 THE COMMISSIONER: Thank you, Mr Kettle. MR KELLY: I’m also acutely aware that one of those doctors is the doctor who we have heard already a great deal of evidence about how helpful it would be if he was available more than he presently is. So I’m conscious that, to the extent that we can, 20 if we can accommodate Dr Helliwell in particular, at a time other than first thing tomorrow morning, that that – I would certainly be open to doing that. THE COMMISSIONER: Yes. All right. Well, I will – I should be able to fit in with your needs, Mr Kelly. 25 MR KETTLE: Yes. As long as they’re both first off for giving evidence tomorrow, that would be suitable. Thank you, Mr Commissioner. THE COMMISSIONER: All right. Thank you, Mr Kettle. Mr Kelly. 30 MR KELLY: Yes. So if we perhaps, Commissioner, with – if it’s suitable to you, if we were to start at 9.30 tomorrow instead of 10. THE COMMISSIONER: Yes. 35 MR KELLY: Then we may run a little bit over, but it shouldn’t inconvenience the later witnesses, who are already intending that we will start at 10. THE COMMISSIONER: All right. Fine. Thank you, Mr Kelly. 40 MR KELLY: In that case, I call Doctors Hudson and Helliwell. And, Commissioner, for your reference, Dr Hudson’s statement is behind tab 12, and Dr Helliwell is tab 16. 45 THE COMMISSIONER: Thank you.

.SPECIAL COMMISSION INTO ICE 14.5.19R1P-695 HELLIWELL/HUDSON

<DAVID HELLIWELL, AFFIRMED [3.56 pm] <BRONWYN NAOMI HUDSON, AFFIRMED [3.56 pm] 5 THE COMMISSIONER: Thank you. Have a seat, Doctor. Thank you. MR KELLY: Dr Helliwell, would you please state your full name, current occupation and professional address for the record? 10 DR HELLIWELL: Dr David Helliwell, visiting medical officer and clinical lead, addiction medicine, New South Wales Local Health District, based at Riverlands Drug and Alcohol Service in Hunter Street, Lismore. 15 MR KELLY: And you’ve been an addiction medicine specialist for 15 years; is that right? DR HELLIWELL: That’s correct. 20 MR KELLY: And you’ve made a statement in this matter dated 8 May 2019? DR HELLIWELL: That’s right. MR KELLY: Do you have a copy of that statement with you? 25 DR HELLIWELL: I do. MR KELLY: Do you wish to make any changes to it at this stage? 30 DR HELLIWELL: I don’t. MR KELLY: And you’ve attached a copy of your CV to that statement? DR HELLIWELL: I did. 35 MR KELLY: Yes. And have you been provided with a copy of the expert witness code of conduct? DR HELLIWELL: Yes. I have. 40 MR KELLY: And have you read that? DR HELLIWELL: I have. 45 MR KELLY: And do you agree to be bound by it today?


DR HELLIWELL: I do. MR KELLY: Thank you. And, Dr Hudson, would you please state your full name, current occupation and professional address? 5 DR HUDSON: Yes. My name is Dr Bronwyn Naomi Hudson. I have multiple roles within our local area health service. I work as a GP with a subspecialty in addiction medicine. I work as an advanced trainee in the unit with Dr Helliwell, and I work as a BMO at Byron Central Hospital. So I have multiple locations. My principal location would be Byron Central Hospital. 10 THE COMMISSIONER: You sound very busy. Good. DR HUDSON: I am. 15 MR KELLY: And have you made a statement in this matter dated 10 May 2019? DR HUDSON: I think my statement is dated 13 May. Dated 10 May, witnessed 13 May. 20 MR KETTLE: I see. MR KELLY: I see. MR KETTLE: It has just been rewritten as to – yes. 25 MR KELLY: Yes. It was signed with a witness on the 13th, yes. DR HUDSON: That’s correct. 30 MR KELLY: And do you wish – do you have a copy of that statement with you? DR HUDSON: I do. MR KELLY: Do you wish to make any changes to it? 35 DR HUDSON: I don’t. MR KELLY: And you’ve – I don’t have a copy of your CV. Would you just explain briefly to the Commissioner your education and experience? 40 DR HUDSON: Sure. That might not be so brief. I studied medicine at the University of Sydney, graduating in 2008. I worked – I did my junior medical years in Sydney at both the Royal Prince Alfred Hospital and Concord Repatriation Hospital. I then worked rurally in Broken Hill Hospital, Mackay Base Hospital and 45 Bega, in the emergency departments. I then trained as a specialist GP in the Northern Rivers, starting up here in 2012, where I worked at both Mullumbimby


District Hospitals and Byron District Hospitals before they merged to form Byron Central Hospital, when I undertook specialist training in addiction medicine. THE COMMISSIONER: So you’ve had a wealth of experience in rural areas. 5 DR HUDSON: Yes. THE COMMISSIONER: Yes. DR HUDSON: Yes. 10 THE COMMISSIONER: Thank you. MR KELLY: And you’re a fellow of the Royal Australian College of General Practitioners? 15 DR HUDSON: I’m a fellow of the Royal Australian College of General Practitioners and a member and candidate for fellowship with the Royal Australian College of Physicians, chapter of addiction medicine. 20 MR KELLY: And have you been provided with a copy of the expert witness code of conduct? DR HUDSON: Yes. I have. 25 MR KELLY: And have you read that? DR HUDSON: Yes. I have. MR KELLY: And do you agree to be bound by it in the evidence that you give 30 today? DR HUDSON: I do. MR KELLY: Yes. Now, could I ask have either of you given evidence 35 concurrently before? DR HELLIWELL: Concurrently? MR KELLY: Yes. 40 DR HELLIWELL: No. DR HUDSON: No. 45 MR KELLY: So what I propose to do is ask some questions probably directed to one or other of you and then ask the other to comment - - -


DR HELLIWELL: Sure. MR KELLY: - - - whether or not there’s anything you wish to add. If at any stage you do feel that something has been raised that you would like to be heard on and I – and it looks like I’m not going to give you the opportunity, then please, by all means, 5 indicate to me that there’s something that you wish to say. DR HELLIWELL: Thank you. MR KELLY: I’d like to start with the existing services in this region, and Dr 10 Helliwell, you refer to that in pages 10 through 16 of your statement. Could you start by explaining what the current available consultation liaison services are that are available in the LHD - - - DR HELLIWELL: Right. So - - - 15 MR KELLY: - - - from drug and alcohol practitioners. DR HELLIWELL: So in the LHD, we have consultation liaison nurses, the clinical nurse specialists. I think there’s a full-time one at Lismore. It’s point 8 at Tweed 20 Heads, point 6 at Grafton, point 4 at Ballina. But one of the problems with those services, besides not being full-time, is that they are invariably not backfilled for leave, sickness, those sorts of things as well. So it’s pretty thin on the ground. MR KELLY: And in terms of other services which are available within the region 25 that are staffed by drug and alcohol practitioners, what are they? DR HELLIWELL: Well, we basically have drug and alcohol counsellors based, I guess, permanently in Lismore, Tweed, Grafton. We then tend to get – and Byron as well. Yes. 30 DR HUDSON: Yes. DR HELLIWELL: Byron too. We then tend to get, sort of, a patchy outreach service to smaller multipurpose services such as Nimbin or Bonalbo that might be 35 there once a week, once a fortnight, that sort of thing. So that’s the – the other sort of coverage through, certainly, drug and alcohol counselling. MR KELLY: And the inpatient service that you referred to, you mentioned at Riverlands earlier. 40 DR HELLIWELL: Yep. Yep. So we’re – we’re actually not a 15-bed unit. We’re a 12-bed unit and we’re actually funded for eight beds in terms of the funding that we get. That basically is staffed by visiting medical officers and a couple of advanced trainees. The visiting medical officers, we have three, and they each work 45 – well, two of them work 18 hours a week, one of them works 12 hours a week, and then we have two advanced trainees: Bronwyn is one; Anthony Solomon, our – our


– our Byron GP is the other one, and they come to us for about six to eight hours a week, once a week as well. MR KELLY: At Riverlands? 5 DR HELLIWELL: At Riverlands, and we have no junior staff, we have no registrars, we have no interns. MR KELLY: In terms of the services that you’ve just described which – is that all of the existing services that are available through the LHD for drug and alcohol 10 services in this region? DR HELLIWELL: The – basically, we’ve got centralised intake which is run out of – of Riverlands. We’ve also got a couple of general practitioner, VMOs, who come and do a session a week in the opioid treatment program, one at Tweed Heads and 15 the other down in Grafton. Have I left anything out, Bronwyn? DR HUDSON: There is a community engagement worker - - - DR HELLIWELL: Yes - - - 20 DR HUDSON: - - - in Byron - - - DR HELLIWELL: Yep. 25 DR HUDSON: - - - which is part-time position that – her role is to assist people actually presenting to services, so those people that struggle to actually get to the hospital, she’ll engage those in treatment. And the only other thing that I’d add to that is that Byron hospital doesn’t have any consultation liaison drug and alcohol services at all. 30 MR KELLY: So in terms of the adequacy of services that are available within the region, Dr Helliwell, do you have anything to say about that - - - DR HELLIWELL: Well, I’d say that they’re sub-adequate. 35 MR KELLY: In what way? DR HELLIWELL: I think both in terms of the level of cover that we have. For instance, we do not have doctors at the inpatient withdrawal unit. From about 8.30 40 am is when they arrive. At about 4.30 pm is when they leave. We don’t have any doctors there. If someone gets sick in the inpatient withdrawal unit, we actually have to send them up to Lismore Base in a – in an ambulance. Lismore Base will not provide us with resident staff to come down and see our patients out of hours, and we don’t actually have a visiting medical officer on call from 11 o’clock at night till 7 45 o’clock in the morning. And basically, calls go through to the drug and alcohol specialist advisory service, New South Wales in that time.


THE COMMISSIONER: Doctor, you mentioned you had 12 beds, but you’re funded for eight at Riverlands. DR HELLIWELL: Yep. 5 THE COMMISSIONER: How does that happen? How do you make that happen? DR HELLIWELL: Well, we only found this out fairly recently, I think, when our – our most recent nursing unit manager sort of dug around and actually found – because we were looking at our occupancy figures and saying, you know, it’s not 10 very good for 12, but when we actually looked at our occupancy, it’s supposed to be eight. THE COMMISSIONER: Right. 15 DR HELLIWELL: It’s like – well, we were running at 125 per cent on some days. THE COMMISSIONER: Right. DR HELLIWELL: So – so there seems to be a mismatch between the funding 20 number and the bed number. THE COMMISSIONER: Has that been made clear to Health? DR HELLIWELL: I – I – I think our general manager is well aware of – of that. 25 THE COMMISSIONER: Okay. Thank you. MR KELLY: Dr Hudson, you say – is there anything that you’d like to add to what Dr Helliwell said there? 30 DR HUDSON: I think in terms of the services being under resourced, the models of care that we run on, there – there are a lot of services that we could provide quite easily that we just don’t because we don’t have the resources. One of those would be ambulatory withdrawal management. Not all patients need to come into hospital to 35 withdraw from certain substances. Certainly, amphetamines is one of those, and if we had the resources to run an ambulatory care unit, it would be a much more efficient model of care. MR KELLY: In your statement at paragraph 28, you say there’s a lack of services 40 for those ATS users who were not in crisis, but are not stable and in recovery. DR HUDSON: Yes. Yes. MR KELLY: And what do you mean by that? 45


DR HUDSON: So, by that, I mean that the stepped approach to care that we – taking mental health and drug and alcohol services, there – there is crisis care. So somebody that – and my colleague’s talking about presentations to the emergency department where people are in acute crisis, and then people that are well in recovery are well cared for by their primary care provider or general practitioner, but there’s a 5 spectrum in between that where people could be cared for in a subacute manner when they weren’t stable, but weren’t at a crisis point, but those services don’t – don’t really exist. And in terms of the general practice model where an ideal place to care for them would be the – the structure of funding for general practice means that it’s not a viable option for general practitioners to engage in that kind of primary 10 care. MR KELLY: And are you aware whether care of that kind – not the general practice care, but you were speaking about, earlier, in the availability of care that isn’t presently available here. 15 DR HUDSON: Yeah. MR KELLY: Do you know if that’s available in other LHDs? 20 DR HUDSON: I don’t. MR KELLY: Dr Helliwell. DR HELLIWELL: Well, I – I – I think what we’re talking about a lot of the time is 25 assertive follow-up where, you know, if – if a patient drops out of – of follow-up, we actually chase them down. To some degree, that may be something that the community engagement team does before people come to our service, but it’s really having that aftercare component. I’m aware that the – the – The Buttery now has a bit of a – an aftercare service up and running, but the most important thing is really 30 about being assertive and persisting in terms of follow-up. It’s one of the messages that I think we’d both like to get across is that amphetamine withdrawal is not severe. It’s not life threatening, but in terms of aftercare, it is crucial that people have good evidence based aftercare for a significant period of time. 35 MR KELLY: Dr Hudson, in this portion of your statement, you also say that the inpatient withdrawal unit is under resourced, which I think Dr Helliwell has already touched on:

There is no clinical director and no funding for such. The unit itself has run 40 successfully and achieved good outcomes based on the work of a solo addiction specialist who is passionate and dedicated to his field. This is an unsustainable model as it is dependent on one person. If this person was to leave the LHD, then the unit would be left without any clinical leadership.

45 Who is that person?


DR HUDSON: It’s my colleague to my left here. DR HELLIWELL: The one who’s blushing. MR KELLY: And Dr Helliwell, do you have anything to say about that? 5 DR HELLIWELL: That I have a passion for addiction medicine? It gives me great joy working with people at the pointy end of society, and we see fantastic outcomes. That’s something – the bit that doesn’t come across to the public, you know. I’ll often get colleagues say, “Well, why do you work with those losers?” And I’d say, 10 well, actually, we get really good outcomes. We – you know, if we can engage people and get them into evidence based treatment, then the outcomes are excellent and you see fantastic turnarounds in people’s health. MR KELLY: And do you agree that the model is unsustainable because it’s 15 currently dependent on you? DR HELLIWELL: I – I – I feel that at 3 o’clock in the morning when I wake up and worry, yes. 20 MR KELLY: In terms of Riverlands, more specifically, could you tell me a little more about the requirements for admission to Riverlands. DR HELLIWELL: Most patients – for the inpatient withdrawal unit? For the inpatient withdrawal unit, most patients will self-refer. So I think it’s about 80 per 25 cent plus of our patients actually refer themselves direct to intake. We obviously receive referrals from MERIT, the Magistrates Early Referral Into Treatment, drug and alcohol counsellors and also through our CL service which tries to pick up those patients from hospital wards and mental health units and also in the accident and emergency departments. And one of the things we’ve certainly tried to do, for 30 instance, is we’ve – we’ve started to split the shifts of our medical officers, so that we just get a little bit more admission time so that we can trying – just be fast on our feet for that patient who does come in in crisis, settles down and then says, “I’d like to engage with treatment,” and they need inpatient withdrawal management. So it’s – it’s – it’s – it’s one of those things where we’re trying to, I guess, get more faster 35 and flexible on our feet in terms of being more acute with our admission processes. MR KELLY: And when the inpatient withdrawal unit is at capacity and someone is referred, what’s your process, then? 40 DR HELLIWELL: We very rarely are at capacity, capacity. Our intake processes is based on there being no waiting list for a patient that needs urgent treatment. So to some extent, part of our intake process is triage. You know, an example might be where you’ve got a highly vulnerable pregnant Indigenous woman who’s in a domestic violence situation and has problems with methamphetamine. You want to 45 get that patient in today or tomorrow. You might have someone else who’s got a residential rehab place booked in three weeks time and you want to get that person


in, in just under three weeks time so they dovetail from inpatient withdrawal unit straight into that residential rehab. MR KELLY: Is there any formal relationship between the availability of residential rehab post admission to the withdrawal unit and admission to the withdrawal unit? 5 DR HELLIWELL: Sadly not. What we have to tell our patients who want to access residential rehab is here’s a list of the rehabs; we may be able to get a worker to help you phone around, but you might have to do a lot of that phoning around yourself because, again, we’re very short-staffed. Once you’ve got, you know, engagement 10 with them and an admission date, let us know; we will get you in. So to some extent the patients have to do a lot of running around in relation to that. MR KELLY: So does that mean they can’t be admitted until they can satisfy you that they have a place in a residential rehab? 15 DR HELLIWELL: No, because a lot of patients don’t require residential rehab. Again, when you look at the evidence based around residential rehab, we certainly know that two groups of people do extremely well in residential rehab. Those are patients who are homeless, and those who are also patients with chronic mental 20 health problems. And I have a suspicion, too, although I’m not an expert in terms of being able to pull figures, that those patients with severe ATS dependency may benefit from a period of residential rehabilitation – I guess because we see a degree of sort of cognitive deficit associated with severe ATS dependency. 25 MR KELLY: Dr Hudson, did you want to add anything to that? DR HUDSON: No. MR KELLY: I will move onto profiles of those patients that you see how are using 30 ATS. Dr Helliwell, can I start at – with you at paragraph 5 of your statement, and you say:

I compared with patients presenting with other substance use disorders. Those presenting with disorders from ATS are more likely to be younger from poorer 35 socio-economic backgrounds from a more rural setting; are more likely to be homeless and identify as indigenous.

Dr Hudson, did you want to add anything to that? Or – sorry, I withdraw that: do you agree with that characterisation. 40 DR HUDSON: I do. Dr Helliwell and I see a very different cohort of patients, so our cohort of patients that we share at Riverlands, I definitely agree with that. The cohort of patients that I see in the community are different again. 45 MR KELLY: And I think at paragraph 9 of your statement you say that patients that you’ve treated that use ATS:


…vary according to type of substance used and reason for use, and it’s not helpful to put all people who use ATS in the same basket.

Are you referring there to different types of demographic - - - 5 DR HUDSON: Yes, different demographics, different motivations for use, whether that’s a motivation to get high and have a good time at a party or at a music – one of our local music festivals, or whether the motivation is to numb the pain of their internal world or to allow them to exist in a home environment that’s not pleasant. So different motivations and then different substances will be used according to 10 those different motivations. MR KELLY: And you do say also:

Due to its affordability and accessibility, people who use ATS tend to be 15 younger from lower socio-economic groups and identify as indigenous. However, in my clinical experience, people from all walks of life are using ATS use in a professional setting where performance is required is also not uncommon. Use in those with a trauma background is also not uncommon. 20

DR HUDSON: Yes. MR KELLY: When you say ATS use in a professional setting, what’s your experience with those users and the types of professions that you’re seeing? 25 DR HUDSON: Yes. Certainly. So it’s certainly – definitely in long-distance transport. The fly out – fly in, fly out workers that Dr Davies was referring to. I have a cohort of medical professions – not doctors, nurses, but other professionals, in the legal profession, in profession that require a high amount of energy, so cleaning professions, for people that need to be awake, alert a lot. So it’s not just defined to 30 blue collar workers; it’s all walks of life and all ages. I have patients ranging from, you know, 12 to 70 who use amphetamines. MR KELLY: Dr Helliwell, do you have anything to say about that 35 DR HELLIWELL: No, I think we’ve covered the spread of ATS use quite well. MR KELLY: And we have been talking about ATS generally. Are you able to unpack, by reference to particular ATS, whether or not you can identify any commonly-occurring demographic features? So for – in a crystal methamphetamine 40 user, for example, do you - - - DR HELLIWELL: Yes. I mean, I think we would say, you know, the dance party phenomena is based more around MDMA than crystal methamphetamine. I think we would certainly say that, you know, injecting drug use is associated with crystal 45 methamphetamine. I think we would say that people using them to enhance their


work abilities would tend to use crystal methamphetamine rather than MDMA. So there’s very much a disconnect between those two substances. DR HUDSON: And professionally they would be more likely to smoke it than inject it. 5 DR HELLIWELL: Yes. MR KELLY: So a person who is using for the purposes of assisting with their work would be more likely to smoke than inject. 10 DR HELLIWELL: Yes. MR KELLY: And in terms of – you’ve said that you see a spread of people from all ages and all professions and all backgrounds that use ATS. Does that apply to both 15 MDMA and crystal methamphetamine? DR HUDSON: Yes DR HELLIWELL: Yes. 20 MR KELLY: Yes. Now, I think, Dr Helliwell and Dr Hudson, now, you’ve mentioned modes of administration. So intravenous use and smoking. Are you able to say, in the proportion of methamphetamine users that you see, what the split is there between modes of administration at all? 25 DR HELLIWELL: Well, I think it would depend on the setting again. Off the top of my head – and I say this is off the top of my head, because I don’t think we’ve got stats for mode of use in our database – but I would say less than 50 per cent are injecting. A lot of patients are smoking crystal methamphetamine and of course 30 that’s one of the very seductive factors around crystal methamphetamine is that you can administer very high doses very quickly through smoking, you know, more rapidly than you can intravenously, just happen to have to burn it a little bit of you’re crystal methamphetamine in the process. So in terms of rapidity of onset, smoking and injecting have a similar rapidity of onset. I think when you’re looking at things 35 like the dance party, seeing things like that, then it’s more likely to be smoke than injected. And I think when we look at, say, our cohort of patients on our opioid treatment program, it might use crystal methamphetamine – they would probably tend to inject because they’ve been used to injecting in the past. 40 MR KELLY: So in your statement, Dr Helliwell, you say that you’re more likely to see injection of crystal methamphetamine amongst people with a history of IV drug use? DR HELLIWELL: Yes. Yes. 45 MR KELLY: Would you agree with that, Dr Hudson?


DR HUDSON: I would definitely agree with that, and I think for a lot of patients there’s a line in the sand. There’s a line between being an injecting drug user of any substance and not, and that’s a line that a lot of people won’t cross, to be – to become an injector. That’s – whereas people with come up to that line, and if they can snort or smoke or inject – not inject, however take that substance, then inject then becomes 5 the line that they won’t cross. MR KELLY: And, Dr Hudson, can I ask you in your capacity as both a GP and as VMO of the emergency department at Byron Central – is that right? You - - - 10 DR HUDSON: I no longer work in emergency. MR KELLY: I see. And how long did you work in emergency? DR HUDSON: I worked in emergency for eight years. 15 MR KELLY: At Byron? DR HUDSON: For five years at Byron and Mullum Hospitals when they were separate, and then when they – when Bryon Central opened that’s when I stopped 20 working in emergency. MR KELLY: Yes. You give some evidence in your statement at paragraph 14 that ATS use in the form of ecstasy MDMA is common in people who attend music festivals in your area. 25 DR HUDSON: Yes. MR KELLY: Yes. What is that opinion based on? 30 DR HUDSON: I’ve – as part of my clinic – my – the clinic that I work at attends the music festivals in a medical capacity where they’re in a harm reduction capacity working in the medical tent. So I’ve attended Splendour in the Grass and Bluesfest a number of times. So first-hand experience at the level of drug use in festivals. 35 MR KELLY: And you heard Dr Davies’ evidence this morning around a spark in MDMA-related presentations around festival time. DR HUDSON: Definitely. 40 MR KELLY: Do you agree with that in your – based on your ED experience? DR HUDSON: Definitely. MR KELLY: Yes. Just sticking with types of ATS at the moment, Dr Hudson, you 45 also say at paragraph 13 that you’re aware of cases where people take stimulate


medication that have been provided for others. And did you hear the evidence of Dr Wims earlier today? DR HUDSON: Yes. Yes, I did. 5 MR KELLY: Dr Helliwell, have you anything to say about the prevalence of diverted stimulant medication in the region? DR HELLIWELL: Certainly in our inpatient withdrawal unit it – it – it’s a rarity, because we’re dealing with highly dependent people. I’m – in other words, I – I’m – 10 I have a suspicion that – that that group of people don’t necessarily develop severe dependency problems compared with, say, the crystal methylamphetamine folk that we’re seeing, because most of it would be dexamphetamine rather than crystal methylamphetamine - - - 15 MR KELLY: I see. DR HELLIWELL: - - - and would be taken orally or snorted than smoked. MR KELLY: Now, just moving to questions around prevalence – and I want to start 20 with, Dr Helliwell, your statement at paragraph 6, where you say that:

In the last 10 years, we have seen a trend of increased ambulance callout and ED presentations in relation to methylamphetamine.

25 And:

This increase is especially significant in rural and regional areas. And then you refer to some studies. Now, is what you say there related to this region 30 specifically? DR HELLIWELL: No. That was actually a study done in Victoria. But basically it was rural and regional. 35 MR KELLY: Yes. DR HELLIWELL: And I think in general the statistics would probably reflect the same sort of ..... in New South Wales. 40 MR KELLY: So is that consistent with your experience in this region? DR HELLIWELL: Yes, it is. MR KELLY: Yes. So you would say that you’ve seen a - - - 45 DR HELLIWELL: Yes.


MR KELLY: - - - trend of increased ambulance - - - DR HELLIWELL: Yes. MR KELLY: - - - callouts and ED presentations. Would you agree with that, Dr 5 Hudson? DR HUDSON: Yes, I would. I would, yes. MR KELLY: And would you also say that you’ve seen – in the same way – or 10 could you – do you have anything to say about the prevalence of the types of severely behaviourally disturbed patients who are presenting in that context? Has that changed over time? DR HELLIWELL: Generally, by the time we see patients they’re – they’re over the 15 acute episode that may have brought them to the attention of either the police or – or the ED or the psychiatric services. So I think that that tends to be less of a problem. I think – I think generally we would – we would tend to see problems – more behavioural problems with methylamphetamine in relation to intoxication. And we tend to see them in the – in really what we call the crash phase, which is after an 20 episode of intoxication. MR KELLY: I see. So you’re not seeing the same behavioural issues when they’re in this crash phase. Is that right? 25 DR HELLIWELL: No. No. They – they – they – they might be a little bit younger, a little bit more impulsive. But that’s, I think, related to the demographic rather than the drug. MR KELLY: And, Dr Hudson, you say at paragraph 8 that you’re not convinced 30 that there are more people using ATS than 10 years ago, but you believe the risk of harm is greater due to easier accessibility and increased strength – potency of the drug. Is that right? DR HUDSON: Yes. 35 MR KELLY: Dr Helliwell, do you have anything to say about that? DR HELLIWELL: Well, I would agree, 10 years ago people tended to purchase amphetamines by the gram. As crystal methamphetamine came in, and is about 10 40 times more potent than amphetamine sulphate, people started to purchase by a point, which is .1 of a gram. And the other thing that came with the increasing purity was the crystallisation and the ability to smoke. So we saw far more smoking of methamphetamine, as crystal methamphetamine became available. And that produces a very rapid rise in the blood stream. So we certainly are seeing differences 45 in potency and I think that has contributed a lot to the issues around crystal methamphetamine, both in the cities and rural areas.


THE COMMISSIONER: Dr Helliwell, can I just ask you while you’re on the topic of smoking, what do you – what’s your view of – the policy that’s adopted, I understand, in some other jurisdictions overseas, of providing smoking apparatus, like pipes, so people - - - 5 DR HELLIWELL: So it’s a - - - THE COMMISSIONER: - - - as a harm minimisation. DR HELLIWELL: So what they call safe consumption rooms. 10 THE COMMISSIONER: Either – well, either a room or - - - DR HELLIWELL: Yes. 15 THE COMMISSIONER: - - - the provision of the utensil to - - - DR HELLIWELL: Yes. THE COMMISSIONER: Yes. 20 DR HELLIWELL: I – I think it’s – it’s an area that’s controversial. I’m a great believer in harm reduction and I think the harm reduction should go to where the users are. So if we had, say, a large injecting scene in Lismore in a particular location in Lismore, then maybe we should have a safe injecting room there. But I 25 think it’s something that you – you look at in conjunction with your epidemiologists and your population health and things like that. THE COMMISSIONER: Yes. 30 DR HELLIWELL: But certainly, I think, in some areas where – where there is considerable consumption of methamphetamine, safe consumption rooms would be useful. THE COMMISSIONER: Thank you. 35 MR KELLY: And just lastly for today, Dr Helliwell, you say in paragraph 6 of your statement that:

We’ve also seen an increase in poly-substance misuse, with methamphetamine 40 being associated with alcohol, opioid and benzodiazepine misuse.

DR HELLIWELL: Yep. MR KELLY: Is that your experience within this region? 45


DR HELLIWELL: It has been, yes. I mean, one of the things that happens when people are using methamphetamine is they reach a point where they’re not getting particularly much out of continuing to use. They’re just sort of feeling what I call tetchy, you know, and all they really want to do is go to sleep. So that’s the person who may well present to their – their GP requesting a prescription for 5 benzodiazepines or might take diverted prescribed – prescription opioids or even some of the newer atypical anti-psychotics, for what we call the come down, which is really when you are no longer going up, and you just really want to sleep. MR KELLY: And you’ve seen an increase in that? 10 DR HELLIWELL: And we’re seeing an increase and, of course, the other thing about methamphetamine, as well, is that it allows you to stay – to think you’re staying sober as you consume vaster amounts of alcohol than you would normally. In other words, patients who take crystal methamphetamine and alcohol don’t fall 15 asleep after 10 standard drinks. MR KELLY: Dr Hudson, do you have anything to say about that? DR HUDSON: Only to add to that, once the patients have reached that point of 20 having consumed a certain amount of amphetamine, they’re also making different decisions around who they’re having sex with, what they’re doing with their time, the risks that they’re taking in whatever behaviour they’re engaging in at the time. So they’re not only at increased risk from the harmful effects of the drug, but at increased risk of harm due to the activities that they – they – and the risks that they 25 might be taking in – in that particular situation. MR KELLY: You also say, at paragraph 12, that:

ATS use rarely exists in isolation and is usually part of poly-substance use 30 scenario.

Is that right? DR HUDSON: Mmm. 35 MR KELLY: And would you agree with that, Dr Helliwell? DR HELLIWELL: I would, too, yes. 40 MR KELLY: Thank you. It’s 4.30. So we may need to adjourn for today. DR HUDSON: Thank you. THE COMMISSIONER: All right. Well, Dr Hudson, Dr Helliwell, I’m sorry 45 you’ve got to come back tomorrow but this is really important evidence for us to hear.


DR HELLIWELL: And we’re first cab off the rank, aren’t we? THE COMMISSIONER: You’re first cab off the rank. DR HELLIWELL: That’s all right. 5 THE COMMISSIONER: We will start early, at 9.30, which almost sounds like banker’s hours, doesn’t it. We – we will be here at 9.30 and you’re first cab off the rank – cabs off the rank. 10 DR HUDSON: Thank you. DR HELLIWELL: Thank you so much. MR KELLY: Thank you. 15 THE COMMISSIONER: All right. You’re excused until tomorrow morning and I will adjourn. Thank you. 20 MATTER ADJOURNED at 4.30 pm UNTIL WEDNESDAY, 15 MAY 2019


Index of Witness Events TOBY CHRISTOPHER LINDSAY, SWORN P-579 EXAMINATION BY MR KELLY P-579 THE WITNESS WITHDREW P-612 EDWINA LLOYD, AFFIRMED P-612 EXAMINATION BY MR BEAUFILS P-612 THE WITNESS WITHDREW P-628 ROBERT JOHN DAVIES, SWORN P-629 EXAMINATION BY MR KELLY P-629 THE WITNESS WITHDREW P-665 EDWARD WIMS, SWORN P-666 EXAMINATION BY MR KELLY P-666 EXAMINATION BY MR KETTLE P-691 EXAMINATION BY MR KELLY P-692 THE WITNESS WITHDREW P-693 DAVID HELLIWELL, AFFIRMED P-695 BRONWYN NAOMI HUDSON, AFFIRMED P-695 Index of Exhibits and MFIs EXHIBIT #LF LISMORE HEARING TENDER BUNDLE, VOLUME 1 OF 1

P-571

EXHIBIT #LF SUPERINTENDENT MENZIE’S STATEMENT ADDED

P-601

Documents

TRANSCRIPT OF PROCEEDINGS...2019/05/14 · 20 Richmond Valley’s rate exceeded the state average in 2017 and 2018. Commissioner, you will hear evidence today from Superintendent