THE family of Lake Macquarie paramedic Tony Jenkins has demanded an apology from NSW Ambulance for inferring he was a drug addict following his suicide in April, after a secret review three months before his death concluded there was “no evidence” he “mis-used” restricted NSW Ambulance medications.
The family is even more determined to push for a public Coroner’s inquest after a NSW Ambulance investigation of events leading up to Mr Jenkins’ death provided no solid proof to back allegations 38 Fentanyl vials at four Hunter ambulance stations were tampered with, or that Mr Jenkins was responsible. Fentanyl is a synthetic opioid painkiller 100 times more potent than morphine.
The investigation instead found NSW Ambulance carried out no routine tracking of Fentanyl usage; that weekly “integrity check” audits of Fentanyl and other restricted medications were lacking and varied from station to station across the state; that secure drug safes were “frequently not closed” and drugs were “handed over” from shift to shift; compliance with dual signing out of restricted drugs varied; and “a culture of trust and mateship” resulted in regular checking procedure “violations” and “routine deviation” from restricted drug policies across NSW.
The investigation also “could not confirm if other staff were or were not involved with medication tampering” at Hunter stations.
Mr Jenkins’ family wants an inquest to explore why he was targeted on April 9 after a morning shift identified allegedly opened Fentanyl at a Hunter station where he worked.
The NSW Ambulance investigation said there was “a sense of urgency to meet with” Mr Jenkins on April 9 but cites an audit seven months earlier identifying him as the second highest paramedic Fentanyl administrator in NSW as the reason he alone was questioned. This was despite a subsequent review in January, without Mr Jenkins’ knowledge, that found “no evidence” of “mis-use” and which “did not identify any concerns regarding the paramedic’s usage”.
Mr Jenkins committed suicide on April 9 less than two hours after he was dropped off, alone, by a manager following an unscheduled meeting part-way through a shift where the manager alleges Mr Jenkins admitted he “relied on Fentanyl” but it was “out of control”.
Despite a NSW Ambulance file note of the April 9 meeting alleging Mr Jenkins admitted replacing used Fentanyl vials with a saline solution, a NSW Ambulance investigation report provided to Mr Jenkins’ family on September 7 was silent on any testing of the 38 vials or conclusions about the tampering allegations. The investigation found collection of the vials on April 9 from four Hunter stations via an ambulance vehicle to an “incorrect location” did not follow policy for the transportation of suspected tampered medications. Mr Jenkins’ family said the failure meant the vials could not be relied on as evidence because of chain of custody questions.
An autopsy found no trace of Fentanyl in Mr Jenkins’ body at the time of his death. The two-page report of the April 9 meeting, written by the manager who dropped Mr Jenkins off alone after the meeting, does not record that he was asked if he had taken Fentanyl before his shift. The file note alleges Mr Jenkins carried two morphine syringes on his person into the meeting and said he’d drawn them up intending to use them on himself. His family slammed the allegation as implausible and unbelievable.
The NSW Ambulance investigation also relied on reports by “a number” of unidentified paramedics of Mr Jenkins “appearing sleepy, a series of near miss accidents whilst driving and clinical records not completed to his usual standard” in the months before his death to justify a conclusion that “these behaviours were early warning signs of a possible addiction to Fentanyl”.
“Their warning signs of a possible addiction to Fentanyl are so vague they could also describe someone who was simply lacking sleep,” Mr Jenkins’ nephew Shayne Connell said.
Mr Jenkins’ family said NSW Ambulance had not responded to requests for formal reports of the “near miss accidents”. His family rejected that he displayed any behaviour fitting the alleged admissions he was “out of control”.
The NSW Ambulance investigation report said the service received a state-wide Fentanyl audit report in September, 2017 commissioned because of an “unrelated matter” involving the prescribing habits of two NSW paramedics. The audit identified Mr Jenkins as the second-highest administrator of Fentanyl in NSW.
It was not until January, 2018 that a second secret review of Mr Jenkins’ Fentanyl administration, conducted without his knowledge, concluded no evidence of mis-use but recommended “education in relation to the Fentanyl pharmacology”. The investigation report found the education “did not occur”.
Mr Jenkins’ widow Sharon, daughters Cidney and Kim and nephew Shayne Connell described NSW Ambulance comments after his death and a subsequent internal investigation as a “disgraceful attempt to posthumously defame and discredit” Mr Jenkins in an attempt to avoid responsibility for events leading up to his death and major deficiencies in the organisation’s systems.
A NSW Ambulance statement after Mr Jenkins’ death included concern that a paramedic “could find themselves so desperate that their only option was to turn to drugs and addiction”.
“They’re trying to portray him as this devious drug addict who’s put the public at risk. They’re blaming him for what happened rather than look at their duty of care to someone they allege was drug tampering, and an addiction for which they have no evidence,” said Mrs Jenkins.
The family was outraged at the opening statement of the NSW Ambulance investigation report which was an examination of “the circumstances whereby a paramedic inappropriately accessed restricted medications from NSW Ambulance, over an extended period, and the subsequent management of the matter once identified”.
“They have no evidence to say any of those things. They’ve provided no evidence to make that statement or even that there was tampering,” Mr Connell said.
“If they’d tested those vials and it came back with salt solution in them don’t you think they’d be rushing to us with those results? But no. Five months after they publicly blamed Tony for using NSW Ambulance Fentanyl we don’t know where those vials are or what’s in them.
“How do you do a root cause analysis of a critical incident into the death of an employee without even saying what’s in the vials? It’s like they’re trying to do a root cause analysis with no evidence and no results. Based on what they’ve given us it’s more like they’ve tried to write a suicide note on Tony’s behalf by portraying him as a drug addict when available evidence says the opposite.”
Mr Jenkins’ family said information in the file note purportedly said by him during the April 9 meeting was factually incorrect, including that he had had a drinking problem, that his wife was a manager at Coles and that he had been treated by his GP for depression. The mistakes raised real doubt about what was said at the meeting and the reliability of the document which was produced without minutes or notes being taken during the meeting or an independent witness, the family said.
A NSW Ambulance spokesperson confirmed the circumstances of Mr Jenkins’ death were being investigated by NSW Police on behalf of the NSW Coroner’s office.
“Therefore NSW Ambulance can make no further comment pending the outcome of those investigations and a coronial inquiry,” the spokesperson said.
“NSW Ambulance offers its sincere condolences to the Jenkins family and continues to offer support during this difficult time.”
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