In my post NSW Ambulance fined for breach of Work Health and Safety legislation (May 3, 2023) I discussed the prosecution of NSW Ambulance for failing to properly manage and audit the use of scheduled drugs. This allowed paramedics to misappropriate drugs for their own use putting them, their colleagues and their patients at risk. One paramedic, suspected of taking drugs, took his own life after being presented with those allegations.
It appears a very similar situation arose in Tasmania and was subject to an inquiry by the Tasmanian Coroner – see Findings, Comments and Recommendations of Coroner Olivia McTaggart following the holding of an inquest under the Coroners Act 1995 into the death of: DAMIAN MICHAEL CRUMP (5 July 2023).
The coroner said (pp. 115-116):
Mr Crump ended his life [on 23 December 2016] following a lengthy course of stealing dangerous drugs from AT, his employer. He was a highly intelligent Intensive Care Paramedic who loved his work and enthusiastically imparted his clinical knowledge to many of his colleagues.
Unfortunately, he suffered long-standing mental illness and unresolved psychological issues. His poor mental health was unrelated to his work at AT. Nevertheless, his practices and behaviour at work regularly exceeded appropriate boundaries and, in the weeks before his death, alarmingly so.
He was never adequately called to account for his behaviour by AT management, the spoken and unspoken view being “That’s just Crumpy!” Further, it was known amongst his colleagues and some managers of his longstanding intention to die by suicide before the age of 40 years. This was not taken further as a welfare issue, despite his deteriorating mental state.
The coronial investigation highlighted severe resourcing deficits in the organisation, inadequate management of staff and a culture of tolerating unacceptable behaviour. These factors substantially contributed to Mr Crump’s behaviour and welfare not being dealt with and his drug thefts remaining undetected. He was therefore able to remain working as an operational Intensive Care Paramedic.
His manager and close friend took it upon herself to look after him, knowing of his mental illness and believing that he was honest with her. He was, however, dishonest about his medical treatment and his drug addiction. He treated her and other managers disrespectfully at times and was generally disrespectful of authority within the workplace. She became conflicted in her managerial role when she was required to report her belief that he had been stealing AT medication to police, and to initiate an internal investigation. There were no processes in AT to ensure that an internal investigation was progressed at all, and therefore Mr Crump was not formally identified as being responsible.
Numerous other opportunities existed for AT to properly deal with his behaviour and actions, including [a] … serious ambulance incident nine days before his death. Appropriate intervention may have uncovered his addiction and thefts at that time.
Because of the unfeasibly large workload of AT managers and their lack of adequate training, there was no proper auditing of medication and there were no pathways to deal with Mr Crump’s behaviour or welfare. He was therefore able to remain at work and able to keep stealing Schedule 8 medications from the drug store.
In the course of her inquiry the coroner identified the following issues that may have contributed to Mr Crump’s death:
Inadequate manager to staff ratios
Duty Managers had far too many paramedics, volunteer ambulance officers and patient transport officers to manage to be able to provide effective guidance or supervision. Figures ranged from 200 to 440 people reporting to a single manager. Apart from staff welfare functions they had to manage the day to day operations looking after rosters, fleet management etc. The coroner said (at p. 86) ‘… it is difficult to be overly critical of individuals in AT, especially those at the Duty Manager level. They were required to operate with little training and support in a system that had not been conducive to sound and efficient decision-making for a long while’.
This span of control made it impossible for the duty managers to deal with what was described as Mr Crump’s ‘inappropriate behaviours, and the reasons for them’ (p. 91).
The coroner was critical of one manager who was also a personal friend of Mr Crump’s. The coroner was of the view that this manager was too close to Mr Crump to be able to properly report and manage his behaviour and take action when he was identified as a suspect in the misappropriation of drugs.
Safety Reporting and Learning System
Ambulance Tasmania had an electronic Safety Reporting and Learning System (SRLS). Issues were reported into the system but the ‘resolution of a large volume of individual reports [was] a “completely overwhelming” task’ (p. 92). There was evidence that reports were not read and were closed off without being properly dealt with. In Mr Crump’s case some issues were raised with managers who discouraged their junior staff from making an SRLS report. The coroner said (p. 92) ‘The SRLS was not effective to resolve issues or complaints in a timely manner, and therefore staff members were reluctant to use it to report incidents’.
The Bus as a means of management
The bus was a metaphorical bus that difficult paramedics were put on to ‘drive them out’ of the ambulance service. Paramedics ‘on the bus’ were ‘treated in a way that they may reasonably perceive as being bullying, harassing, intimidating, marginalising’ (p. 94). The Coroner said:
… The Bus developed as a management technique which at least several managers considered a viable pathway to deal with risks or disciplinary issues. Of course, such a construct was unfair, lacked transparency and induced significant angst in AT employees.
In my view, The Bus was only able to become an entrenched technique for behaviour modification because of the lack of sufficient leadership and clear pathways for formal disciplinary and welfare processes.
It was accepted that the Bus was abolished in 2014 but even after that time ‘there remained a lack of formal procedures for disciplinary action in respect of AT employees and a culture of reluctance of reporting inappropriate behaviour’. As such colleagues were unwilling to report Mr Crump’s behaviour in part due to a sense of loyalty, a recognition that his career would be jeopardised rather than his welfare advanced and a fear of repercussions to themselves.
The coroner’s recommendations
Some of the coroner’s recommendations were that Ambulance Tasmania:
- Implement random drug and alcohol testing for all employees as a matter of priority.
- Conduct regular reviews of the operation of its policies relating to the management, storage, safekeeping, handling and accountability of drugs to ensure that the policies are effective and contemporary.
- Provide regular training for all staff and managers regarding their obligations in respect of each policy relating to the management, storage, safekeeping, handling and accountability of drugs held by Ambulance Tasmania; and implement and maintain robust systems of accountability that ensure a high degree of compliance.
- Implement a system of regular mandatory psychological assessments for its employees in order to identify mental health and psychological issues, and any changes, over the whole period of their employment with Ambulance Tasmania.
- Continue to make efforts to reduce the span of control for duty managers and other managers.
- Regularly review the ability of front line managers to undertake their duties of supervision adequately.
- Provide regular training for all managers in managing staff generally and in responding to mental health issues.
- Provide training for managers who are required to conduct or oversee investigations under a policy; this training to include knowledge of the policy, basic investigation skills, reporting requirements in SRLS or other electronic platform and identifying and managing conflicts of interest.
What’s an ambulance service to do?
This is a necessarily complex area. Ambulance services and paramedics have legal and ethical duties to look out for the welfare of their staff and colleagues. Paramedics are reminded that they have a professional obligation to report colleagues who practice paramedicine whilst under the influence of alcohol or other drugs (Health Practitioner Regulation National Law, definition of ‘notifiable conduct’).
Where a paramedic is abusing drugs and suffering a mental health crisis, they may be a threat to themselves, their colleagues, patients, and the community. Reporting them may however lead to a punitive response (see for example Dismissal of Queensland paramedic for unlawful drug use on duty confirmed (June 29, 2019)).
The coroner recognised that a factor that may have contributed to Mr Crump’s death ‘may have been a failure of AT to appropriately manage him and, if necessary, discipline him or terminate his employment (p. 7). But the job may be all that is holding the person together. In evidence, Dr Sale a consultant psychiatrist, said (at p. 44) that if Mr Crump had been dismissed:
“I think he would’ve been devastated, because it’s obvious from the stuff I’ve been reading and these various statements by colleagues and, I think, Dr Frampton and a couple of others that the job was his life. This was a man who, in retrospect, is somewhat psychologically fragile for some time and that one of the things that kept him together was his job.
The Manager who was also Mr Crump’s friend was torn between ‘understanding that her role required managing him appropriately; but, as his friend, wanting to ensure that he remained in his work, with the loss of his job potentially catastrophic for him’ (p. 68).
Ambulance services cannot compel their staff to seek mental health treatment. In Hegarty v Queensland Ambulance [2007] QCA 366, a claim for damages by a paramedic for PTSD, Keane JA said ([43]-[46]):
The area of debate in the present case concerned the extent to which the defendant was duty-bound to ensure that its superior officers should intervene with individual ambulance officers in relation to possible signs of deterioration in their mental health. The private and personal nature of psychological illness, and the consequential difficulties which attend the discharge of an employer’s duty in this respect, must be acknowledged as important considerations. The dignity of employees, and their entitlement to be free of harassment and intimidation, are also relevant to the content of the duty asserted by the plaintiff. Issues of some complexity arise in relation to when and how intervention by an employer to prevent mental illness should occur, and the likelihood that such intervention would be successful in ameliorating the plaintiff’s problems.
The case made for the plaintiff at trial, and which was ultimately accepted by the learned trial judge, was that the plaintiff’s supervisors should have been trained to identify possible signs of stress and invited him to seek professional help. The plaintiff’s case means that the employer must be concerned, not only with non-performance by the employee as an employee, but also with possible episodes of unhappiness in the employee’s private life. It is not self-evidently necessary or desirable that employees’ private lives should be subject to an employer’s scrutiny. To some extent in this case, the plaintiff’s case, as it was developed in the course of evidence and in argument in this Court, depended on an assertion of a culpable failure by the plaintiff’s superiors to scrutinise aspects of the plaintiff’s private life away from work.
Issues did necessarily arise, however, as to the identification of a sufficient basis for the making of a suggestion by the defendant that the plaintiff seek psychological assessment and treatment. The resolution of this issue is fraught with difficulties peculiar to cases of psychiatric injury. In cases of apprehended psychiatric injury, unlike cases concerned with the amelioration of physical risks in the workplace, important values of human dignity, autonomy and privacy are involved in the formulation of a reasonable system of identification of psychiatric problems which may warrant an employer’s intervention and the making of a decision to intervene. An employee may not welcome an intrusion by a supervisor which suggests that the employee is manifesting signs of psychiatric problems to the extent that help should be sought, especially if those problems are having no adverse effect upon the employee’s performance of his or her duties at work.
Employees may well regard such an intrusion as an invasion of privacy. Employees may rightly regard such an intrusion as a gross impertinence by a fellow employee, even one who is in a supervisory position. If an employee is known to be at risk of psychiatric injury, prospects of promotion may be adversely affected and questions may arise as to the entitlement, or even obligation, of the employer to terminate the employment. Employees who are ambitious, and eager for promotion, and whose signs of dysfunction might equally be signs of frustrated ambition, might rightly be deeply resentful of suggestions which reflect an adverse assessment of the employee’s ability or performance and prospects of promotion. …
(See also QAS not negligent in management of paramedic’s PTSD (December 12, 2018)).
In Mr Crump’s case, he assured supervisors that he was getting medical help, but on this he lied even going so far as to forge a medical certificate from his treating psychiatrist (p. 96).
If ambulance services cannot compel people to seek treatment, and if for whatever reason people are unwilling to disclose their own impairments then all ambulance services (and other employers) can seek to do is identify through other means, such as drug audits and drug and alcohol testing where there is a problem. Where paramedics are discovered using drugs or are otherwise unfit for duty the only option may be to terminate their employment, but this too is likely to aggravate their illness. One can only wonder whether, if Mr Crump had been managed and probably terminated, it would have saved his life by removing his access to drugs and encouraging him to seek professional help, or whether it would have encouraged him to take his life earlier? On the other hand, if people are unwell and are being made unwell by their employment, some of which cannot be avoided – police, paramedics and firefighters must as part of their employment be exposed to traumatic events – then it may be in their best interests to leave that employment regardless of how much it defines them.
I don’t have a solution. Ambulance services must have regard to the well-being of all their staff, their patients and the community and that will at times require intervention into the lives of their staff and possible dismissal from employment. Those that look to coroners’ findings and prosecutions under Work Health and Safety laws to serve as a message to ambulance services to ‘do better’ may find that ‘doing better’ means more supervision, less trust and faster action to not only identify those struggling to cope but also to remove them from the front line, if not the service all together.
This blog is made possible with generous financial support from the Australasian College of Paramedicine, the Australian Paramedics Association (NSW), Natural Hazards Research Australia, NSW Rural Fire Service Association and the NSW SES Volunteers Association. I am responsible for the content in this post including any errors or omissions. Any opinions expressed are mine, and do not necessarily reflect the opinion or understanding of the donors.
Australian Emergency Law 
Not legal related, but radical reform may be required. For example if I am a police officer in the UK I will not have access to firearms in the main but have to call upon a special squad. This was of course done not for the staff benefit but to meet community expectations about armed police. The benefit for me though is I’m never going to get accidentally shot by a colleague or myself.
Over the years more and more drugs and equipment have been provisioned in ambulances, essentially incrementally, like boiling a frog. There are many drugs that ambulance services have that are dangerous, but I suspect only a few are drugs of dependence. Do we need to have every ambulance, particularly in cities carrying the full range? Could we restrict the drugs of dependence to a small number of staff and vehicles so as to minimise the exposure to staff. Yes this will cost money, but why not? They represent a clear danger and you can’t remove the danger but you could lessen the exposure probably by 90%.
Giving pain relief is a humane part of our jobs. These are given in the forms of NSAIDs (which generally don’t work well for significant pain – which is why people call ambulances), s4d & S8’s – methoxyflurane, opiates, ketamine but also benzos for seizure management/patient management etc.
It wouldn’t be feasible or humane to call an s8 ‘pain relief car’ to give pain relief within a reasonable amount of time as patient presentation is very commonly pain related all around the state.
I know there are other options as IV paracetamol, but last I read there is no difference between that and oral.
It’s a difficult dilemma, but I think it works the way it is (in my state anyway). It sounds like the entire situation was mismanaged in the beginning. Luckily it is a very very small issue. I do agree with random drug testing.
There should be random mandatory urine tests like they do in the mining at a minimum – NSW does not do this.
Except in the NSW example of Paramedic Tony Jenkins there was no evidence found by the Police or the coroner or the subsequent investigations that he has misappropriated drugs. The allegations made by NSW Ambulance managers that led to his suicide were false and part of a bullying campaign that protected other guilty individuals.
That is clearly contestable. The evidence before the court set out the circumstances that led to suspicion of of Mr Jenkins. At [31]-[32] the Court said
Later that day, A/DDO Akester and DOM O’Connor met with Paramedic Jenkins. During the meeting, Paramedic Jenkins disclosed the following information:
He had been taking Fentanyl from ASNSW stocks and using it as a sleeping aid.
He initially obtained the Fentanyl by taking residual medication leftover after treating patients.
In the past several months, his need for Fentanyl had increased and he had started tampering with Fentanyl vials at various stations in the Hunter Zone by withdrawing Fentanyl from the vials and replacing it with saline solution.
On the morning of 9 April 2018, having discovered that all the Fentanyl had been removed from the safe at Belmont Station, he took two vials of Morphine instead.
Two broken vials of morphine had been left in the ambulance vehicle he had been working in earlier which was parked at Birmingham Gardens Station.
Following the meeting, DOM O’Connor found a further two vials of Fentanyl in the ambulance vehicle that Paramedic Jenkins had been using during his shift that day. Those vials were also suspected of having been tampered with. DOM O’Connor attended the Birmingham Gardens Station and located an empty vial of Morphine in the ambulance vehicle that Paramedic Jenkins had driven earlier that day. There was a syringe in the rubbish bin.
I cannot find a report of any coronial inquiry into Mr Jenkins’ death (https://www.coroners.nsw.gov.au/coronial-findings-search.html) so we cannot know what the coroner found (if anything).
As for the suggestion this was ‘part of a bullying campaign that protected other guilty individuals’ I’m well aware of that view within the sector which is why I thought it important to report the case – because if people thought that was why NSWA was being prosecuted, that Safework had identified that Mr Jenkins had been bullied to death – then they need to know that was not the basis of the prosecution. I make no claim to know what actually happened, but the allegation by Safework was not related to the treatment of Mr Jenkins and the evidence before the court (whether you accept it or not) was that Mr Jenkins made admissions of drug misues.
And yet this is only the testimony of the ANSW managers. There was no evidence found by Police or the Coroner of illicit drug use. Under NSW legislation there is not offence of corporate manslaughter or that may have been the charge made by SafeWork.
The culture in organisations and industries, such as the defence force or emergency services or aviation or the medical or legal profession, is often not a friendly environment to openly delcare you have mental health issues. As a result, this often results in the individual suffering in silence out of fear that it may have repercussions on their livelihood and careers if they come forward with mental health issues. It’s a paradoxical cycle of distress for many colleagues and friends I have seen go down this path. They want to seek help and take time off, but they don’t want this to affect their livelihood and identity. Workplaces are making effors to destigmatise and improve wellbeing support services of their workers, but there is still a long way to go. Also with the increasing demands for service delivery, bosses are often more concerned with meeting operational demand (‘bums on seats and more trucks on the road’) and health and safety liability (‘bum-covering’), and consequently, individual welfare of the worker becomes a secondary concern. Although, in the long run, we do know a healthier workforce makes a better one, and it certainly reduces costs of workers compensation claims, litigation and complaints.
That’s true but the point I was trying to make is that there are limits on what employers can do. Sometimes declaring mental health issues will reveal that the employee is not safe or is being harmed by their employment so the only and appropriate option for the employer is to try and transition the person out of that employment. Certainly the implications of the findings in this inquest were that Mr Crump should have been managed and possibly had his employment terminated. His supervisor was aware of that conflict and that, according to the coroner made her conflicted. It is difficult but it is not as simple as saying that people should be able to disclose issues without those affecting their work, or identity, because sometimes they have to. It is because of that that I suggest this case, and the prosecution of NSW Ambulance, may lead to a less supportive culture as employers have to have in place procedures to detect issues that may not be self reported for very understandable reasons.