An ice user who thought he was God and died after being physically restrained at a Sydney hospital was let down by systemic failures in the healthcare system, a coroner has said.
Dane Oliver Lockwood died at Prince of Wales Hospital on August 19, 2019 after consuming crystal methamphetamine and attending the emergency department for treatment.
He told nurses he had stopped taking his medication two weeks earlier. Admitting he had smoked ice, he said the television was talking to him and he thought "he (was) God".
Appearing unsettled, threatening and increasingly aggressive, security guards and later police were called to physically restrain Mr Lockwood, who refused to remain in the hospital.
The 33-year-old died shortly afterwards.
On Friday, Deputy State Coroner Erin Kennedy found the cause of death was methamphetamine toxicity with "antecedent causes" being the physiological effects and his resistance to being restrained.
Ms Kennedy acknowledged the compassion of staff in responding to a medical crisis with "limited means and resources" available.
She highlighted failures in NSW's health system as exacerbating the "tragic, unexpected loss".
"It is a general systemic failure in the current model that let Dane and his family down. It let the staff and patients down," she wrote.
"The general systemic failure starts at the point where criminals manufacture and supply drugs of addiction leading to a raft of social ills so often present in the Court system: broken families, violence and criminal charges."
Those living with the illness of addiction required an adequately funded health system, and law and order response, she wrote.
"Dane's death highlights that significant changes are required for those who are brave enough and invested enough to seek help for serious drug addiction."
Mr Lockwood had lived with drug addiction for over a decade, making numerous attempts at rehabilitation including a long-term attendance with Narcotics Anonymous.
On the day he died, he told his friend Clinton Carle: "All I want is to live, I just want a normal life and a job and a family."
After posting three Instagram videos on August 19 in which he was "thought disordered and grandiose", he agreed to go to Prince of Wales for treatment.
However, his internal state of mind was muddled on arrival, walking in and out of the hospital as he grappled with whether he wanted treatment or not.
At one point, he got into his car and drove 50 metres down the road before reversing it, almost crashing into an ambulance before going back inside.
"It is a terrible scene where some part of Dane knew that he needed help. The other part, the drug affected part, was not helping him," Ms Kennedy said of CCTV footage within the emergency department.
He was eventually restrained, sedated and put into a hospital gurney were he was shackled with wrist restraints.
As his skin turned blue and his pulse faded, attempts by medical staff to resuscitate him failed.
"The behavioural disturbance might have been ice, or the period of days without sleeping, which can itself trigger a psychosis. The consumption of methamphetamine put into train or triggered a series of cascading events, leading to his death," Ms Kennedy wrote.
She noted that Prince of Wales Hospital had, before the tragedy, committed to restructuring its emergency department and improving care offered to patients arriving with toxicological, behavioural or addiction-related problems.
"This is a sensible response to the health crisis arising from ice addiction (and other causes of behavioural disturbance)," she wrote.
"It is not suggested that such a unit will prevent escalation in all cases, but it is an important step in giving those patients an opportunity to seek help in a way that might reduce the need for restraint."
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