Report confirms 'failure in the decision-making process' before paramedic Tony Jenkins' death

The ambulance service has taken disciplinary action against some senior employees after Mr Jenkins was questioned, without an independent support person, at a meeting called without warning on April 9, 2018, only hours before his death, about allegations he used ambulance-issue Fentanyl from Hunter ambulance stations.

There was "a failure in the decision-making process" about the nature of the meeting, the policies to be applied and "the manner in which Mr Jenkins' legal rights and welfare were to be protected'', external reviewer Kylie Nomchong, SC, found in a report to NSW Ambulance chief executive Dominic Morgan.

A summary of medical records provided to Mr Jenkins' widow Sharon in early September, that forms part of a NSW Police brief to the NSW Coroner's Office, shows a history of work-related trauma and treatment before the April, 2018 meeting, including a 2004 post traumatic stress diagnosis.

While NSW Ambulance senior staff asked Mr Jenkins about his welfare during the meeting and offered support, Ms Nomchong found that file notes "inappropriately" written "retrospectively" and backdated after his death "were drafted to over-emphasise those welfare steps".

The summary of Mr Jenkins' interactions with Hunter doctors and hospitals and NSW Ambulance employee services "clearly shows he used the services offered to him", and raised questions about allegations he self-medicated with Fentanyl taken from Hunter ambulance stations, Mrs Jenkins said.

A toxicology report found Mr Jenkins had no Fentanyl or other drug in his system when he died.

"The picture they've tried to paint of him is not consistent with the medical records or with the evidence that is available," she said, while repeating her view that an inquest is needed to provide answers about her husband's death.

"If we hadn't said anything that would be what everybody's left with about Tony, and that's not right."

Mr Jenkins, 54, took his own life about two hours after he was dropped off to his car, alone, by a senior NSW Ambulance officer on April 9, 2018 part-way through his shift after the meeting over the Fentanyl allegations.

An initial NSW Ambulance investigation said there was "a sense of urgency to meet with" Mr Jenkins on April 9 after allegedly tampered Fentanyl bottles were found that morning at the station where he worked.

He was questioned after an audit seven months earlier identified him as the second highest paramedic Fentanyl administrator in NSW, but a subsequent review without Mr Jenkins' knowledge found "no evidence" of "mis-use" and it "did not identify any concerns regarding the paramedic's usage".

In a letter to Mrs Jenkins in June after Ms Nomchong's external review NSW Ambulance chief executive Dominic Morgan blamed a drafting "mistake" for a "regrettable error" in an initial ambulance root cause analysis report in 2018 that incorrectly claimed Mr Jenkins handed two syringes of morphine to senior officers at the April 9 meeting.

Mr Morgan did not explain how the "mistake" was made but said Ms Nomchong found the syringe allegation in the root cause analysis report was "not consistent with the records advanced by" senior officers at the meeting.

Mr Morgan said Ms Nomchong found Mr Jenkins should have been driven home after the meeting, and not dropped at his car to drive home alone, but "this was not a causal factor in Mr Jenkins' suicide".

A summary of Mr Jenkins' medical records compiled by police shows a medical examination when he started with NSW Ambulance in 1990 noted he had no drug or alcohol problems and was not suffering from any form of mental illness .

By 1992 he was experiencing "stress and fatigue" from his Lake Macquarie to Sydney commute for work while raising a young family, and he was twice issued with WorkCover certificates for time off in 1998.

He was issued with two more WorkCover certificates in 2004 and diagnosed and treated for post traumatic stress after a "violent and threatening situation" during a work call-out, which was exacerbated when he was sent to the same address after returning to work, the medical summary shows.

A doctor reported Mr Jenkins's "frustration with being exposed unnecessarily to dangers at work" and his anger at NSW Ambulance for "constant exposure and inadequate information provided to officers".

By 2012 a corporate support service noted Mr Jenkins was "becoming worried about other people's sad circumstances" requiring a plan to "protect self from others' circumstances", but he had a low risk of suicide.

The medical summary showed treatment for asthma and prescribed drug therapy for depression with positive results until the end of 2017. A doctor who prescribed Panadeine Forte and Valium on December 19, 2017 for a flare-up of back pain has made a statement to police about her interaction with Mr Jenkins where he made no mention of depression and said he was not taking other medications.

Mrs Jenkins said Ms Nomchong's external review answered more questions but her family was not happy with NSW Ambulance's responses and "that's why we're hoping to get more answers from an inquest".

"It's important it is held," Mrs Jenkins said.

"The way this has been handled by NSW Ambulance affects everyone else because there are a lot of Tonys around who have experienced work-related trauma."

In his letter Mr Morgan said NSW Ambulance had already taken "significant action in response to these issues by introducing a more robust risk management process".

"From these tragic events, NSW Ambulance recognises and accepts that more is needed to both support staff members who may be at risk or present a risk to themselves/others as well as to provide greater guidance to senior managers tasked with responding to such matters," Mr Morgan said.

Lifeline: 13 11 14.

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