Legislative Council Fifty-Fourth Parliament, Second Session (54-2) 54 2 Parliament of South Australia Legislative Council published Question Time Mental Health Services Mental Health Services The Hon. F. PANGALLO Legislative Council Mental Health Services The Hon. F. PANGALLO (15:13): I seek leave to make a brief explanation before asking the Minister for Health and Wellbeing a question about the death of a mental health patient while in a state-run facility. Leave granted. The Hon. F. PANGALLO Legislative Council The Hon. F. PANGALLO: The Deputy Coroner, Anthony Schapel, this week released findings into the death of a heavily medicated man with no teeth who was given a sandwich and then left to choke, alone and unmonitored in a secure psychiatric facility. Mr Schapel said security camera footage showed 'harrowing' scenes as the man choked in his cell at the Margaret Tobin Centre at Flinders Medical Centre in September 2015. The security vision shows that after he collapsed from choking he lay on the floor of the cell for 11 minutes before he was noticed by medical staff. Three nurses were within metres of the screen that showed the man choking, but none of them noticed because they were distracted by paperwork, magazines or mobile phones. He died four days later as a result of extensive brain damage. My question to the minister is: 1.	Has the minister yet read the Deputy Coroner's report and the recommendations he made that nurses and medical staff should consider the medication of patients and their level of agitation before giving them food unsupervised? 2.	Will the government implement his recommendations or, like the majority of coroner's reports, ignore the recommendations? The Hon. S.G. WADE Legislative Council Minister for Health and Wellbeing The Hon. S.G. WADE (Minister for Health and Wellbeing) (15:15): I thank the honourable member for his question. I can assure him that—in response to his last comment—it is not correct to say that coroner's recommendations are ignored. In fact, there is a well-developed process for coroner's recommendations to be considered by the department and responses provided to those recommendations. Some recommendations in coroner's reports can be to a range of agencies; for that matter, they can be to me as minister or to the department or to local health networks. In relation to the coroner's report the honourable member refers to, I am awaiting a report from SA Health in terms of their response to the recommendations and will be responding to the Coroner in due course. The President Legislative Council The PRESIDENT: The Hon. Mr Pangallo, supplementary.