Special reports

Ambulance Victoria (AV) paramedics engaged in serious corrupt conduct, namely the theft, trafficking and use of drugs of dependence, and misappropriation of AV equipment.

IBAC’s investigation uncovered a culture of illicit drug use and misappropriation of AV equipment by individuals and among certain groups of AV paramedics, particularly in the Barwon South West region. Based on evidence obtained during the investigation, IBAC considers it is likely that this conduct occurs beyond that identified in the investigation.

AV proactively responded during and after the investigation with measures to address the vulnerabilities identified by introducing new policies and practices that aim to minimise opportunities for the possession, use and misappropriation of drugs of dependence. AV has also taken steps to limit opportunities for misappropriation of AV equipment.

The investigation was the subject of a special report tabled to State Parliament in September 2017.

IBAC is Victoria's anti corruption body responsible for preventing and exposing public sector corruption and police misconduct.

The following is a summary of an IBAC investigation called Operation Tone.

In November, 2015, IBAC commenced an investigation into allegations that Ambulance Victoria paramedics in the Barwon South West region engaged in serious corrupt conduct, namely, the theft, trafficking and use of drugs of dependence, and misappropriation of Ambulance Victoria equipment.

During the investigation IBAC identified that:

• two paramedics were involved in the trafficking, use and possession of illicit drugs;
• several paramedics were found to be using illicit drugs;
• one paramedic had stolen and used Ambulance Victoria drugs of dependence, including fentanyl and morphine;
• several paramedics were using and sharing Ambulance Victoria drugs, as well as personal medications, including temazepam and oxycodone;
• some paramedics were misappropriating Ambulance Victoria supplies to inappropriately treat themselves, colleagues, family members and friends, this conduct extended to paramedics taking intravenous bags, along with cannulation equipment, to treat the symptoms of hangovers.

While the investigation focused on conduct on the Barwon South West region, based on evidence obtained during the investigation, IBAC considers this conduct and corruption vulnerabilities are likely to be more widespread across Ambulance Victoria.

During Operation Tone:

• one paramedic's employment was terminated, and
• eight paramedics resigned while under investigation;
• six paramedics retained their employment with a formal warning; of these, five were relocated to different regions for varying periods and were enrolled in an ethics counselling course, and precluded from development opportunities for 12 months.

Following the IBAC investigation, one witness plead guilty in the Geelong Magistrates' Court to breaching a confidentiality notice and misleading IBAC, and was fined $5000.

Ambulance Victoria has proactively responded to the vulnerabilities identified in Operation Tone by introducing new polices and practices to minimise opportunities for the possession, use and misappropriation of drugs of dependence, to prevent the misappropriation of Ambulance Victorian equipment.

IBAC has recommended that Ambulance Victoria conduct a comprehensive review of the use of illicit drugs and misuse of drugs of dependence by its employees and well as the development and implementation of a more robust framework to prevent and detect such drug use.

IBAC has further recommended the Department of Health and Human Services consider the issues raised in Operation Tone and whether similar vulnerabilities could exist in other Victorian health services.

Ambulance Victoria is to provide IBAC with a progress report by 30 March 2018.

Both Ambulance Victoria and the Department (DHHS) are required to report to IBAC by 28 September 2018 on the implementation of the recommendations.

To download a copy of the report visit www.ibac.vic.gov.au or click on the link in the description below.

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To

The Honourable President of the Legislative Council

and

The Honourable Speaker of the Legislative Assembly

In accordance with section 162(1) of the Independent Broad-based Anti-corruption Commission Act 2011, I present IBAC’s report concerning an investigation into allegations concerning drug use and associated corrupt conduct involving Ambulance Victoria paramedics.

IBAC’s findings and recommendations are contained in this report.

Yours sincerely

Stephen O’Bryan QC

Commissioner

1.1 Introduction

The Victorian community places great trust in paramedics. Paramedics are often among the first to arrive at the scene of an emergency and are responsible for treating and stabilising patients. They have access to an array of powerful, prescription medications that they can administer (in accordance with clinical guidelines) depending on a patient’s needs and circumstances. Victorians rightfully expect that paramedics will demonstrate professionalism and expertise in carrying out their duty of care to patients.

This report concerns an investigation by the Independent Broad-based Anti-corruption Commission (IBAC) into allegations that Ambulance Victoria (AV) paramedics engaged in serious corrupt conduct, namely the theft, trafficking and use of drugs of dependence, and misappropriation of AV equipment.

Many paramedics are exemplars of their profession. However, Operation Tone has identified a culture of illicit drug use and misappropriation of AV equipment by individuals and among certain groups, particularly in the Barwon South West region.

Based on evidence obtained during the investigation, IBAC believes it is probable that this conduct occurs beyond that identified in this investigation.

Illicit drug use by paramedics is concerning on several fronts:

• Illicit drug use, possession and trafficking are criminal offences and contravene the Code of Conduct for Victorian Public Sector Employees and the AV Workplace Conduct Policy. A paramedic who procures and uses illicit drugs is, by definition, engaging in criminal conduct.
• The use of drugs of dependence undermines the safety of the Victorian community. It is imperative that a paramedic’s judgement and performance not be impaired by illicit drugs, particularly when they are dealing with patients. The use of drugs of dependence also poses a safety risk for individual users and their AV colleagues. Since 2012, fentanyl or morphine have been involved in three paramedic deaths in Victoria.
• The use of drugs of dependence erodes public confidence in AV.

AV has proactively responded to the vulnerabilities identified in Operation Tone. When IBAC commenced its investigation in November 2015, AV’s capacity to identify and expose at-risk paramedics was initially limited. During IBAC’s investigation, AV introduced new policies and practices to minimise opportunities for the possession, use and misappropriation of drugs of dependence. New AV policies and practices also limit the opportunity for misappropriation of AV equipment.

AV has advised it accepts the content of this report and the recommendations made. AV also advised it has continued to implement initiatives to address illicit drug use and misuse of drugs of dependence since the completion of IBAC’s investigation.

During Operation Tone, one paramedic was terminated and eight paramedics resigned while under investigation. Six paramedics retained their employment with a formal warning; of these, five were relocated to different regions for varying periods, were enrolled in an ethics counselling course, and precluded from development opportunities for 12 months.

Following the IBAC investigation, one witness pleaded guilty in the Geelong Magistrates’ Court to breaching a confidentiality notice and misleading IBAC, and was fined $5000.

Drugs of dependence:

In this report, drugs of dependence refers to prescription medicines that have a recognised therapeutic need but also a potential for misuse, abuse and dependence.

Fentanyl, morphine, cocaine and methylenedioxymethamphetamine (MDMA) are all classed as drugs of dependence pursuant to Schedule 11 of the Drugs, Poisons and Controlled Substances Act 1981 (Vic). Fentanyl and morphine are also listed under Schedule 8 of the poison standard in the Therapeutic Goods Act 1989 (Cth). Within AV, these drugs are commonly referred to as Schedule 8 drugs.

In this report, ‘AV drugs of dependence’ refers to those drugs specifically stocked by AV.

Illicit drugs:

In this report, illicit drugs refers to drugs that are prohibited from manufacture, sale or possession in Australia, for example cocaine, heroin and ecstasy.

Trafficking of drugs of dependence:

In this report, trafficking of drugs of dependence refers to both illicit drugs and drugs of dependence.

1.2 The early stages of the investigation

Operation Tone was an ‘own motion’ investigation conducted pursuant to section 60(1)(c) of the Independent Broad-based Anti-corruption Commission Act 2011 (IBAC Act).¹

Information obtained during Operation Apsley (an IBAC investigation into illicit drug use by Victoria Police officers²) indicated that two AV paramedics were involved in the use and/or trafficking of drugs of dependence (primarily cocaine and MDMA), and the misappropriation of AV equipment or drugs.

IBAC approached AV with these allegations. Subsequently, AV notified IBAC of numerous incidents of suspected misappropriation of drugs of dependence by former paramedics. AV had already investigated those thefts, most of which related to fentanyl and morphine, and on each occasion reported them to Victoria Police.

Trafficking and possessing a drug of dependence are indictable offences against the Drugs, Poisons and Controlled Substances Act 1981, and fall within the definition of a relevant offence under the IBAC Act.

1.3 The entities and people involved

1.3.1 Ambulance Victoria

Ambulance Victoria was established on 1 July 2008 following the merger of the Metropolitan Ambulance Service, Rural Ambulance Victoria, and the Alexandra District Ambulance Service. AV is a statutory agency reporting to the Minister for Health and Ambulance Services via the Department of Health and Human Services (DHHS).

The organisation’s legislative responsibilities are enshrined in the Ambulance Services Victoria Act 1986. AV provides the core service of emergency pre-hospital medical response and other services such as non-emergency patient transport, emergency management and air ambulance.

AV employs different types of paramedics. Those most relevant to Operation Tone include³:

• Qualified paramedics: Most AV paramedics are trained to Advanced Life Support (ALS) level, which means they can insert intravenous cannula (drips), administer pain relief medication, perform advanced airway management, give intravenous (IV) drug therapy for cardiac arrest patients and perform IV fluid replacement for trauma patients.
• Clinical instructors: Clinical instructors provide the on-road, day-to-day training of graduate paramedics and paramedics returning to work after an absence. Clinical instructors focus on clinical, operational and professional development.
• Graduate paramedics: Graduates with appropriate tertiary qualifications spend one to two years receiving ongoing training and familiarisation in AV procedures and protocols.

As at June 2016, AV had more than 3400 full-time equivalent on-road clinical staff (including paramedics, team managers, patient transport officers, retrieval registrars, clinic transport officers and clinical instructors).⁴ This figure excludes management and operation support staff.

In addition, AV engages 357 Community Emergency Response Team (CERT) volunteers and employs approximately 650 Ambulance Community Officers (ACO). ACOs are first responders employed on a casual basis to provide advanced first aid in remote communities where the caseload is low and the branch is not staffed full-time.

1.3.2 Overview of paramedics involved

AV paramedics are regarded as ‘public officers’ as they are employed in the public sector under the Public Administration Act 2004. They are accountable under the Code of Conduct for Victorian Public Sector Employees and are required to uphold the public sector values.

Twenty-two paramedics were investigated during Operation Tone. They included ALS level paramedics, clinical instructors and graduates. Operation Tone found that several line managers were aware of widespread practices such as the misappropriation of AV equipment for personal use, but were not directly involved.

Structurally, AV is divided into seven regions, comprising two metropolitan and five regional divisions. Most paramedics investigated as part of Operation Tone, particularly in relation to the use and/or trafficking of drugs of dependence, were based in the Barwon South West region.

1.4 The allegations in brief

It was alleged that AV paramedics:

• stole and/or used AV drugs of dependence
• used and/or trafficked drugs of dependence
• ‘cannulated out of scope’
• misappropriated AV equipment.

1.5 The conduct of the investigation

1.5.1 Information obtained

AV and individuals involved in this investigation provided a substantial amount of documentation to IBAC, either voluntarily or by way of summons.

A total of 46 summonses were issued in relation to financial records, examinations and documents.

IBAC also approached three former AV paramedics who were dismissed from AV for the theft and misuse of AV drugs of dependence. These former paramedics agreed to be interviewed to assist with the investigation.

1.5.2 Private examinations

IBAC summonsed 18 witnesses to attend private examinations to assist the investigation. The private examinations were conducted between January and October 2016.

1.5.3 Targeted drug tests

Operation Tone resulted in the targeted drug testing (hair and urine) of 22 paramedics. Evidence obtained during the investigation indicated that two paramedics were involved in the trafficking, use and possession of illicit drugs. AV initially conducted drug testing on these two paramedics, then expanded the scope of testing upon notification to IBAC of numerous incidents of suspected thefts of drugs of dependence.

1.6 Recommendations

2.1 Misappropriation and use of AV drugs of dependence

It was alleged that AV paramedics stole and/or used AV drugs of dependence.

During Operation Tone, and with the assistance of AV, IBAC identified a culture of misappropriation and misuse of drugs of dependence among some AV paramedics.

2.1.1 History of misappropriation and misuse of AV drugs of dependence

During Operation Tone, IBAC identified that one serving paramedic, referred to in this report as Paramedic A, stole and used AV drugs of dependence, including fentanyl and morphine.

This was not a lone incident. AV reported 27 instances of misappropriation of drugs of dependence (mainly fentanyl and morphine) by AV paramedics since 2012. Seventeen of these incidents were attributed to paramedics who were working at AV at the time.

During the early stages of Operation Tone, AV provided IBAC with a list of paramedics who had previously been detected stealing and misusing AV drugs of dependence and had subsequently been dismissed. AV determined a variety of methods had been used to obtain the drugs of dependence including:

• stealing ampoules (small capsules that contain a measured quantity of liquid ready for injecting) and amending drug registers
• tampering with ampoules and replacing the medications with saline
• stealing residual medication after administration
• stealing residual medication disposed of in sharps containers
• removing medications from an AV safe.

Around the time of – and during – IBAC’s investigation, there were two further instances of misappropriation of fentanyl. One AV paramedic, who was alleged to have stolen fentanyl, died in October 2015 and fentanyl was subsequently found to have been involved.⁵ Separately, another paramedic self-reported that they had stolen fentanyl. The paramedic was subsequently dismissed and later died from a suspected drug overdose, however it is not known whether fentanyl was involved.

2.1.2 Evidence of misappropriation and use of AV drugs of dependence

The following case studies drawn from the Operation Tone investigation highlight how AV paramedics were able to steal and use drugs of dependence.

2.1.3 Sharing of AV drugs and prescription medications

Operation Tone identified several paramedics who used and shared AV drugs (not Schedule 8 drugs) or personal medications.¹¹ One paramedic admitted to injecting a friend with liquid maxolon to relieve the effects of alcohol poisoning while off-duty. They stated they either had the maxolon at home (with no prescription) or took expired maxolon from the AV drug safe to give to their friend.

In evidence to IBAC, another paramedic admitted they may have offered their prescription medication to others and that a colleague had offered them, as recently as the night before their IBAC private examination, their prescribed temazepam.

One paramedic admitted to having ondansetron in their first aid car kit. This had been supplied to them by a nurse from Barwon Hospital, without prescription. The paramedic had given it to their partner when their partner was ill. Similarly, another paramedic gave evidence that they provided oxycodone to a friend. The oxycodone had been prescribed to the paramedic’s child.

2.2 Use and trafficking of drugs of dependence

It was alleged that AV paramedics used and/or trafficked drugs of dependence.

During Operation Tone, IBAC found evidence to support this allegation, as the following case studies show.

2.2.1 Evidence of illicit drug use and drug trafficking by AV paramedics

2.2.2 Results of AV’s drug testing

At the commencement of Operation Tone, AV did not have a policy to conduct random drug and alcohol tests. While it was explicit that paramedics were not to present to work affected by alcohol or drugs, the threshold and parameters around use were not clear.

As a result of Operation Tone, AV drug tested 22 paramedics. Of these, IBAC identified 16 persons of interest, 12 of whom admitted to using illicit drugs in their private examinations. Of these 12, three tested positive to illicit drugs through either a hair or urine test.

While AV has taken action to clarify its position in relation to drug testing, concerns around the adequacy of AV’s current drug testing regime still remain. This is discussed further in chapter 3.

IBAC’s investigation did not reveal evidence of paramedics using drugs of dependence or being affected by drugs of dependence while on-duty or on-call.

2.3 Unauthorised cannulation by paramedics

It was alleged that AV paramedics ‘cannulated out of scope’. For the purpose of this report, ‘cannulating out of scope’ involves the administration of saline solution via an IV needle, performed either off-duty, outside work hours or in a capacity unrelated to official duties.

Evidence obtained by IBAC suggests that ‘cannulation out of scope’ was widely practised among AV staff and often involved misappropriation of AV equipment (discussed further in section 2.4).

Several of the investigated AV paramedics were found to have regularly cannulated their colleagues, family members or acquaintances, usually to mitigate the effects of alcohol through rehydration.

2.3.1 Evidence of unauthorised cannulation by paramedics

‘It’s normal in ambulance culture to practise cannulation. I know that – this will probably be frowned upon as well – but when students come out, like, green students from uni…some paramedics let them cannulate them so that they can practise’ (evidence from a paramedic in their private examination).

2.4 Misappropriation of AV equipment

It was alleged that AV paramedics misappropriated AV equipment.

Case studies 6 and 7 provide specific examples of misappropriation; however, it appears that taking AV equipment for personal use was not uncommon in AV.

2.4.1 Evidence of misappropriation of AV equipment

IBAC’s private examinations revealed that some paramedics were removing AV supplies to treat themselves, colleagues, family members and friends. This conduct extended to paramedics misappropriating IV bags along with cannulation sets to treat the symptoms of hangovers. Misappropriated equipment usually included sharps containers and IV cannulation equipment that were often used for ‘cannulating out of scope’.

One paramedic admitted to having a sharps container (taken from their AV branch) in their personal first aid kit and said they had obtained a second sharps container from the Geelong hospital for their sister-in-law who used it for dry needling (a method of using acupuncture needles to treat muscle pain). Another paramedic explained that the sharps container was used to dispose of cannulation needles, when they cannulated others outside of scope.

Some paramedics failed to recognise these behaviours as being misappropriation of AV property.

AV has been proactive in addressing the vulnerabilities identified in Operation Tone. It has introduced new policies and procedures from a corruption prevention and a risk management perspective, commissioned an external review of its drug handling procedures and has committed to establishing an integrity unit.

Notwithstanding these significant steps, IBAC identified several opportunities to further strengthen AV’s approach to preventing and detecting illicit drug use by AV officers.

3.1 Developing and communicating clear policy and procedures

3.1.1 Awareness of current AV policies on conduct and ethics

At the commencement of Operation Tone in November 2015, AV had several policies on the conduct and ethical behaviour of employees in the workplace. These policies, which remain in place today, include:

• Workplace Conduct: The policy covers matters such as responsibility to other staff members, gifts and benefits, conflict of interest, occupational health and safety, and management of breaches of the policy.
• AV Code of Conduct: The code outlines the AV mission, values and ethical and professional standards of the organisation. The code cites and complements the Workplace Conduct policy, and vice versa.
• Fitness for Duty: The policy and procedures state AV’s commitment to a safe working environment by ensuring that all employees are in a fit condition to perform the full extent of their duties without compromising their own safety, the safety of others or members of the public.

As public sector employees, paramedics are also bound by the Code of Conduct for Victorian Public Sector Employees.

The Workplace Conduct policy and AV Code of Conduct align AV values with the VPS-wide code and stress the importance of not being affected by alcohol or drugs in the workplace. The Fitness for Duty policy states it is the ‘responsibility of employees to take reasonable care of their own health and safety, and the safety of others who might be affected by their actions’. Similarly, the Code of Conduct for Victorian Public Sector Employees states that ‘public sector employees carry out their work safely and avoid conduct that puts themselves or others at risk. This includes the misuse of alcohol, drugs or other substances when at work or when engaged in work related activities’.

AV employees are made aware of the code of conduct and guidelines. For example, upon commencement of employment, all AV employees undertake a two-week induction program that involves training relating to policies and procedures. New employees are also required to complete online learning which includes an assessment component to demonstrate understanding of policy, including those relating to conduct and being fit for duty. The suite of policies and procedures is also available on the AV intranet and, in the event of any update, staff are advised via email, bulletins and at team meetings.

During the investigation, IBAC found there was a general understanding of what constitutes appropriate conduct – although this was sometimes expressed as ‘common sense’ rather than AV policy. For example, when queried whether paramedics who knew that equipment had been misappropriated would be expected to advise senior officers, one paramedic responded, ‘I’m just going off, I guess, common sense that…they would expect anyone who knew about it to tell them’.

However, not all paramedics were aware of the specific content of relevant policies, and there appears to be some lack of general understanding of their purpose and content. The conduct revealed by Operation Tone suggests there needs to be a greater reinforcement of AV’s position on such matters.

All AV employees and CERT volunteers have a responsibility to model the values outlined in the Code of Conduct for Victorian Public Sector Employees and the AV Code of Conduct, and to comply with organisational policies.

3.1.2 Forging signatures on drugs registers

I had to keep telling [them] I don’t cross my f***ing 7s’ (text message from a paramedic to a colleague)

Operation Tone identified at least two paramedics who both forged the signature of colleagues and allowed others to sign on their behalf. The forging of signatures related to drug registers and shift swap forms.

IBAC obtained evidence that suggested a paramedic allowed another paramedic to forge their signature on the drug register multiple times to remove drugs from the drug safe to restock the ambulance. That same paramedic also admitted forging a colleague’s signature on a shift swap form on at least one occasion.

IBAC understands these actions were examples of sloppy practice and not necessarily indicative of an intention to steal drugs. AV has since reinforced strict protocols around countersigning and introduced electronic shift swap forms.

3.1.3 Culture of self-protection

Other actions identified through Operation Tone suggest that some paramedics were aware of what constituted appropriate conduct and what might be considered questionable behaviour.

Operation Tone revealed a culture of denial and selfprotection among some AV paramedics. In evidence to IBAC, one paramedic admitted to deleting all text message conversations with a colleague, who had died just prior to the commencement of the investigation. They also deleted all messages that referred to IBAC.

The paramedic stated ‘… at the time it seemed like deleting links [with their colleague who had died] was an appropriate or normal thing to do’. The paramedic further acknowledged having had discussions with colleagues about deleting those same text messages, in case they were stood down.

One paramedic was concerned about the likelihood of an inquiry into the forging of signatures on drug registers (described in section 3.1.2) and texted a colleague to express a concern about having allowed this to occur. In response, the colleague texted: ‘If it comes back to it just deny’.

3.1.4 Explicit statements about zero tolerance

While AV policies at the time of IBAC’s investigation were explicit that AV paramedics were not to attend work affected by alcohol or drugs, it was not clear whether the organisation’s position extended to zero tolerance on and off-duty.

On 2 January 2017, AV introduced an Alcohol and Other Drugs (AOD) policy. The policy sets clearer parameters around the use of alcohol and other drugs.

The policy states that AV employees must not:

• have any detectible levels of illicit substances when on-duty or on-call
• misappropriate AV medications
• possess, distribute or dispense AV drugs within the workplace, unless within the capacity of their duties as expressly authorised
• provide their own personal medication for use by others.

3.1.5 Support for those reporting or experiencing drug use

AV needs to address the perception among some paramedics that they will not be supported if they approach management regarding their own or another paramedic’s use of drugs of dependence.

For example, a former paramedic stated there is currently little incentive to speak up if a paramedic is experiencing problems with drugs of dependence. They could not recall any paramedic who had been rehabilitated and resumed operational duties following an admission of illicit drug use, believing most to be ‘pretty much sacked straight away’.

AV’s new AOD policy goes some way toward being a statement of organisational support. It states that ‘any employees who report their or another employee’s use of AOD and its potential impact on fitness for duty (FFD) will not be penalised or disadvantaged by such reporting’. It also says ‘employees who selfreport will be required to undergo a FFD assessment and managed according to the AOD Supportive Framework to facilitate their return to work’.

3.1.6 Clearer policies on ‘personal use’ of AV equipment and supplies

The AV Workplace Conduct policy is clear. It states that AV assets must only be used for the benefit of AV and not for personal use. However, at the time of IBAC’s investigation, there was an entrenched cultural practice of cannulation equipment being taken for personal use and a failure by AV managers to enforce the policy.

When one paramedic asked a union representative whether taking cannulation equipment was permissible, the representative reportedly stated, ‘…there was no policy on such things and [the union representative] had cannulation gear in [their] first aid kit, and [they] knew all [their] other colleagues to do the same. And I asked [the union representative] about using AV stores, and [they] said no, we are told to restock our first aid kits from AV stores’.

The stocking of personal first aid kits using AV supplies is a grey policy area. AV encourages new employees to purchase a first aid kit. Several paramedics who gave evidence in IBAC private examinations stated that their managers encouraged and/or gave permission to stock their first aid kits with AV supplies. There is no formal policy governing this arrangement.

Clearer AV policies and increased promotion and awareness of those policies, will ensure AV employees understand their obligations.

3.2 Assessing the adequacy of AV’s drug testing regime

3.2.1 Drug testing as a deterrent

At the commencement of IBAC’s investigation, three policies relating to AV’s drug testing were:

• Workplace conduct
• Counselling and disciplinary
• Internal investigation.

When Operation Tone commenced, AV did not have a policy to conduct random drug and alcohol tests. Testing was restricted to targeted testing and work group testing¹⁵ that was infrequent and rarely returned positive results.

This limited approach was highlighted in the private examination of one paramedic who stated they had ‘never’ been drug tested in the six years they had worked at AV. They were also unaware of any colleagues who had been drug tested at work.

Former paramedics interviewed by IBAC indicated that if a drug testing regime had been in place when they worked for AV, it would have acted as a deterrent to their misuse of drugs of dependence.

The new AOD policy provides AV with the authority to conduct random alcohol and drug testing of its employees.

There would be merit in AV considering its approach to drug testing to ensure the most accurate possible testing is conducted. For example, hair sampling is substantially superior to urine testing. Illicit drug residuals and metabolites remain in the hair for many months after use, while urine metabolites for most illicit drugs are excreted within three to five days after use.¹⁶

3.2.2 Issues with drug testing

Despite the new AOD policy, certain issues warrant further consideration:

• While the new AOD policy appears to stipulate a zero-tolerance stance, it is not clear whether the policy extends to ‘off-duty’. If a paramedic has a detectible level of illicit substances at work, then irrespective of whether the drug was taken on-duty, on-call or off-duty a positive test will be in breach of the AOD policy.
  As the policy does not explicitly refer to ‘off-duty’, a paramedic may contemplate taking drugs and risk being caught through random drug testing, believing ‘off-duty’ to be outside of scope.
• AV does not have an official annual target for random drug and alcohol testing so it is unclear how many tests AV intends to conduct annually. It is also unclear what proportion of tests will be urine and what proportion hair.
  Victoria Police, in its interim response to IBAC’s recommendations arising out of Operations Apsley, Hotham and Yarrowitch, has advised it has identified increasing random drug testing as an area of improvement, after IBAC determined the current proportion of the workforce (five per cent per annum) subject to random testing was inadequate.
• Timing is also an issue. If too much notice is given to work units undergoing random or designated work unit testing, the effectiveness of testing is undermined. Similarly, if urine testing is not conducted immediately following a ‘reasonable belief’ that a paramedic is using drugs of dependence, AV may not obtain a positive test.
• The AOD policy is not clear about what constitutes ‘detectible levels of illicit substances’. The Special report concerning illicit drug use by Victoria Police officers highlighted that Victoria Police has adopted the European Guidelines for Workplace Drug and Alcohol Testing in Hair 2015. Under those guidelines, the positive cut-off levels effectively allow for infrequent or occasional illicit drug use. Low level detections which may indicate occasional or one-off drug use are likely to be reported as negative, thereby allowing officers who have used illicit drugs infrequently to evade detection.

Taking this into consideration, AV will need to be consistent in its messaging around all facets of its drug testing arrangements. Its policy and procedures will need to be applied consistently to provide clarity to AV paramedics around AV’s expectations.

3.2.3 Drug testing under the National Registration and Accreditation Scheme

In November 2015, Australian Health Ministers agreed to progress the inclusion of paramedics in the National Registration and Accreditation Scheme (NRAS) administered by the Australian Health Practitioner Regulatory Authority (AHPRA). Under the NRAS, national boards¹⁷ and AHPRA work together to ensure that practitioners are appropriately qualified and competent to practise a registered health profession. It is anticipated that Victorian paramedics will be part of this scheme by late 2018.

In relation to nurses, AHPRA works closely with that profession’s national board to conduct random urine drug screens and tri-monthly hair tests for those who have an identified substance-related impairment. A former paramedic who is now a nurse, is subject to that process and advised IBAC they ‘…had restrictions that I couldn’t work casually and that I had to inform the organisation I was working for of all my conditions and that they had to provide a three-monthly report detailing how I’m progressing’.

Inclusion in the NRAS adds another layer of complexity around drug testing for AV. AV will need to establish how its drug testing arrangements will complement that administered by the national regulator.

3.3 Assessing the adequacy of current drug controls

3.3.1 Reducing opportunities for misappropriation of drugs of dependence

Paramedics have access to powerful medications, particularly Mobile Intensive Care Ambulance paramedics who have even greater autonomy than ALS level paramedics.

Prior to and during Operation Tone, AV significantly strengthened controls around the handling of Schedule 8 drugs. Changes to the access and handling of drugs of dependence – specifically fentanyl – include:

• reducing size of ampoules from 600 micrograms to 250 micrograms
• implementing swipe access to all AV stations
• amending the presentation of fentanyl intranasal ampoule to tamper-proof packaging
• implementing swipe access to medication rooms, with access to the room restricted to on-duty paramedics.

Despite this, IBAC identified that the inappropriate disposal of residual medication continues to be an issue. Current medication management protocols state that any used medication must be discarded in a manner that makes it irretrievable. However, the protocols are not always adhered to.

IBAC identified concerns with:

• ampoules or syringes commonly being discarded with small quantities of medication still in them
• opportunities to forge signatures on drug registers
• colleagues not being present to witness the disposal of residual medications.

Previous offenders have taken advantage of some colleagues’ lack of vigilance in relation to the disposal of medications. A former paramedic who was dismissed for stealing fentanyl observed ‘one of the officers was very careful to watch the discarding so [I] never did it with [them]’.

The possibility of misappropriation will always be an issue for AV. IBAC recognises it is a delicate balance in empowering paramedics to make life-saving, time-critical decisions within the context of a sound risk management framework.

However, a change in culture is required to reduce the opportunities for misappropriation of drugs of dependence. Reinforcement of stringent observance to policy, particularly by team leaders and clinical instructors, will positively affect behavioural and cultural norms.

3.3.2 Action in response to commissioned review of drug handling procedures

In June 2015 AV commissioned an advisory firm to conduct a comprehensive review of drug handling procedures. The consultancy recommended that AV:

• engage an independent employee to conduct audits of restricted medication, at each branch, every three months
• transfer the recording of medications to an electronic inventory as opposed to the current paper based model, which is vulnerable to error and manipulation
• improve protected disclosure procedures¹⁸ to encourage reports on inappropriate behaviour.

AV has advised it is working towards implementation of these recommendations.

3.4 Strengthening recruitment processes and policies to address risks

3.4.1 Robust recruitment processes

Robust recruitment processes are an opportunity for organisations to recruit people committed to the agency’s values, with the appropriate skills, expertise and psychological profile.

In 2015/16 AV recruited 256 paramedics, including 241 university graduate paramedics.¹⁹ The new intake provides AV with an opportunity to promote AV policies and instil positive behaviours and practices.

AV should examine its recruitment processes and consider ways they can be strengthened to more effectively inform prospective applicants of the organisation’s position on illicit drug use, and to help identify candidates who may require further assessment or risk management due to declared prior illicit drug use.

3.4.2 Psychological screening of applicants

‘[There is] absolutely a link between mental illness and the job AV officers do’ (former paramedic).

Operation Tone revealed that some paramedics who were detected misusing drugs of dependence used the drugs to deal with psychological issues and were reluctant to see a psychologist for fear of workplace repercussions.

Paramedics cited factors such as work-related trauma, sleep difficulties, the need for pain relief, and long shifts as precursors to debilitating stress, which ultimately led some paramedics to use AV drugs of dependence.

AV commenced psychological testing of its applicants in February 2017. Psychological testing of applicants will provide AV with an indication of those at risk of future psychological injury. The information acquired through psychological screening of applicants, for example, could assist with the development of a risk matrix to identify factors that may lead to the misuse of AV medications.

3.4.3 Drug testing of applicants

AV has also commenced drug testing applicants. The combined system of psychological and drug testing will provide AV with a more robust approach to preventing the misappropriation and use of drugs of dependence. The AV website states ‘candidates are required to undertake alcohol and other drug testing as part of their medical and physical assessment, as well as psychological screening’.

The 2013 National Drug Strategy Household Survey found that about 43 per cent of Australian adults had used illicit drugs in their lifetime. It is likely that a significant proportion of paramedic applicants have used drugs before applying to join AV.

AV should encourage applicants to be entirely truthful by advising applicants that a declaration of prior drug use will not automatically preclude their application from progressing.

4.1 Conclusion

Paramedics are entrusted with the safe handling, storage and administering of drugs of dependence. All drugs of dependence should be accounted for and used only for lawful purposes. There are significant risks associated with misusing drugs of dependence, including serious injury and death.

Misappropriation of AV drugs of dependence can have safety implications for members of the public if drug registers are not accurate and ambulance vehicles are not stocked with the appropriate medications. Non-adherence to policies and procedures can negatively pervade an organisation’s culture, where lax behaviours go undetected and unaddressed by team leaders and employees alike.

Most AV paramedics are highly-skilled and ethical in their conduct. They act in line with relevant codes of conduct and relevant policies and procedures. They do an impressive job in often challenging circumstances.

However, Operation Tone identified a culture of illicit drug use and misappropriation of AV equipment among certain groups and individuals, particularly in the Barwon South West region. On the balance of evidence, this conduct likely occurs beyond that identified in Operation Tone.

Operation Tone is timely given the rise in the use of fentanyl across Australia. As mentioned in this report, recent reports by IBAC’s interstate counterparts have cited the misappropriation and use of opioids as a topical and important issue.

When IBAC commenced Operation Tone in November 2015, AV’s capacity to initially identify and expose at-risk paramedics was limited. However, during and since IBAC’s investigation, AV has introduced new policies and practices to minimise opportunities for the possession, use and misappropriation of drugs of dependence and misappropriation of AV equipment. IBAC acknowledges AV has been quick to respond to the vulnerabilities identified in Operation Tone.

The recommendations outlined below are offered as next steps on the path to a robust framework for preventing and detecting illicit drug use and misuse of drugs of dependence within a critical Victorian emergency service organisation.

4.2 Recommendations

That DHHS consider the issues raised in Operation Tone and whether similar vulnerabilities could exist in other Victorian health services. The Department is to report to IBAC by 28 September 2018 on steps taken to address any such vulnerabilities in the broader health sector.

Appendix A: Natural justice requirements and responses

Pursuant to section 162(2) of the Independent Broad-based Anti-corruption Commission Act 2011, this report was provided to the principal officer of Ambulance Victoria. Ambulance Victoria’s response accepted the contents and recommendations of the report and noted that since the conclusion of the IBAC investigation, Ambulance Victoria has continued to implement initiatives to address illicit drug use and misuse of drugs of dependence.

Appendix B: Previous IBAC special reports

¹ IBAC can start an ‘own motion’ investigation at any time, in relation to any matter that falls within its jurisdiction.

² Independent Broad-based Anti-corruption Commission, Special report concerning illicit drug use by Victoria Police officers: Operations Apsley, Hotham and Yarrowitch, December 2016. To download the report, visit www.ibac.vic.gov.au

³ www.ambulance.vic.gov.au/paramedics/types-of-paramedics/

⁴ Ambulance Victoria Annual Report 2015/16.

⁵ The death was the subject of a coronial inquiry.

⁶ Gibson, A. et al. The extent of diversion of fentanyl for non-medical purposes in Australia: what do we know? NDARC Technical Report no. 265, National Drug and Research Centre, University of New South Wales, Sydney, 2016.

⁷ Roxburgh, A. and Breen, Accidental drug induced deaths due to opioids in Australia, 2012. National Drug and Research Centre, University of New South Wales, Sydney, 2016.

⁸ Roxburgh, A. et al. ‘Trends in fentanyl prescriptions and fentanyl-related mortality in Australia’, Drug and Alcohol Review. Volume 32. Issue 3. May 2013.

⁹ Queensland Crime and Corruption Commission, Queensland public health sector responses to incidents of theft: summary audit report, June 2017.

¹⁰ Western Australia Corruption and Crime Commission, Report on the supply and management of Schedule 8 controlled drugs in certain public hospitals in Western Australia, June 2017.

¹¹ These medications included maxolon, temazepam, ondansetron and oxycodone. Maxolon is used to treat conditions including nausea and vomiting (www.healthdirect.gov.au). Temazepam is used to treat sleeping problems or insomnia, ondansetron is used to prevent nausea and vomiting, and oxycodone is used for pain relief (www.healthdirect.gov.au).

¹² Ketamine is used for anaesthesia and pain relief (www.healthdirect.gov.au).

¹³ Norketamine is a product of the breakdown of ketamine (druginfo.sl.nsw.gov.au).

¹⁴ Psilocybin is a hallucinogenic chemical found in some kinds of mushrooms (druginfo.sl.nsw.gov.au).

¹⁵ Work group testing is available to managers who are responsible for employees who may be at particular risk or where audit anomalies are not able to be resolved by investigation. Where work group testing is deemed necessary, all employees in the work group (for example a branch roster) are directed to provide an alcohol and drugs testing sample.

¹⁶ For further discussion on drug testing, see the Special report concerning illicit drug use by Victoria Police officers on the IBAC website.

¹⁷ Each health profession that is part of the NRAS is represented by a national board. National boards are responsible for registering practitioners and students, as well as other functions, for their professions.

¹⁸ Pursuant to the Protected Disclosure Act 2012.

¹⁹ Ambulance Victoria annual report 2015/16.

²⁰ Coroners Court of Victoria, Coroner’s Prevention Unit, ‘Suicide rates among people in selected occupations, Victoria 2008–2014’. Coroner’s Prevention Unit, 7 July 2015.

²¹ Australian Institute of Health and Welfare, National Drug Strategy Household Survey 2013 online tables – table 5.7, 2014, (www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129549638).