Given the Coronial inquiry into this case it would be inappropriate for ACT Health to comment directly on any fact or evidence from the inquest, or submissions of Counsel Assisting the Coroner or a party to the inquest.

Commenting on the details of this case would re-litigate issues arising from the inquest and may be regarded as an attempt to bypass the coronial process.

ACT Health responded to the issues raised during the hearing, and the conclusions drawn by Counsel Assisting the Coroner or a party to the inquest, in its written submissions. These written submissions were filed on 29 March 2016.

These are standard coronial procedures.

A copy of the written submission of Counsel Assisting the Coroner can be accessed through the Coroner's Court.

The Minister for Health and Wellbeing will provide the government's response to the Coroner's report during the August sitting period.

Since 2010 there have been many changes in practice and ACT Health will be in a better position to answer specific questions, unrelated to Mr Fennessy's case, once the government's response has been tabled in the next sitting period.

Second ACT Health statement, September 2017:

Firstly, ACT Health would like to acknowledge Paul Fennessy and his life and offer our sincere condolences to his family at the tragic loss of their son and brother.

The Minister for Health and Wellbeing understands that Paul's family would like to understand what other changes in practice and approach have occurred over the intervening years that may not have been the subject of the Coroner's investigation. This is understandable and the minister would like to provide that advice to Paul's family. She has suggested that this may be a process assisted by the Office of the Health Services Commissioner.

The minister has also undertaken to discuss with the Attorney-General the processes for family support during the coronial process and whether there is an opportunity to strengthen ways of working with families during an inquest.

Last month, the Minister for Health and Wellbeing tabled the ACT government's response to the recommendations arising from the coronial inquest into the unfortunate death of Mr Fennessy. The government's response (which supported both recommendations) can be found at: www.hansard.act.gov.au/hansard/2017/pdfs/20170817.pdf

Throughout the inquest, ACT Health supported the coronial process, and since the Coroner's recommendations were handed down last year, ACT Health has made great strides in terms of weekly reporting and improved electronic monitoring of controlled medicine prescribing and dispensing in the ACT. This is through the implementation of the Drugs and Poisons Information System (DAPIS) system here in the ACT.

The aim has been to ensure that real time reporting is valid and transparent for controlled medicines going forward to ensure the safety of all Canberrans. Through the rollout of DAPIS, the ACT Health Protection Service has also been proactive in working with pharmacies to improve reporting to reduce the harms associated with misuse or abuse of controlled medicines in the community.

In addition, there have been improvements and upgrades to clinical records systems in operation in our hospitals and health facilities. A scoping study is currently underway as well, to investigate the feasibility of integrating the different clinical record systems in ACT Health.

Moving forward, ACT Health strongly supports the rollout of the DAPIS Online Remote Access (DORA) system as an important public health measure and is actively working to ensure the delivery of the system in the ACT by March 2019.

Given the coronial inquiry into this case, ACT Health will not be commenting further. As part of standard coronial procedures, ACT Health has responded to the issues raised during the hearing, and the conclusions drawn by counsel assisting the Coroner or a party to the inquest, in its written submissions and in the government's response tabled in the Assembly last month.

In saying this, ACT Health would like to reiterate our sincere condolences to the Fennessy family.