Inquest Into The Death Of Simon Gaskill: Systemic Gaps In Discharge Planning For Patients Experiencing Homelessness

Background

Roughly four months before his death, Simon Gaskill was admitted to Barwon Health with severe alcohol withdrawal, a seizure, malnutrition, confusion and falls. Imaging showed multiple thoracic spine fractures. He was clearly unwell, clearly vulnerable, and already sleeping rough. By December 2021 he was discharged into homelessness, with his housing status not properly recorded and his follow up care effectively tied to an address he no longer had.

The inquest recorded that Simon expressed interest in alcohol and other drug (AOD) support while in hospital. An inpatient AOD review was planned but did not occur before discharge. Outpatient appointments were arranged, but the letters went to an old address. No one appears to have stopped and asked the question: how will this man, with no fixed place to live, actually receive and act on this plan?

Barwon Health’s care during the admission itself was not the main target of investigations. The Coroner accepted that his acute withdrawal was treated and that appropriate investigations were ordered. The problem sat at the point of transition, where discharge planning treated Simon as if he were a ‘standard’ community patient, not a homeless man with complex dependence, cognitive issues and no stable way to be contacted.

The Gaps within the Discharge System

The inquest into Simon’s death exposes a significant gap in the hospital discharge process for patients experiencing homelessness. It shows that discharge planning cannot be assessed only by whether referrals were made or appointments were listed on paper. For vulnerable patients, particularly those with no fixed address, alcohol dependency and complex health needs, the real question is whether the follow-up plan is practical, accessible and capable of being acted upon. In Simon’s case, the arrangements made after discharge did not adequately account for the realities of homelessness, including the difficulty of receiving letters, attending appointments and navigating multiple services without stable support.

Under the discharge plan system, a patient may technically be discharged with follow-up arrangements in place, but if those arrangements depend on an address the patient does not have or require a level of stability the patient cannot realistically maintain, the system does not provide meaningful continuity of care. The Coroner identified this issue in direct terms when considering homelessness as a context in Simon’s death. At paragraph [23], the Coroner found:¹

“While my investigation has been unable to determine Simon’s cause of death, it is evident that many of the mechanisms identified as contributing to reduced life expectancy among people experiencing homelessness were present in his case, including untreated alcohol use disorder, liver disease, and lack of adequate health-care follow-up following his discharge from University Hospital Geelong.”

This observation showed that Simon’s death was an example of how inadequate follow-up can compound the risks already faced by people experiencing homelessness. The Coroner distilled the issue to a basic human rights concern: Simon should have had a genuine opportunity to access housing, health care and ongoing support after discharge. That human rights lens was then expressly applied to Simon’s experience of the healthcare system at paragraph [33]:²

“Consider this human rights lens ought to and must be viewed as highly relevant to Simon’s experience of the healthcare system as a man experiencing homelessness.”

The finding is blunt, and the Coroner concluded that Simon was failed when he was discharged without proper recognition of his homelessness and without realistic arrangements for follow up. The inquest called for clear processes to support vulnerable patients in similar circumstances, including better identification of homelessness, more active coordination of care, and discharge pathways that do not rely on postal letters to nowhere.

Systemic Changes

Although Simon was tragically lost to the system due to his state of homelessness and his issues with alcohol dependency and subsequent health issues, this inquest resulted in several recommendations, with many directed at Victoria’s Department of Health.

The most pertinent is adequate patient verification, in relation to whether they are homeless and the risks associated with same. Particularly, communication methods following discharge when an individual has no fixed place of abode. [6-7]³

Furthermore, appointments should be scheduled before discharge and recorded in the patients ’My Service Diary, or another communication method nominated by the patient. Staff should also document all contact and attempted contact about outpatient appointments in the patient’s record and explore ways to strengthen support for outpatients experiencing homelessness through integrated housing and health programs or allied health professionals. [7]⁴

There were also additional recommendations made in respect to patients with alcohol dependency which make them vulnerable patient on discharge due to the increase in risks. These being direct referral to drug and alcohol services and general and psychiatry teams aware of the patients process and referral for DAS among other recommendations. [8]⁵

Realities for the most vulnerable

Simon’s case demonstrates that discharge planning cannot be treated as a purely administrative step, especially where a patient has no fixed address, limited capacity to attend appointments, and significant ongoing health needs.

The Coroner’s findings show that it is not enough for hospitals to arrange follow-up in a formal sense if those arrangements are unlikely to reach, or be acted upon by, the patient. Viewed through a human rights lens, the failure to properly recognise Simon’s homelessness meant that he was not given a meaningful opportunity to access continuing healthcare, housing support or alcohol and other drug services after discharge. The broader lesson is that reasonable care for vulnerable patients requires more than standard discharge procedures. It requires active identification of risk, realistic communication methods, coordinated referrals and practical steps to ensure that follow-up care is accessible. In this way, the inquest exposes a systemic gap between the discharge plan recorded on paper and the lived reality of patients who are already at risk of falling through the cracks.

Footnotes

1 Subheading – Homelessness as a context in death – See link: SIMON CHRISTOPHER GASKILL BC202607597

2 Ibid.

3 Recommendations – SIMON CHRISTOPHER GASKILL BC202607597

4 Ibid.

5 Ibid.

Contributors

Ren Li, Senior Associate

Jemillah Hughes, Law Graduate