Shae Paszkiewicz was found unconscious from a heroin overdose a day after being released from prison on a drug treatment order. Five days later he was dead.
A Victorian coroner wants the state government to overhaul support provided to drug users when they are released from prison to help prevent more tragic deaths like Mr Paszkiewicz's.
The 40-year-old had been in Port Phillip Prison for a burglary he blamed on his methamphetamine use before being released on a drug treatment order in December 2017.
The next day, he got an injecting kit from a vending machine outside North Richmond Community Health and was found unconscious on the footpath about 10 minutes later.
He died five days later in hospital.
Coroner Jacqui Hawkins on Thursday called for reforms including the immediate introduction of a take-home naloxone program for released prisoners with a history of opioid use.
Naloxone is a fast-acting drug that reverses the effects of opioids, including overdoses.
The coroner recommended the health department form an advisory group on how to better support and reduce death among drug users released from prison.
Ms Hawkins also wanted the different departments to start collating statistics about the health outcomes of these prisoners and report the findings publicly at least once a year.
"The death of Mr Paszkiewicz occurred, tragically, in circumstances that Victorian coroners encounter all too often," she said.
"Fatal overdose after leaving prison is a public health issue and demands a public health response.
"The starting point for such a response is to understand the frequency and nature of the issue."
Mr Paszkiewicz's overdosed and died before the start of a safe injecting room trial at the North Richmond centre.
He began using cannabis at the age of 15 and heroin two years later, and went on to serve 11 prison sentences and 13 community orders for 176 offences.
His father, John Pascoe, said the family was always trying to help get Mr Paszkiewicz off drugs.
"He would be good, but it was a cycle and he would always fall back into it. He would always say, 'Dad, it's so hard'," Mr Pascoe said.
Mr Paszkiewicz had anxiety, depression and an acquired brain injury, and was released on a two-year court order with drug and alcohol testing and treatment conditions.
He attended a testing appointment the day he overdosed, and was found with heroin, alcohol, pregabalin, amitriptyline, ethanol, morphine and codeine in his system.
In 2017, Victoria recorded 220 deaths associated with heroin overdoses. Of these, 90 involved people who had spent time in prison and 10 occurred within seven days of release.
Ms Hawkins said the risk of fatal drug overdoses was particularly elevated in the weeks and months after someone got out of jail.
Her recommendations also included calling on the health department to adopt formal responsibility for reducing drug-related deaths in this cohort.
"Over the past 20 years Victoria's coroners have repeatedly highlighted this risk in their findings and accompanying recommendations," the coroner said.
Australian Associated Press