Coroners Act 1995
Coroners Rules 2006
Rule 11
(These findings have been de-identified in relation to the name of the deceased, family and friends by direction of the Coroner pursuant to s. 57(1)(c) of the Coroners Act 1995.)
I, Simon Cooper, Coroner, have investigated the death of Mr G with an inquest held at the Hobart Coroners Court, 27 Liverpool Street, Hobart in Tasmania on 2 February 2015.


Mr G died in room seven of the Department of Psychiatric Medicine at the Royal Hobart Hospital Hobart on 11 April 2014. At the time of his death Mr G was the subject of a treatment order made pursuant to section 37 of the Mental Health Act 2013. Section 24 of the Coroners Act 1995 provides that an inquest must be held if the deceased "was immediately before death a person held in care".

Section 3 of the Coroners Act defines a "person held in care" to mean, inter alia, a person subject of an order of the type that applied to Mr G at the time of his death. 

Formal Findings:

In every case the subject of a Coronial Investigation section 28 of the Coroners Act requires a Coroner to make, if possible, various findings. In that regard the evidence at the inquest persuades me that the following findings should be made: 

(a)    The identity of the deceased has been confirmed as Mr G;

(b)   Mr G died in the circumstances described in this finding;

(c)    Mr G died as a result of sudden cardiac arrest;

(d)   Mr G died on 11 April 2014 at the Royal Hobart Hospital, Hobart in Tasmania;

(e)    Mr G was aged 50 years at the time of his death;

(f)    Mr G had never been married and his occupation at the date of death was an Information Technology specialist; and

(g)    No person contributed to the cause of Mr G's death.


Mr G was the son of Mr and Mrs G. He is described as throughout his childhood being a typical healthy young Australian who excelled in the sports of soccer and swimming, competing in the latter to Queensland state level.

In about 1988 Mr G reportedly suffered a nervous breakdown whilst working on South Molle Island. He seems then to have been diagnosed as suffering from schizophrenia. After a short period of hospitalisation in North Queensland, Mr G was treated in the community for this condition with a very high level of success. In 1994 whilst a student at TAFE on he suffered another acute psychotic episode.

He worked in a variety of occupations throughout his life and from about 2002 worked as an IT specialist in Tasmania. Mr G was very highly regarded by his employer and his colleagues. In addition to his work Mr G reportedly had a variety of interests including photography, music and formal Japanese gardens. He was a popular man and had a number of close friends.

Throughout all this time his medical treatment was managed by his General Practitioner (GP) with the assistance of a variety of other specialists. It is apparent that the support he received from his GP, Dr Graham Jones, was entirely appropriate. Significantly he was for a very long time medicated with the drug clozapine, and the management of his mental health undertaken at the clozapine clinic at the Royal Hobart Hospital. He kept himself in good physical condition notwithstanding the fact that he suffered Type 2 diabetes. He drank no alcohol but smoked in the order of 10 cigarettes per day.

Mr G seems to have suffered some atypical chest pain which was investigated by a cardiologist with a normal stress test resulting in 2010.

In February 2014 Mr G was started on the drug varencline, which is used to assist with giving up smoking. It is notable that the drug is one with a documented side-effect with respect to use and patients suffering from pre-existing neuropsychiatric disorders.

Medical material indicates that from the start of 2014 Mr G's clozapine was being reduced in dose, but in a manner entirely appropriate.

In March 2014 (shortly before his death) Mr G again suffered from atypical chest pain. That chest pain led to him being referred to Dr Warwick Bishop, cardiologist and Dr Hugh Jackson, gastroenterologist for review and investigation. Various tests and investigations were carried out, in particular by Dr Bishop. Those tests and investigations included a CT coronary angiogram as well as electrocardiography (ECG) testing. Neither investigation revealed any sign of coronary abnormality.

Circumstances Surrounding the Death: 

On 2 April 2014, Mr G was admitted to the Psychiatric Unit of the Royal Hobart Hospital as a consequence of suffering an acute relapse of schizophrenia for which he was being treated.

Medical notes indicate that upon his presentation at the emergency department of the Royal Hobart Hospital on 1 April 2014 he was suffering from a psychotic illness. Due to his mental state no medical history was readily available from him although the admitting doctor in the Emergency Department noted that Mr G was suffering from atypical chest pain and diabetes.

After admission to the Psychiatric Intensive Care Unit (PICU) Mr G was assessed and treated for an acute relapse of schizophrenia.

As his treatment was being undertaken various steps were taken pursuant to the provisions of the Mental Health Act 2013 to formalise the circumstances of Mr G's admission. The complete file relating to those applications was tendered at the inquest. I have reviewed that material and am satisfied that at the relevant time (i.e. as at the date of Mr G's death) he was lawfully subject to a treatment order made by the Mental Health Tribunal pursuant to section 37 of the Mental Health Act 2013.

In addition to treatment for schizophrenia, Mr G underwent blood tests and other investigations as part of his admission process. An electrocardiogram was carried out on 5 April. The result of that investigation showed sinus rhythm with a right bundle branch block appearance. QT interval was at 487 millisecond, which although high was not sufficiently high (i.e. in the order of 500 millisecond) to warrant any concern. In addition it was unchanged from an ECG carried out on 14 February 2014 as part of the investigations carried out in that month. Other investigations were carried out which did not reveal any particular underlying pathology and especially no cause for concern with respect to his cardiac function. 

Medical records reveal that on 10 April 2014 Mr G had significantly improved. The improvement was so marked that he was authorised for three hours unaccompanied leave from the hospital. 

At 9:05am on 11 April 2014, Mr G was found lying in his bed, in his room at the hospital non-responsive. His pupils were not responsive to light. There were no heart or breath sounds. A code blue alert was called and CPR immediately commenced. That treatment was ceased after 15 minutes when it was confirmed that he was deceased. 

Police and the Coroner's Office were immediately notified. Police Officers attended more or less immediately, and an investigation was commenced under the Coroners Act 1995. No suspicious circumstances were identified at the scene. After formal identification, Mr G's body was subject to an autopsy carried out by Dr Donald McGillivray Ritchey, Forensic Pathologist. Dr Ritchey expressed the opinion, after autopsy, that the cause of Stephen's death was atherosclerotic and hypertensive cardiovascular disease causing sudden cardiac arrest. I accept this opinion. Noted at autopsy was that the heart was enlarged and there was an increased thickness of the left side of the heart. Of particular significance was that it was identified by Dr Ritchey that there was marked small vessel arteriosclerosis.

Samples taken at autopsy were forwarded to Forensic Science Service Tasmania for analysis. A Forensic Scientist at that laboratory identified the presence of a variety of drugs including clozapine, all of which were present in therapeutic levels and all of which were drugs prescribed for and provided to Mr G for the treatment of his schizophrenia and its side-effects. 

Report on the Deceased's Care:

Section 28 (5) of the Coroners Act 1995 provides:

"If a coroner holds an inquest into the death of a person who died whilst that person was a person held in custody or a person held in care or whilst that person was escaping or attempting to escape from prison, a secure mental health unit, a detention centre or police custody, the coroner must report on the care, supervision or treatment of that person while that person was a person held in custody or a person held in care."

There is a very sound policy reason underpinning this legislative requirement. It is fundamentally important that the death of every person who is detained in any state-run institution by reason of an order of a court, tribunals, or the executive is carefully and transparently examined.

To this end the inquest was held. As part of the inquest a careful and comprehensive review of all of the treatment afforded to Mr G in the lead up to and during his period of admission in the Royal Hobart Hospital as a consequence of the treatment order already referred to was undertaken by Professor Bell MD FRACP FCICM, medical consultant to the Coroner's Office. Prof Bell expressed the view that Mr G had attentive general practitioners "who managed [his] medical problems well".  Prof Bell concluded that Mr G's chest pains were investigated comprehensively and appropriately, including review by an experienced cardiologist. No tests done (and the tests were in Dr Bell's view entirely appropriate) were diagnostic of cardiac disease.

Significantly Prof Bell expressed the view that the treatment afforded to Mr G whilst the subject of the mental health order was of an appropriate standard.

Prof Bell expressed the opinion that Mr G had structural heart disease not previously diagnosed which caused sudden cardiac death. His opinion accords with the view expressed by the pathologist who conducted the autopsy on Mr G's body. I accept that opinion.


I am of the view on the basis of all the material tended at the inquest that Mr G's death occurred in the circumstances outlined in these findings. The treatment afforded him prior to, and after, his admission was of an appropriate standard. The heart pathology which caused his death was not able to be diagnosed. I am satisfied that no person or persons contributed to the cause of Mr G's death.

I wish to convey my sincere condolences to Mr G's family on his passing.

Dated:         6 February 2015 at Hobart in the State of Tasmania.


Simon Cooper