RECORD OF INVESTIGATION INTO DEATH (WITHOUT INQUEST)
Coroners Act 1995
Coroners Rules 2006
I, Donald John Jones, Coroner, having investigated a death of
Karen Elizabeth BLACKABY
WITHOUT HOLDING AN INQUEST
(a) Karen Elizabeth BLACKABY died on or about 4 June 2009 at Unit 1, 51 George Street, Latrobe.
(b) Karen Elizabeth BLACKABY was born in Latrobe, Tasmania on 9 June 1956 and at the time of her death she was aged 52 year(s).
(c) Karen Elizabeth BLACKABY was a divorced person whose occupation at the date of death was a Carer.
(d) I find that the deceased died as a result of drowning in a bath.
(e) At the time of the deceased person’s death she was not being treated by a medical practitioner.
Circumstances Surrounding the Death:-
On 4 June 2009, Police attend the residence of the deceased, Ms Karen Elizabeth Blackaby due to a concern for her welfare. Upon arrival Police located Ms Blackaby deceased in the bath of her residence. A search of the premises located several letters describing how alone she felt and how the medication and illness was affecting her. She talked about how she was losing her independence and was having to rely on others for help.
History of Ms Blackaby’s health matters:
Ms Blackaby first consulted Dr Ashraf at her practice in August 2007 and was seen again in September. The Doctor stated Karen presented exhibiting symptoms of anxiety and stress following a separation from her partner. Karen also exhibited signs of depression, she was teary and had suffered weight loss; there was no suggestion she was feeling suicidal or had held thoughts of suicide. Dr Ashraf referred her to a local Psychologist for counselling and psychotherapy. This appeared to be successful, when reviewed by Dr Ashraf a number of times until 27 February 2008, when Karen indicated she was feeling better, was eating and was no longer feeling depressed.
Subsequently, on 29 December 2008, Karen again presented at Dr Ashraf’s practice complaining of nausea, headache and feeling lethargic. She was sent for blood tests and other appointments with other medical practitioners. A Dr Quasim, after admitting Karen to hospital diagnosed her as suffering from secondary Addison’s Disease and was prescribed Cortisone Acetate.
Following her discharge from hospital, she was seen by another medical practitioner who disagreed with the diagnosis of Addison’s Disease and recommended she be weaned off the cortisone and that she be examined by an endocrinologist.
On 7 April 2009 she was seen by another doctor, a Dr Greenway at the Royal Hobart Hospital, and was admitted on 14 April. Before her discharge she was again prescribed Cortisone Acetate. Following her discharge and further medical investigations, Dr Greenway confirmed that Karen did not have Addison’s disease and requested the Cortisone Acetate be stopped.
On 28 May she again attended on Dr Ashraf for review and informed him she was not sleeping and feeling depressed. Dr Ashraf did not consider her to be suicidal and he prescribed 15mg of Mirtazapine daily. In discussions between Dr Ashraf and Dr Glynn they formed the opinion Karen may have been suffering from an undiagnosed eating disorder, although Karen denied this when questioned. Dr Ashraf then referred her to a dietician. He considered the possible need to obtain a psychiatric evaluation as well.
On 31 May Karen attended the Accident and Emergency at the Mersey Hospital and was reviewed by a doctor who discussed her condition with an on call psychiatrist. It was suggested that Karen should be reviewed on the following day by a Mental Health team and an appointment was made for her for the following day at Oldaker Street, Devonport.
Having been reviewed by the Mental Health team she was advised to increase her Mirtazapine to 30mg daily and an urgent appointment was made for her to to see the Psychiatrist at Oldaker Street Clinic.
Evidence from Dr Glynn states:
"...In the 18 months that I treated Ms Blackaby she attended 8 sessions with me. She was not always consistent with attending sessions and would only come when she needed to talk about what was making her angry. She attended 5 sessions from February to June 2009.
Ms Blackaby reported that she had been diagnosed with Addison’s disease, unfortunately there were problems with this diagnosis and Ms Blackaby spent the next 3 months undergoing a number of tests and assessments to gain a clear diagnosis. As a result of this Ms Blackaby appeared to become angry about the lack of a clear diagnosis, she also reported that she had very little support during this time. During this time my role was to support her and help her deal with her anger. Over time she was losing weight she was becoming very weak and was having difficulty in walking.
At my last session with Ms Blackaby she reported that she had spent a number of hours at the Mersey Hospital on the previous evening, she was having trouble walking and standing. She reported she was assessed by the Mental Health team and sent home. She at this time was very angry about everything especially the lack of family support and she also reported that her sickness benefits would end in July…”
Family, friends and work colleagues observed changes in Ms Blackaby’s demeanour and behaviour in the months leading up to the time of her death. It wass noted that her word usage changed, and she had begun swearing, which was out of character for her. She appeared to become angry and bitter about matters and this was most of the time. She had become very depressed when she was informed that she was not suffering Addison’s Disease.
Nora Davis, a work colleague, had spent time with Ms Blackaby on the day preceding her death. During their conversations, Ms Blackaby has said that she had had enough, and was talking of committing suicide. She had discussed three methods of taking her own life. From the content of the conversations, Ms Davis formed the view that she had given some thought to suicide as she has said she could take an overddose but did not have sufficient tablets, she also said she could crash her motor vehicle into a tree, or cut her wrists. Ms Davis became concerned as to Ms Blakaby’s state of mind and told her she needed to be in care. She said that Ms Blackaby agreed with her but indicated this could only be admitted into care if she had first attempted suicide. Immediately before leaving, Ms Davis told Ms Blackaby that she would contact the surgery and would make enquiries as to what domestic and financial support was available to her.
On leaving Ms Blackaby, Ms Davis attempted to contact Ms Blackaby’s psychologist, but was unsuccessful. She was informed by the receptionist that the psychologist was unable to speak with her because of the provisions of the Privacy Act. She informed the receptionist of her conversation with Ms Blackaby and her concern that she may attempt suicide and stressed that the matter was urgent and that her concerns be conveyed to the psychologist immediately. Ms Davis was of the belief that there was a suicide crisis team which would take action straight away once notified.
Tragically, this call for help appears not to have been followed up.
On Thursday 4 June 2009, Ms Irene Gabriel arrived at Ms Blackaby’s residence to drive her to a doctors appointment as arranged the previous day, however Ms Gabriel could not locate Ms Blackaby. Ms Gabriel then contact the doctor’s surgery, Ms Blackaby’s mother and the hospital in an attempt to locate her but she was unsuccessful. Ms Gabriel then contacted police with her concerns for the welfare of Ms Blackaby.
Comments and Recommendations:
I find the deceased Karen Elizabeth Blackaby died as a result of drowning.
An analysis of the deceased’s blood revealed alcohol negative, carboxyhemoglobin negative, caffeine present, oxazepam 8mg/L within reported fatal range, diazepam indicated, nordiazepam present, temazepam present,mirtazapine present; less than 0.06mg/L sub-therapeutic and ibuprofen present; less than 0.3mg/L sub-therapeutic.
From the evidence before me, I find Ms Blackaby had expended all her sick pay entitlements and then applied for sickness benefits. However she knew if she had been diagnosed with ‘Addison Disease” she would have been able to get a disability pension but this diagnosis was later changed. It is apparent that her financial position was playing on her mind and she was worried about how she was going to manage financially.
I note that during Ms Blackaby's professional counselling sessions she did not indicate ever contemplating suicide, quite the opposite. There is evidence stating that she made comment of her strong feelings against suicide. This was strengthened because she had become very distressed and angry about her son-in-law's three attempts over the last 20 years. She found it hard to understand and stated that "life was precious".
However, on the day before her death she discussed several methods of committing suicide to a friend Nora Davis. Ms Davis made several attempts to get professional assistance for her at this time, to no avail. Ms Davis was informed that she needed written permission from Ms Blackaby before she could speak with her counsellor. Unfortunately Police were not notified of the impending possibility that Ms Blackaby maybe contemplating taking of her own life.
I find Ms Blackaby was deeply depressed and decided to take her own life due to her failing health problems and her financial situation.
I find no other person(s) responsible for the actual death of Ms Blackaby.
Before I conclude this matter, I wish to convey my sincere condolences to the family of the deceased for their loss.
This matter is now concluded
DATED: Wednesday 11th November 2009 at Burnie in the state of Tasmania.
Highlights the need for more education to be given as the the impact of the Privacy Act and when matters are of a life threatening nature the provisons of Privacy Act should not impede the giving support. Need to review the provisions of legislation and either change it or educated medical personnel as to the actual provisions.
Neither HEALTH INFORMATION nor SENSITIVE INFORMATION
Under provisions of Privacy Act 1988