Record of Investigation Into Death (Without Inquest)
Corners Act 1995
Coroners Rules 2006
Rule 11
I, Stephen Raymond Carey, Coroner, having investigated the death of Gordon Stefan BLASCHKE
Find that:
(a) The identity of the deceased is Gordon Stefan Blaschke (“Mr Blaschke”);
(b) Mr Blaschke died on 11 February 2013 at Royal Hobart Hospital, Hobart;
(c) Mr Blaschke was born in Hobart on 17 January 1984 and was aged 29 years;
(d) Mr Blaschke never married, was the father of a 3 year old daughter and was unemployed;
(e) Mr Blaschke died as a result of hypoxic brain damage, due to combined drug (methadone & benzodiazepine) intoxication;
(f) At the time of his death Mr Blaschke was being treated by a medical practitioner: and
(g) No other person contributed to Mr Blaschke’s death.
Circumstances Surrounding The Death:
Mr lived with his parents in Sydney until he was approximately 18 months old at which time his father brought him to Tasmania. He lived with his father until he was approximately 13-14 years old when he went to reside with his mother. The reason for this move was reportedly because he was not permitted to smoke cannabis at his father’s home. Mr Blaschke’s mother, by her own admission, was a regular user of drugs from her teenage years and at the time of Mr Blaschke’s death she was aged 51 years and had not taken any illicit drugs for the previous 11 years, other than what she received being part of the methadone program. At this time Mr Blaschke’s lifestyle deteriorated as he alternated residing with his mother, his father and also at youth and men’s shelters as he commenced committing more serious offences in order to support an increase in illicit drug use. At the time of his death Mr Blaschke had been in a relationship with Ms T for a number of years. This was described as a volatile relationship where there were numerous family violence incidents and both partners regularly used illicit drugs. During this time Mr Blaschke’s mother stated that Ms T and her son regularly used Xanax, speed, ADHD medications. Valium and cannabis. This was a period when both were on the methadone program. In 2010 a daughter was born of this relationship but the illicit drug use and violence continued within the relationship. In October 2010 Mr Blaschke committed an armed robbery and in May 2011 he was convicted and sentenced to 2 years imprisonment to be served cumulatively with other periods of detention. Mr Blaschke is described as having spent the majority of his adult life in some form of detention, this all being traced to his significant problem with the use of illicit drugs. His drug-related history is described in a report from Dr Chris Wake, Clinical Director Correctional Primary Health Services, in which he summarises as follows:
“Mr Blaschke was a person who injected drugs including Methadone, morphine analogues, Valium and Xanax. In addition he took large amounts of alcohol. These depressant drug and alcohol combinations are very dangerous to life and are common causes of drug related death in Tasmania. He had been placed on community drug treatment programs on more than one occasion but his poor behaviour and compliance with that treatment led to him being removed from the program. From 2004 until 2009 he was at various times given Methadone as Pharmacotherapy. In 2009 he was changed to Suboxone because of its greater safety profile – it is 10 times less likely to cause death in overdoes than Methadone. He came to prison in January 2009 and continued Suboxone treatment until April 2009 whilst in prison. In the community upon release he did not attend drug and alcohol services for dosing and was removed from the program. On return to prison in May 2009 ADS [Alcohol and Drug Services] requested that he not be restabilised but rather go onto a wait list for restabilisation in the community at an appropriate time. He was eventually restarted on the program but was again removed for non-compliance. He returned to prison in January 2011 on serious charges. At this time Mr Blaschke asserted that his serious offending was related to being removed from the program. He quickly came under threat from drug associates in the prison and was moved to the Hobart Remand Prison for protection purposes. He returned to the minimum security area of the Risdon Prison Complex in October 2012 which is where he stayed until discharge in 2013.
Mr Blaschke was known to be a regular injector of drugs whilst in prison. The prison pharmacotherapy program is not available at the Hobart Remand Prison and consequently Mr Blaschke was not offered a drug treatment replacement program whilst in prison between 2011 and 2013. In the months prior to discharge Mr Blaschke did not seek further pharmacotherapy placement despite the matter of his lack of tolerance to opioid analgesics being discussed in the context of an increased risk of post-prison death.”
In November 2012 whilst Mr Blaschke was in prison Ms T had a male staying with her at her residence in North Hobart. At about this time the male sexually assaulted Mr Blaschke’s daughter. Ms T attended the prison to inform Mr Blaschke of what had occurred, however he had already been made aware of this and blamed Ms Tr accusing her of being in a relationship with the offender. Ms T denied being in a relationship and advised that he was only staying at her residence for a short period whilst he carried out motor vehicle repairs to her vehicle.
On Tuesday 5 February 2013 Mr Blaschke was paroled from prison after serving approximately 18 months of his sentence. As part of his parole there were a number of conditions and of relevance were:
• Condition 8
Must attend a recognised drug treatment course and continue ongoing counselling with the Tasmanian Aboriginal Centre.
• Condition 13
Be of good behaviour and not violate any law and in particular should not commit any offence involving:
a) Intoxication;
…
f) possession or use of prohibited drugs.
• Condition 14
Not, other than in strict accordance with a Doctor’s directions, use, possess or administer any drug or substance which cannot be legally obtained without prescription from a Doctor unless the parolee has such a prescription.
• Condition 15
Not to remain in the presence of any person using or administering any prohibited substance.
• Condition 17
Abstain from the consumption of intoxicating liquor.
Upon his release from prison, Mr Blaschke was collected by his father. He drove him to Ms T's address where he was paroled to reside. Although some concern was expressed as to this, Mr Blaschke wanted to reside with his daughter. Mr Blaschke’s father spoke to him every day after his release and, on occasion, warned him about using drugs and also alcohol, reminding him that his tolerance levels would be lowered since his period of imprisonment. Mr Blaschke’s father saw him on Thursday 7 February 2013 when he advised that he had consumed a bottle Jim Beam whiskey the previous night and had possibly also used cannabis. His father counselled him about risking the breach of his parole to which Mr Blaschke replied that he “would be right” and “wouldn’t blow it”.
On Friday 8 February 2013, Ms T collected three 100ml Methadone bottles as her prescribed dosage as it would cover the long weekend at that time. There is some uncertainty as to what occurred when the couple returned to their residence. Ms T initially advised that she had secreted the Methadone doses in her clothing drawer, but upon another occasion she stated that she had shared some of it initially with Mr Blaschke. In any event, Mr Blaschke has had access to this Methadone and has used a significant amount of it by way of injection whilst also consuming Endep and Valium. At some stage in the afternoon, Ms T had noticed the toilet door was shut and locked, Mr Blaschke would not or could not unlock the door and Ms T gained entrance by opening the door lock from the outside. She observed Mr Blaschke squatting underneath the basin slurring his words and nodding his head back and forth. Although it is not specifically addressed in the material before me, I infer that Ms T also observed the drug taking equipment at or upon Mr Blaschke’s body at this stage and also empty medication blister packets. She left that bathroom area and when she returned a short period later the door had once again been locked. She, again, gained entry and found Mr Blaschke unresponsive.
Ambulance services were contacted, and she was directed to lay Mr Blaschke on his back and directions were provided to her about how to provide CPR. Ambulance personnel attended the address and moved Mr Blaschke from the bathroom to the living room area where treatment continued for around 40 minutes. During the course of this treatment a heartbeat was regained and Mr Blaschke was conveyed to the Royal Hobart Hospital. Upon admission to the Royal Hobart Hospital, Mr Blaschke’s condition was critical and he required life support equipment to maintain his respiration effort. Mr Blaschke remained unconscious in the Intensive Care Unit that weekend. On Monday 11 February 2013 the parents of Mr Blaschke, based upon medical advice, agreed to have his life support equipment discontinued. The attending physician certified life extinct and expressed the opinion that death was as a result of a poly-pharmacy overdoes that lead to cardiac arrest and hypoxic brain injury.
The forensic pathologist who conducted a post-mortem confirmed that the cause of death was hypoxic brain damage due to combined drug intoxication (Endep, Diazepam and Methadone).
Comments and Recommendations:
I have decided not to hold a public inquest hearing into this death because my investigations have sufficiently disclosed the identity of the deceased, the date, place, cause of death, relevant circumstances concerning how his death occurred and the particulars needed to register his death under the Births, Deaths and Marriages Registration Act 1999. I do not consider that the holding of a public inquest hearing would elicit any significant information further to that disclosed by the investigations conducted by me.
Mr Blaschke had an extensive past history of drug use and unfortunately did not positively engage with those attempts made to provide him with assistance in reducing or ceasing his abuse of illicit and prescribed drugs. Immediately prior to his death he was clearly upset concerning what had occurred to his daughter and he perhaps harboured some self-blame in that regard. However, I am not persuaded that his actions, although deliberate in taking the amount of drugs he did on this occasion, were actions taken by him with the intent to end his life.
Before I conclude this matter, I wish to convey my sincere condolences to Mr Blaschke’s family.
DATED: 30 May 2014 at Hobart in the state of Tasmania.