Record of Investigation Into Death (Without Inquest)

Corners Act 1995
Coroners Rules 2006
Rule 11


These findings have been partially de-identified in relation to the name’s of the deceased by direction of the Coroner pursuant to S.57(1)(c) of Coroners Act 1995

I, Donald Jones, Coroner, having investigated the death of Mr C

I have decided not to hold an inquest into the death because the investigation into the death has sufficiently disclosed the identity of the deceased person, the time, place, cause of death, relevant circumstances concerning the death and the particulars needed to register the death under the Births, Deaths and Marriages Registration Act.

Having conducted an investigation I do not consider that the holding of an inquest would elicit any information further to that disclosed by the enquiries conducted.

Find that:

(a) The deceased is Mr C who died on the 6th of February 2011 in the ambulance en route to the Launceston General Hospital.

(b) Mr C was born in Launceston, Tasmania in 1960 and was aged 50 years at the time of his death.

(c) I find that the deceased died as a result of combined drug (morphine, thebaine & amitriptyline) intoxication.

(d) At the time of his death Mr C was being treated by ambulance personnel.

Circumstances Surrounding the Death:

Mr C was born March 1960. He was one of three children.

Mr C lived in Launceston, Tasmania with his de facto. Ms R and Mr C  had been involved in a relationship for approximately eighteen years.

Mr C suffered from an ongoing heart complaint. He was being treated for this complaint by his doctor and at the specialist clinic at the Launceston General Hospital on 28 June 2010. In 2010, Mr C underwent heart monitoring and was diagnosed with an irregular heart beat. Although follow-up appointments were made for Mr C he made no further contact with the Cardiology Department.
Mr C began taking drugs in his teenage years. In later years Mr C’s drug habit developed and progressed until he was ingesting and injecting illicit drugs on a regular basis. Mr C used a variety of illicit and prescription drugs including morphine, opiates and cannabis.

On the morning of the 6th of February 2011, Ms R remained in bed until midday before joining Mr C as he watched TV in the lounge room, prior to her joining him his activies that morning are unknown, but Ms R believes that he may have had a few visitors.

At approximately 2:30pm Mr C and Ms R were watching a movie in the lounge room when Mr C collapsed and began convulsing. The convulsions continued for a few minutes during which time Ms R rolled Mr C over onto the floor. When Mr C stopped convulsing he had difficulty moving and communicating. Ms R assisted Mr C back onto the couch. Ms R asked Mr C  if he wanted an ambulance to which he replied, “Yes”. Mr C then began convulsing again and Ms R telephoned for an  ambulance. Whilst waiting for the ambulance Ms R commenced CPR and continued this until assistance arrived.

Ambulance personnel arrived at Mr C’s address at 2:40pm. Mr C was treated by ambulance staff at his address for over an hour before being conveyed to the Launceston General Hospital. En route to the hospital Mr C passed away.

On the morning of the 10th of February 2011, police conducted a consensual search of Mr C’s address. Ms R was present at the time of the search. A number of drug related items were located at the address and seized by police.

A post mortem conducted by Dr Lawrence found that Mr C died as a result of combined drug (morphine, thebaine & amitriptyline) intoxication.

Toxicology testing revealed that Mr C had a potentially toxic level of morphine in his blood. Codeine, amitriptyline, thebaine, nortriptyline and TCH-COOH were also detected.

The combined presence of these alkaloids strongly indicates that an opium poppy tea or extract had been consumed prior to Mr C’s death.

A detailed investigation into the circumstances surrounding the death of Mr C was completed by Tasmania Police.  The death was not considered suspicious.

Comments and Recommendations:

Mr C was a 50 year old man who was known to have an addiction to illicit drugs.  He also suffered from ischaemic heart disease and was hepatitis C.

It is unlikely the heart condition cause his death; the toxicology disclosed a combination of drugs in his blood at the time of death which lead to a drug overdose of opiate.

It is likely that the opiate had been unlawfully removed from a Tasmanian poppy plantation as there were traces of thebaine in his blood.  Thebaine is found in poppies grown in Tasmania for prescription medication, oxycodone.

Whilst it cannot be said exactly how the drug was administrated it is likely from the ingestion of “poppy tea” or intraveniously injecting extract from poppies.

There is nothing to suggest that Mr C took his own life intentionally but has died from an accidental overdose of illicit drugs.

I make no recommendations.

Before I conclude this matter, I wish to convey my sincere condolences to the family of the deceased.

This matter is now concluded.

Dated:  The 23 November 2011 at Launceston in the state of Tasmania.

Donald Jones