Record of Investigation into Death (Without Inquest)
Coroners Act 1995
Coroners Rules 2006
These findings have been partially de-identified in relation to the name of the deceased by direction of the Coroner pursuant to S.57(1)(c) of Coroners Act 1995
I, Stephen Raymond Carey, Coroner, having investigated a death of Ms F
(a) The identity of the deceased is female;
(b) Ms F died on a date unable to be precisely determined but in May 2012 at home in Southern Tasmania;
(c) The deceased was aged 24 years;
(d) The deceased was unmarried and was unemployed at the date of her death;
(e) I find that Ms F died as a result of mixed prescription drug toxicity (methadone, amitriptyline, diazepam);
(f) At the time of her death was not being treated by a medical practitioner, and
(g) No other person contributed to her death.
Circumstances Surrounding the Death:
At the time of her death Ms F was aged 24 years and had recently been released from prison for breaching a Court Mandated Diversion program. She was unemployed and was the subject of a Drug Treatment Order. Due to her issues with years of drug abuse and family violence her 4 year old daughter had been placed in the care of her paternal grandmother.
Ms F had, in the years leading up to her death, been the subject of several convictions for traffic, violence, dishonesty and drug offences. These offences appear to have stemmed from her continued drug abuse during this period. Ms F had significant addictive problems with abuse of drugs including marijuana, morphine, methadone and benzodiazepines, in particular diazepam and alprazolam. The deceased had been engaged by a number of State health services where endeavours were made to curtail her continued dangerous drug abuse. During the period from 2006 until 2011 she presented to the Royal Hobart Hospital on a number of occasions in respect of drug overdoses or psychiatric issues. She received referrals to community mental health which were not taken up. During 2011 and 2012, numerous unsuccessful attempts were made by the Eastern and Clarence Adult Community Mental Health Service to arrange an initial mental health assessment of the deceased.
On 15 March 2011, Ms F appeared in Court to face charges relating to dishonesty, firearms, family violence and the theft and forging of prescription forms. She was sentenced to 14 months imprisonment which was wholly suspended on condition she not commit an imprisonable offence for 2 years. However, in April 2011, further offences were committed by Ms F when she stole prescription forms whilst attending a doctor's appointment and following this she forged and uttered the prescriptions at various pharmacies to obtain medications. On 22 August 2011, Ms F was placed on a drug treatment order as part of a Court Mandated Diversion program to which she was subject. However, it became apparent from the numerous failed urine drug tests that the deceased continued to misuse drugs.
The breaching of the drug treatment order and her non-compliance or failure to engage with support services that were provided resulted in Ms F being required to serve 14 sanction days of imprisonment at Risdon Prison. These sanction days commenced on 20 January 2012. She was released from prison on 3 February 2012 and on 21 February 2012 was apprehended stealing products from various stores in Hobart. Due to her ongoing issues of drug use and non-compliance with her drug treatment order further sanction days were pursued against Ms F. She attended Court on 13 April 2012 in this regard and obviously anticipated being imprisoned for further sanction days as it was determined that she had taken a significant number of diazepam tablets before being committed to prison prison on that day. It was also determined that she secreted within her numerous tablets which she thereupon smuggled into prison. The following day, 14 April 2012, Ms F was found to be affected by drugs to such an extent that she was required to be transferred from the prison to the Royal Hobart Hospital. After a period of observation she was returned to prison. Later that same day she was once again found to be significantly affected by drugs and the full cache of drugs that she had secreted was then located.
As a result of continued non-compliance with her drug treatment order and the incident involving the smuggling of drugs into the prison the Court Mandated Diversion program co-ordinator commenced a reassessing of the deceased's suitability to continue with the program. It was considered by a number of those involved with this program that Ms F was too high of a risk for Community Corrections to manage within the community and that she needed to be in prison to receive the level of supervision she needed. An application to cancel Ms F's drug treatment order and participation on the Court Mandated Diversion program was heard on Monday, 30 April 2012. The application was not confirmed by the Court and Ms F was permitted to continue with additional conditions including:
Keep a diary in which daily entries were to be made;
Contact Missiondale in an endeavour to be accepted into that program;
Appear before the Court for review of her drug treatment order twice a week; and
Reside with her mother or father and not live at her own Housing Tasmania property.
Ms F was released from prison on 1 May 2012 and took up residence with her mother. As a precautionary measure her treating general practitioner, limited her prescriptions to only 5 day supply at a time.
Ms F was noted to have maintained her diary until 2 days prior to her death and in that diary she spoke of an intention to stop using illicit drugs. The investigation has identified that the deceased seemed to manage quite well for the first few days however there were then incidents where she argued with her mother, with her mother's partner, with her partner and she then failed a drug test which would have resulted in further sanction days being imposed upon her.
On Thursday, 10 May 2012, it appears that Ms F became anxious at the prospect of being again sanctioned due to the failed drug test and she then, once again, sought out and obtained physeptone (methadone) and commenced using this. This medication in tablet form was obtained from an associate who was receiving this medication upon prescription for pain relief. That person has been charged with offences in relation to supplying this medication to the deceased. The police investigation has identified that Ms F obtained the physeptone on Friday, 4 May 2012. She was subjected to a urine drug test on Wednesday, 9 May 2012 which she failed. She had a subsequent urine drug test on Thursday, 10 May 2012 which she passed, noting that this would have been some 6 days after she had used the physeptone. After passing this test she seems to have turned again to the use of physeptone/methadone that night and used it probably again on the Friday night and, based upon post mortem findings, on the night of Saturday, 12 May 2012.
On 12 May 2012 Ms F was with her mother at her mother's residence. They spent the evening watching television and at about 10:20pm Ms F's mother told her that she was tired and was going to bed, she reports that her daughter stated that she would do likewise. At about 6:30am on 13 May 2012, the deceased's mother discovered her daughter in a room used as a store room at the house. An ambulance was called however no resuscitation was attempted as she was obviously dead. Investigating police located evidence that she had injected physeptone/methadone. Empty physeptone tablet packs and injecting equipment were located in the vicinity of the deceased.
The autopsy findings by forensic pathologist, Dr Donald Ritchey, determined that:
"There were no significant injuries and an anatomic cause of death could not be identified. Microscopic sections of lung revealed copious foreign debris resulting from intravenous drug use. Toxicology testing of samples obtained at autopsy revealed the presence of multiple drugs including methadone, amitriptyline and diazepam and their metabolites. All of these drugs are strong central nervous system depressants. That, especially in combination, decreased the respiratory drive resulting in death."
Both Dr Ritchey and the deceased's treating general practitioner comment that Ms F was at heightened risk of accidental death following administering these types of drugs as she had recently had a period in prison where there was an abstinence of drug taking. The risk being that if Ms F commenced taking drugs at her usual level her body's sensitivity would have been less able to cope and she would have risked overdosing. Additionally the foreign debris found in her lungs which was as a result of injecting tablet form medication also decreased her respiratory function.
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 time, place, relevant circumstances concerning how her death occurred, and the particulars needed to register her 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 important information further to that disclosed by the investigations conducted by me.
The deceased, despite considerable endeavours from community health services in various forms, was unable to positively address her significant drug problem. The obvious risk that her continued drug abuse posed tragically lead to her death.
Before I conclude this matter, I wish to convey my sincere condolences to the family of the deceased.
Dated: 23 April 2014 at Hobart in the State of Tasmania