Record of Investigation Into Death (Without Inquest)
Corners Act 1995
Coroners Rules 2006
I, Stephen Carey, Coroner, having investigated the death of Steven John GRANT.
WITHOUT HOLDING AN INQUEST
(a) Steven John Grant (“Mr Grant”) died on or about 11 November 2013 at Deloraine.
(b) Mr Grant was born at Launceston in Tasmania on 9 May 1975 and was aged 38 years at the time of his death.
(c) Mr Grant was a single man and at the date of his death and he was in receipt of a disability pension.
(d) I find that the Mr Grant died as a result of positional asphyxia due to alcohol and alprazolam intoxication..
Circumstacnes Surrounding The Death:
Mr Grant lived in a Housing Tasmania unit as part of a block of units in Deloraine. From time to time Ms Regina Booton would stay with him as they had been in a relationship for approximately 18 months. However, Ms Booton retained her residence in Devonport and would reside with Mr Grant from time to time; there had been problems throughout the relationship with domestic violence issues associated with Mr Grant’s excessive use of alcohol.
Mr Grant had moved to the Deloraine area from Launceston and, upon that move, came under the care of Dr Joseph Etta from December 2012. Dr Etta advises that during the period that he knew Mr Grant there was a complicated medical and social background that was challenging. It was apparent to Mr Etta that Mr Grant was abusing alcohol, at one stage he was referred to the Drug and Alcohol Services but this referral was never followed through with by Mr Grant. Soon after this, Mr Grant fractured his left ankle and this became a source of management difficulties as Mr Grant was not compliant with instructions from the fracture clinic and accordingly was agitated about ongoing pain in his leg and insomnia. Dr Etta reports that in early August 2013 he received a letter from the Community Health social worker who was involved in Mr Grant’s care. This set out a number of Mr Grant’s psycho-social problems and suggested that in the past he had been successfully managed on alprazolam in respect of his severe anxiety/panic disorder. Accordingly Dr Etta commenced a trial of this medication however, it became apparent that Mr Grant was returning earlier than usual to request further prescriptions indicating that he was exceeding the prescribed dosage. On his last consultation with Dr Etta on 10 September 2013, there was a long discussion regarding the “judicious use of his Xanax”.
The District Community Health social worker who was involved in Mr Grant’s care was Ms Libby Beyerle, who noted that Mr Grant had in the past attempted to overcome a history of alcohol and drug abuse and in fact attended an 18 month rehabilitation course at the Bridge Program in Hobart in 2008. She outlined a number of family and social issues impacting upon Mr Grant and did recommend to Dr Etta that there be a trial using Xanax as Mr Grant advised that his had worked well for him before in managing his anxiety. In the period from August to October 2013 Ms Beyerle’s case notes indicate there were occasions upon which Mr Grant attended with a positive attitude and some confidence as to the future with a wish to engage in community programs. However, there were other occasions when there were strong indications that he continued from time to time to abuse alcohol.
Ms Booton provided advice confirming that she would usually stay with Mr Grant three or four nights a week and return to her home when he commenced drinking alcohol. She reported that he could drink up to five bottles of whiskey a week and if he did not have the money to buy these spirits he would purchase and consume cask wine. On 8 November 2013 she attended at Mr Grant’s residence at approximately 11:45am and found him “blind drunk”. By Saturday 9 November 2013, when she left, he had consumed four bottles of whiskey from approximately 7 November 2013. When she left him on Saturday 9 November 2013, he was described as “drunk and asleep in his chair”. However, at some time between 6:00pm and 7:00pm that night he was refused service at the local hotel bottle shop due to the level of his intoxication. Ms Booton contacted him by phone at 9:30 on 10 November 2013 stating that he sounded sober; he was doing some housework and appeared to be in good spirits. Apparently subsequent to this call he has once again gone to his local bottle shop, had appeared affected by alcohol and had been told that he would not be served and was not welcome back. He was seen to walk into town and, I infer, obtain alcohol from some other outlet. Ms Booton then attended at his residence on 11 November 2013 at about 10:30am, she let herself in as the front door was unlocked and she noticed Mr Grant lying between the couch and the wall. She noted that he was not breathing and he was cold and rigid. She called the ambulance; they arrived 10-15 minutes later but no resuscitation endeavours were commenced as it was confirmed that Mr Grant was dead.
Police attended and an investigation took place which indicated that Mr Grant had fallen into the position in which he had been found. Marks on his head and damage to furniture were consistent with this conclusion. It was concluded that Mr Grant had fallen and become stuck between the wall and the couch. There was a prior history of Mr Grant falling upon occasions when he was affected by alcohol. The toxicology report upon his blood as part of the post-mortem process determined an alcohol reading of 0.282gm/100ml of blood and alprazolam present in the potential toxic range. The autopsy also revealed some petechiae and superficial injuries consistent with positional asphyxia which was believed could have played a role in his death. It was also noted that Mr Grant had significant ischemic heart disease which was, of itself, sufficient to cause sudden death.
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 Mr Grant, 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.
Before I conclude this matter, I wish to convey my sincere condolences to the family of Mr Grant.
This matter is now concluded
DATED: 11 August 2014 at Hobart in the state of Tasmania.