Record of Investigation into Death (Without Inquest)
Coroners Act 1995
Coroners Rules 2006
I, Stephen Raymond Carey, Coroner, having investigated the death of;
WITHOUT HOLDING AN INQUEST
Find That :
(a) ‘The deceased’ died in June 2009 at the Royal Hobart Hospital (RHH) and was aged 54.
(b) The deceased was a married woman and mother of three children.
(c) The deceased as a result of mixed drug toxicity (paracetamol and venlafaxine) and bronchopneumonia.
Circumstances Surrounding the Death :
At the time of her death, ‘Mrs K’ was residing with her husband, and youngest daughter,. In addition to this residence ‘Mr and Mrs K’ owned another property which is the property in front of the main residence and was known as the yellow house or cottage.
In late May until early June 2009 ‘Mrs K’ had been travelling overseas with her husband.. Whilst oversees the deceased received phone calls relating to the pregnancy of her youngest daughter. For a variety of reasons this pregnancy was a source of distress to the deceased.
Prior to travelling overseas ’the deceased’ was told by another daughter, that her grandfather, ‘the deceased’s’ Stepfather, had made indecent suggestions and advances to her. ‘Mrs K’ was concerned and intended to address this issue upon her return.
Mrs K’s son, had been a concern to her for many years due to his having a long history of health problems relating to drug use. Prior to travelling overseas her son had made threats towards his grandfather as a consequence of the above allegations.
‘Mr K’ reports that these various matters had been discussed with their children over the last three days of their trip and that ‘the deceased’ had plans upon her return to discuss the baby with her daughter and speak to her mother and stepfather in relation to the matters with her other daughter.
On Thursday 11 June 2009 ‘Mrs K’ attended at the Gateway Café following her return from overseas. The manager of, the Gateway Café noted that ‘Mrs K’ appeared unwell. ‘Mrs K’ told her that she had been taking "heaps of panadol" and that she might have "caught a bug overseas". ‘Mrs K’ told ‘Mrs H’ that she had "taken three packets of panadol". ‘Mrs H’ expressed her concern and suggested that the deceased see a doctor.
‘Mrs K’ had made arrangements to meet her daughter in Hobart on Friday 12 June 2009 to discuss further the incidents with her grandfather and was then going to talk to her mother about them. She did not do this as she stated she was unwell. Arrangements were made for her to meet her daughter in Kingston on 13 June 2009.
‘Mrs H’ saw ‘Mrs K’ again on Friday 12 June 2009 at which time ‘Mrs K’ said she had not yet seen a doctor, was "still taking Panadol but not as many". ‘Mrs K’ told ‘Mrs H’erring that she was excited about seeing her daughter the next day but was not looking forward to seeing her parents to discuss an issue that had arisen between her Stepfather and her daughter.
‘Mrs H’ recalls ‘Mrs K’ telling her that prior to driving to her daughter’s house she had to get something out of the "the yellow house" as she was taking it to her daughter. She does not know what item/s ‘Mrs K’ was referring to. ‘Mrs H’ has stated that ‘Mrs K’ had a habit of locking doors behind her.
On the morning of 13 June 2009 at approximately 9.30am ‘Mr K’ left their residence with the intention of playing golf. ‘Mrs K’ confirmed at that time that it was her intention to travel to Kingston to see their daughter, and to visit her parents to discuss with them the allegations made by her daughter.. ‘Mr K’ noted nothing unusual about her health although "she was still distressed".
Her daughter spoke to ‘Mrs K’ on the morning of 13 June 2009 at approximately 9.30am. ‘Mrs K’ advised her she "would see her at her house at around lunch time". Her daughter has stated that ‘Mrs K’ "seemed fine on the phone". When ‘Mrs K’ did not arrive as arranged her daughter became concerned and attempted to contact her. When she could not, she spoke to her father who advised her not to worry as her mother would not be far away. She called the Café and spoke to the manager and asked her to check if her mother was alright.
‘The manager’ and another Café staff member went to the main house. ‘Mrs K’s’ vehicle was parked in the laneway. All the doors and windows were locked, but for one upstairs. They also went around the exterior of "the yellow house" and knocked on all the doors and windows but did not receive a response.
‘Mrs H’ attended the Golf Club with the intent of notifying ‘Mr K’ but instead gained the assistance of ‘Mr K’s son from his first marriage. They returned and gained entrance and checked the main residence noting there was no sign of ‘Mrs K’. ‘Mrs H’ returned to the Café and called ‘Mrs. K’s daughter to obtain the number of, the cleaner of the "the yellow house" so that a key could be obtained to check there.
‘Mrs A’ attended but found the key to the "yellow house" was not where it was normally stored. She was then joined by her daughter, and a family friend.
All three checked "the yellow house". They noticed an odour near the back door and thought it may have been gas. ‘Ms W’ called ‘Mrs K’’s step-daughter who advised that the easiest way to obtain entry would be by forcing the front door. When entry was gained ‘Mrs K’ was located, lying unconscious, on the floor. She was breathing very loudly, although her breaths were shallow. An ambulance was called and a neighbour assisted. ‘Ms T’ is a nurse in training. She took ‘the deceased’s’ pulse and suggested that the others look for tablets. None were located.
An ambulance arrived at 3.35pm and and it was noted that ‘Mrs K’ was unresponsive to verbal commands or pain stimuli, her airway was not clear and her breathing was inadequate. ‘Mrs K’s breathing was assisted with intermittent positive pressure ventilation, a cardiac monitor was applied and she was transferred to the RHH during which time she had two episodes of cardiac arrest requiring cardioversion.
‘Mrs K’ arrived at the RHH at 5.37pm at which time she was being assisted with ventilation by accompanying paramedics. She was noted to be hypothermic. ‘Mrs K’ was transferred to a resuscitation bay and was intubated and received approximately 5 litres of intravenous fluid and was started on mechanical ventilation. Attempts to gently warm with external warm air blankets and using warm intravenous fluids were started. ‘Mrs K’ remained hypotensive and was very unstable going into either ventricular tachycardia or ventricular fibrillation seven times requiring external chest compressions and cardioversion via external pads during the first hour.
‘Mrs K’s family were shown into the resuscitation area and it was explained that ‘Mrs K’s condition was extremely serious with the likelihood of multi organ damage, including brain damage, heart damage and damage to other organs if she survived, which was assessed as unlikely. ‘Mrs K’s’ family were advised that external chest compressions could only be performed for a limited period. ‘Mrs K’ then stabilised and an opinion was sought from the Intensive Care Unit. At this time a very high level of paracetamol was discovered in ‘Mrs K’s’ system and an N acetyl cysteine infusion was started. ‘Mr K’, upon questioning conceded that it was possible his wife had attempted suicide.
‘Mrs K’ was transferred to ICU under the care of Dr Turner, Director, Critical Care Medicine after approximately 2 hours in the Emergency Department. Her heart rate was 55bpm, she was cold and her pupils were fixed and dilated. There was evidence of livedo of the skin, suggesting a lack of blood flow to the skin for a prolonged period and GCS remained at 3. Other examination revealed a patch of bronchial breathing at the right lung base suggesting that she may have had an episode of aspiration either before or during her transport to hospital.
Dr Turner advised ‘Mrs K’s’ family that as high paracetamol levels were detected in the bloodstream there was a slight possibility that there were other agents in her blood that might be affecting her neurology and her heart and it was therefore worth treating her for a period of time in order to see if there was any reversibility as a result of these potential agents being removed from her system. The family advised Dr Turner that ‘the deceased’ must have planned the overdose as there was no panadol at all in the house, nor were there any empty packets.
At approximately 30 hours post admission to ICU ‘Mrs K’ had a further episode of cardiac arrest and the on-call cardiologist, Dr Galligan was consulted. Whilst the cardiologist was arriving at the RHH ‘Mrs K’ had a further episode and cardiac rhythm was not able to be obtained. Dr Galligan felt that ‘Mrs K’s prognosis was poor. Dr Galligan spoke to her husband and it was agreed that it was unreasonable to persist further with active management. The treating specialist, Dr Turner agreed with this assessment as ‘Mrs K’ had now had a secondary insult to her brain and her cardiac instability had not improved despite supportive measures in ICU over the preceding period.
‘Mrs K’ died at 0128 hours on 15 June 2009.
Dr D Ritchey, Forensic Pathologist reported the presence of paracetamol following post mortem blood analysis at approximately 240mg/L and venlafaxin at 6mg/L. Of note is the result of blood analysis whilst in ICU which showed a reading of 6175mcmol/ (933.7 mg/L). He comments that autopsy of the deceased revealed;
"…..widespread damage to liver (hepatic necrosis) characteristic of acute paracetamol overdose. Paracetamol is toxic to the liver in overdose. Death results from metabolic derangements and multiple organ failure produced by liver failure."
Forensic Scientist, Mr Andrew Griffihts at Forensic Science Service Tasmania who analysed the post mortem blood reports that;
"A paracetamol concentration within the reported fatal range for this drug taken alone was identified. Venlafaxine was also identified at an elevated concentration and this drug has been related to serotonin toxicity when taken in overdose. This drug combination would cause a severe toxicity and a high potential for death in most individuals. As paracetamol toxicity results in liver and kidney dysfunction it is possible that this resulted in a accumulation of venalafaxine due to a failure to metabolise the drug in the liver or a reduction of the renal excretion of the drug."
Tasmania Police Officers attended the residence of the deceased 14 June 2009. They noted that all windows at the residence were secure and there was no sign of forced entry, excluding the damage to the front door made by neighbours. The rear door lock was working and the keys to the residence were in the rear door lock on the interior. Medications were located in a cupboard at ‘the cottage’. These were ‘Mr Ks prescriptions and were not paracetamol based. The deceased’s vehicle was searched with no medications being found.
I am satisfied that a full and detailed investigation has been undertaken in relation to the death of ‘the deceased’ and that there are no suspicious circumstances.
It is clear from the evidence that ‘the deceased’ had been concerned about issues concerning her children. A statement from ‘the deceased’s’ General Practitioner supports that ‘Mrs K’ was seen in October 2003, March 2004 and December 2004 for stress and anxiety. Family problems were cited as a contributing factor to her anxiety.
’Mrs. K’ had admitted to taking large quantities of Panadol (paracetamol) in the days prior to her death. ‘Mrs. K’s’ daughter, has stated that following ’Mrs. K’s’ death a prescription packet of Efexor-XR capsules 75mg which contain the drug Venlafaxine which had been previously prescribed for her was noted to be missing.
I find that on the morning of 13 June ’the deceased’ entered her residence and locked the door from inside. The purpose of her attendance at "the cottage" was most likely to collect an item for her daughter.. It is apparent that she poured a glass of water, entered the bedroom, shut the blinds, closed the door and commenced removing her trousers in order to rest, at which time she collapsed. This resulted in ‘the deceased’ falling to the floor. There were no empty medication packets found at "the cottage". There was no note from ‘the deceased’ located.
I find that ‘Mrs. K’s’ death resulted from mixed drug toxicity (paracetamol and venlafaxine) and bronchopneumonia. Although there is some suspicion, the evidence does not establish that ‘the deceased’ took this medication with the intention of deliberately causing self harm or death. Rather she was apparently over medicating with paracetamol and self medicating with her daughter’s Efexor –XR (Venlafaxine) in response to the emotional and psychological distress she was suffering at the time.
Given the indications of her poor health in the period after her return from overseas and her admitted excessive use of paracetamol over that period the toxicity possibly developed over that period rather than necessarily as a result of one terminal episode of overdose. The extent of liver damage found at autopsy is indicative of a period of overdose perhaps for an even longer period that resulted in a lessening of her liver’s ability to deal with the paracetamol being consumed.
This tragic case serves as a clear warning of the dangers of taking over the counter medications (such as paracetamol) for a prolonged period or at a dosage in excess of that recommended.
Also highlighted is the risk associated with self medicating with drugs not prescribed for a person’s use. ‘The deceased’ was obviously very disturbed and anxious in the period immediately before her death and sought to deal with the effects upon her health in her own way without seeking professional assistance. This is perhaps another example of the reluctance of many within our community to seek appropriate advice and treatment for mental illness due to the perceived stigma attached to such illness. I commend the numerous awareness programmes presently being conducted by organisations seeking to address this negative perception and highlighting the prevalence of such illness within the general community.
I wish to conclude by conveying my sincere condolences to the family of ‘the deceased’.
DATED: 26 October 2010 at Hobart in the State of Tasmania.