RECORD OF INVESTIGATION INTO DEATH (WITHOUT HOLDING AN INQUEST)
Coroners Act 1995
Coroners Rules 2006
I, Stephen Raymond Carey, Coroner, having investigated the death of
WITHOUT HOLDING AN INQUEST
(a) The deceased is Ms M who died on 14 December 2011 in the Derwent River at Hobart.
(b) Ms M was born on 1 June 1990 and was aged 21 years at the time of her death.
(c) Ms M was a single person who was in receipt of a disability pension.
(d) Ms M died as a result of the combined effects of multiple blunt trauma and drowning sustained in a probable fall from height into water.
Circumstances Surrounding the Death:
Ms M’s early childhood was uneventful, however she was a high achiever in her schooling and at the end of Grade 8 she received a scholarship. However in or about Year 6 or Year 7, Ms M’s parents report that they noted behavioural changes with her and she no longer presented as the confident young person that she once was. There were indications that she had developed an eating disorder and she also started self-harming by cutting her forearms. Apparently by Year 8 she had already required at least one period of hospitalisation following an overdose of “Panadol”. There were some indications that this change in her mental health may have been as a result of some traumatic event such as a sexual assault, however no clear detail was ever obtained in this regard as Ms M’s descriptions of same were varied and inconsistent.
However by her later years at high school Ms M was attending medical practitioners and receiving psychologist support for her poor mental health and in particular her instances of self-harm. By the end of her high school years Ms M commenced requiring periods of in-patient treatment, however her school grades remained exceptional, she managed to perform part-time employment and she also had other social engagements. Ms M’s mother describes that it was when she was in year 12 that things started to “spiral out of control”. Ms M’s mother describes that it was during this year that her daughter:
"...continued to self-harm, the eating disorder started to get worse. These incidents appeared to occur around every 2-3 months. An incident would occur, she would require hospitalisation, sometimes ICU, she would rehabilitate. Small incidents would then slowly build up to a bigger/major incident again. Some of these incidents involve - drinking anti-freeze, being found on her bed with a cable tie around her neck and her face was blue from lack of oxygen.”
Ms M did not finish Year 12 of her schooling. The following year (2009) she was admitted to the Department of Psychiatric Medicine at the Royal Hobart Hospital for a period of nine months, being released on 27 January 2010. Upon her discharge she was accommodated in a single unit at Elphinstone Road that was arranged for her through the Peacock Centre and the Housing Department. From this time on she was overseen by the Hobart and the Southern District Adult Community Mental Health Service. She received case management from this Service who report that in the time that the Service was overseeing her there were five volumes of clinical files over and above those generated by her frequent presentations to the Emergency Department, and admissions to the Department of Psychiatry at the Royal Hobart Hospital. It was noted that a significant number of those presentations to hospital and admissions were due to threats of suicide and self-harm. The Service provided a weekly meeting by a Case Manager and at times twice weekly if required. An examination of the medical records of the Royal Hobart Hospital show that during the period 17 December 2010 until 28 November 2011 there were 15 occasions where Ms M presented to the Department of Emergency Medicine and of those six related to some form of indication of suicide. Three other attendances related to self-harm. On 14 January 2011 and 8 March 2011 her presentation at hospital followed her removal from the Tasman Bridge where she had indicated suicidal intent.
Ms M’s treating psychiatrist at the time of her death was Dr M Davie, at the Hobart Clinic, who provided a report dated 1 February 2012. His introduction as to Ms M is that:
“She had been a patient of the public mental health system since aged 16 and had been referred to the Hobart Clinic (THC) intermittently since aged 19. Ms M had three admissions to the THC, the last from 30 September 2011 to 28 October 2011. She had several admissions to the RHH, both to A&E and the Department of Psychological Medicine mainly after self-harm events.
Her last admission to the THC in September 2011 was precipitated by a worsening of psychotic symptoms, in particular what she called “paranoid attacks” caused by a person called “Brett” who was revealed to her through visual and auditory hallucinations. She stated he “told” her that other people were going to attack her and suggested self-harm. She also reported low mood and poor sleep.”
During her period of in-patient care her medication both anti-psychotic and anti-depressive medication was amended. When discharged on 28 October it was noted that her condition had improved even though command visual and auditory hallucinations were still present, they seemed less distressing for her. She was unable, due to transport problems, to attend to day clinics at the Hobart Clinic, however she was subject to ongoing monitoring by her Case Manager from the Peacock Centre, Mr James Knight, Psychiatric Nurse who also worked at the Hobart Clinic and was able to provide regular feedback about her progress.
She was reviewed for a final time by Dr Davie on 21 November 2011. It was noted that in the intervening period her general practitioner had increased her anti-depressant medication. At this appointment chronic auditory and visual hallucinations were still present, however Ms M reported that she was dealing with those by being busy on her computer. On this occasion Ms M attended with her mother who confirmed that anti-psychotic medication did not appear to make much of a difference over the period of time that Ms M was unwell. The management plan at that time was to try and rationalise her medications, which at that time were multiple, and approach a situation where she was taking only one anti-psychotic and one anti-depressant in order to improve compliance.
She was seen again by Dr Davie on 9 December 2011 after a discharge from the Royal Hobart Hospital following an overdose. At this time she admitted to having forgotten to take her medication due to her smoking cannabis. She says that the voice of “Brett” had got worse and had encouraged her to self-harm. At this time it was stressed to Ms M that it would be difficult to treat her hallucinations if she continued to use cannabis, alcohol and/or any other illicit drugs as the prescribed medications would be rendered even less effective. Ms M accepted this advice and advised that she would try to stop.
Ms M’s mother reports that following a phone call that she made to her daughter on 7 December 2011 she went to her daughter’s unit and found her to be semi-conscious. An ambulance was summoned and she was admitted over night to the Royal Hobart Hospital with a suspected drug overdose. At the consultation that occurred with Dr Davie on 9 December 2011, Ms M’s mother became aware that her daughter did not have any money. This was a surprise given that in November 2011 she had $1,500 in her bank account. This topic was raised again with Ms M on Monday 12 December when her mother obtained copies of her bank statements and noticed numerous withdrawals for $140 and at times withdrawals for larger amounts. Ms M advised that two female associates were making her withdraw that money so that they could buy drugs, although Ms M admitted that she had been smoking marijuana. On Tuesday 13 December further discussions were had between Ms M and her parents concerning the money that was missing from her account and also her complaint of a stolen mobile phone. Ms M was returned to her unit at about 6.30pm that evening. The next morning Ms M’s mother visited her unit at approximately 9.30am and noted she was missing. She made certain enquiries before reporting her missing to Tasmania Police at approximately 11.00am. Based on statements made by associates of Ms M it is apparent that she had been using marijuana on a regular, if not daily, basis for a significant period of time. There is also an allegation that from approximately September 2011 she commenced using “speed”, both by ingestion of the drug and also injecting.
Mr D met Ms M in the Hobart Clinic in April 2011. They maintained a close friendship from that time and this became an intimate relationship approximately six weeks prior to Ms M’s death. He reports that she openly discussed with him hearing three voices in her head, one was male called “Brett” and there were two female voices. Since he had met Ms M he was aware of her committing self-harming acts on at least six occasions. He reports that Ms M smoked marijuana on a daily basis and that she did this because it took the “voices” away. He says that she also starting taking “speed” in September 2011 and she did this because she liked the feeling. With regard to her medication, he indicates that Ms M would take as much or as little of her prescribed medication as she believes she needed. This was dependent upon how she felt and on some occasions she did not take any medication. Apparently Mr D did not approve of the use of illicit drugs by Ms M and this led to his indication to her that their relationship was over. Mr D resided at the Huon Quays at the Domain. At approximately 7.00am on 14 December 2011 he observed that there was a note pushed under the door of his room. He had been awake at 4.00am and recalled that the note was not there then. He identified the writing as being that of Ms M. That note contained an apology from Ms M as to the way in which she had treated him and expressed her love for him then and into the future. It also ended with a goodbye. Mr D initially took this note to be a “goodbye” to their relationship rather than as a suicide note.
In the early afternoon of Wednesday 14 December 2011 Ms M’s body was located washed ashore on Howrah Beach. The autopsy findings of multiple blunt trauma injuries suggest that Ms M has jumped from the Tasman Bridge. She had previously discussed this method with associates as a possible means of suicide and as noted previously had been apprehended on the Tasman Bridge on previous occasions where she has displayed suicidal intent. The fact that Ms M’s body could travel from the Tasman Bridge to Howrah Beach in a short period of time was noted as possible by Sergeant Paul Steane, an experienced Tasmania Police Officer with the Search and Rescue Division.
Comments & Recommendations:
This is a desperately sad and tragic case. I express my sincere condolences to the parents of Ms M who have clearly supported their daughter throughout her troubled years and ensured all reasonable medical assistance and support has been made available to her.
Unfortunately Ms M was a very troubled and unwell person who in the period leading up to her death further complicated her condition by non-compliance with medication and the use of illicit drugs. No blame at all can attach to her in relation to her conduct given her poor mental health status which fundamentally compromised her ability to make rational decisions.
Dr Davie describes the situation thus:
“Ms M was a complicated patient because of the concurrent problems of significant psychotic illness which proved to be treatment resistant, a personality prone to mood swings, impetuous and self-harming behaviour and a propensity to use illicit psychoactive drugs with concomitant non-compliance with prescribed treatment. Such a psychological burden usually results in severe chronic impairment in functioning and a very high probability of death through suicide.”
As noted in my findings an inference has been made that Ms M jumped from the Tasman Bridge. There is no direct evidence as to that fact. Although there are cameras affixed to the Tasman Bridge they are primarily for vehicular traffic flow management and operate on a “real time” basis with no recording. In order to secure evidence of pedestrian incidents on the bridge and also to provide a means for possible emergency service intervention, it is recommendation that consideration be given to:
• ensuring that the cameras affixed to the Tasman Bridge can monitor pedestrian as well as vehicular traffic;
• provide a 24 hour recording capability from those cameras which is held for a reasonable period (at least one week) to allow access for investigation purposes not only for pedestrian incidents but also vehicular accidents;
• provide a capability for a 24 hour, 7 day a week monitoring of the “real time” camera transmission to allow an ability for a timely intervention if a pedestrian is noted to be acting dangerously, inappropriately or suspiciously on the Tasman Bridge. Possible facilities where such a monitoring system could be established might include the Police Radio Room, Hobart Police Station Enquiry Office, or Tas Ports Control Room.
DATED: 27 August 2012 at Hobart in the State of Tasmania